Painful perianal conditions

Question 1

Pathophysiology of anal fissures (2)

Answer 1

1. Stretching of the anal mucosa beyond its capacity (e.g. by constipation, increased intra-abdominal pressure)
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2. Spasm of internal anal sphincter impairs blood supply and therefore healing

Question 2

Symptoms (2) of anal fissures, and the most common location

Answer 2

• Fresh PR bleeding upon wiping
• Severe pain with/after defecation
• Fissure usually located posteriorly in the midline

Question 3

Management of anal fissures

Answer 3

1. Sphincter relaxants (topical nitrogylcerin, Ca channel blockers, botox)
2. Symptomatic releif (Sitz baths, topical anaesthetics)
3. High-fibre diet/stool softeners
4. Surgery (anal stretch, lateral sphinterotomy)

Question 4

Common organisms causing perianal abscesses (2)

Answer 4

1. Staphylococcus, MRSA

2. E.coli and other GI bacteria

Question 5

Symptoms of perianal abscess (2)

Answer 5

1. Throbbing perianal pain, worse on sitting and before a bowel movement
2. Purulent discharge

Question 6

Management of perianal abscess

Answer 6

1. Surgery (incision and drainage with post-op wound packing)
2. Antibiotics if septic

Question 7

Complications of perianal abscess (2)

Answer 7

1. Fistula

2. Sepsis

Question 8

Risk factors (3) for pilonidal cysts

Answer 8

1. Excessive sitting, especially in bumpy cars
2. Being hairy
3. Age 15-35

Question 9

Pathophysiology of pilonidal cyst

Answer 9

Hair becomes embedded in a midline pit or track

Question 10

Symptoms (2) and locations (3) of pilonidal cysts

Answer 10

1. Intermittent perianal/tailbone pain (not present if draining)
2. Purulent discharge

Locations: perianal, between fingers, posterior neckline

Question 11

Management of pilonidal cysts

Answer 11

1. Antibiotics
2. Depilatory creams
3. Surgery (lancing, excision, flap (Z-plasty))

Question 12

Pathophysiology of haemorrhoids

Answer 12

Constipation and/or increased abdominal pressure causes inflammation and swelling of haemorrhoid cushions

Question 13

Symptoms of haemorrhoids (2)

Answer 13

1. Painless PR bleeding (covering the stool if internal)

2. May be painful if thrombosed or necrotic

Question 14

Management of haemorrhoids

Answer 14

1. High-fibre diet, hydration
2. NSAIDs
3. Surgery (rubber band ligation, sclerotherapy, cauterisation, excision, dearterilisation, stapling)

Question 15

Causes of anal fistulas (8)

Answer 15

1. Infection
2. TB
3. Trauma
4. Foreign body
5. Radiation damage
6. Crohn’s
7. Iatrogenic (drains)
8. Carcinoma

Question 16

Symptoms of anal fistulas (3)

Answer 16

1. Recurrent perianal abscess
2. Purulent or bloody discharge
3. Pain

Question 17

Management of anal fistulas

Answer 17

Surgery