Perianal Disease Flashcards
List 5 symptoms of perianal disease
Pain Bleeding Prolapsed anal lumps and swelling Itchiness Discharge
What components make up the examination for perianal disease?
Inspection Palpation of perineum DRE Sigmoidoscopy Proctoscopy
Indications for flexible sigmoidoscopy
??
Indications for rigid sigmoidoscopy
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What kind of cancers can occur in the anus?
SCC
BCC
Melanoma
What kind of cancers can occur in the rectum?
Adenocarcinoma
What kind of cancers can occur at the anorectal junction?
SCC
BCC
Melanoma
Adenocarcinoma
List 7 common non-malignant perianal conditions
Anal fissure Haemorrhoids Anal skin tags Anal fibrous polyps Anal fistula Anal warts Rectal prolapse
What perianal conditions are usually painless?
Perianal skin tags Haemorrhoids (1st, 2nd and 3rd degree) Rectal prolapse Anal fistula Cancer (anal margin, low rectal) Anal fibrous polyps Anal warts Pruritis ani
When can anal/rectal cancers cause pain?
When they invade nerves, bones and/or sphincters
When do haemorrhoids usually cause pain?
When strangulated or prolapsed
What is proctalgia fugax?
Sudden, severe episodes of pain
Sporadic and resolves
Not related to defecation
What other perianal conditions cause pain?
Anal fissure
Perianal haematoma
Anal abscess
30 year old woman, 3 months post-partum, presents with anal pain on defecation for several weeks
Associated symptoms include bright red bleeding per rectum
DDx?
Anal fissure
Strangulated or prolapsed haemorrhoid
Perianal haematoma
Exclude abscess, fistula, cancer
What are the 3 principles of treatment of anal fissure?
Simple measures
Chemical sphincterotomy
Surgical sphincterotomy
What causes proctalgia fugax?
Spasm of the levator ani (typically the pubococcygeus muscle)
What simple measures are used to treat anal fissure?
Topical anaesthetic ointment
Stool softeners, coloxyl and senna
Sitz bath
What agents can be used to achieve a chemical sphincterotomy?
Rectogesic ointment (0.2% GTN; can give headache) Nifedipine 0.5%/lignocaine 5% gel Botulinum toxin injection (40-60U into intersphincteric space)
What are the aims of a chemical sphincterotomy?
To relax pressure on sphincter and reduce spasm
What is the rationale underlying botox for treatment of anal fissure? What are some of the risks?
Relaxes anal sphincter to allow fissure to heal (does reverse but provides a 60-day window for healing)
Risk of poor bowel control
How may a surgical sphincterotomy be achieved?
Lateral sphincterotomy
Fissurectomy or mucosal flap repair
What is the risk with surgical sphincterectomy?
Most effective but has risk of minor flatus incontinence (esp in females)
Reserved for intractable cases and in males
What is the typical presentation of perianal haematoma?
Acutely painful perianal swelling
Mx of perianal haematoma
Conservative
Incisional drainage under LA
What are perianal skin tags a sequelae of?
Perianal haematoma
What is the typical presentation of perianal skin tag?
Painless
Perianal itch
Mx of perianal skin tags
Conservative
Excision
25 year old man presents with painful perianal swelling, unable to sit down, with associated fever
Likely Dx?
Perianal abscess
Describe the different classifications of perianal abscess
Superficial perianal
Deep, ischiorectal or supralevator abscess
Describe the different classifications of anal fistula
Low, perianal
High and complex: intersphincteric, transphincteric, extra-sphincteric, supra-levator
What are the Sx of perianal abscess and anal fistula?
Chronic discharge of pus
Bleeding
Irritation
Mx of complex anal fistula
Insertion of Seton to eradicate fistula and preserve sphincter function
Provides drainage and guides subsequent surgery, fistulotomy or repair
Sx of haemorrhoids
Bleeding
Prolapse
Mucus discharge
Describe the classification of haemorrhoids
First degree: internal, bleeds
Second degree: prolapse and reducible spontaneously
Third degree: non reducible
Fourth degree: thrombosed, painful
How are first degree haemorrhoids treated?
High fibre diet to regulate bowel habit
Avoiding constipation and straining
Injection sclerotherapy for bleeding
5% Phenol in almond oil
How are second degree haemorrhoids treated?
Diet
Rubber band ligation
Injection sclerotherapy for symptomatic cases
How are third degree haemorrhoids treated?
Diet
Surgery by haemorrhoidectomy
How are fourth degree haemorrhoids treated?
Analgesia followed by surgery
What are the standard and newer ops available for haemorrhoidectomy?
Standard: Milligan-Morgan excision ligation
New: stapled haemorrhoidectomy, Doppler-guided haemorrhoidal artery ligation
What are the different types of rectal prolapse?
Full thickness
Internal mucosal
Sx of rectal prolapse
Anal lump Bleeding Discharge Incontinence Unable to sit
Sx of anal warts (condyloma acuminata)
Bleeding
Discharge
Anal lumps
Sx of anal cancer
Bleeding
Pain
Lump
Discharge
Mx of anal cancer
If in doubt, perform biopsy
Treatment depending on staging: local excision if small and clear of sphincter, usually chemo-irradiation therapy
Sx of low rectal carcinoma
Bright red bleeding
Mucus discharge
Tenesmus
What factors are important to assess on DRE if you are concerned about a low rectal carcinoma?
Soft or hard rectal mass
Assess position and distance from anal verge
Sx of pruritis ani
Common, mild to severe intractable itch
Bleeding
Causes of pruritis ani
Moisture from soiling or discharge
Infestations
Dermatological
Mx of pruritis ani
Dependent on underlying cause but may include: Topical steroid Anti-fungal Oral anti-histamine Avoiding excessive wiping Diet Excision of skin tags
