Perianal issues Flashcards
Pruritis ani causes
Anus is moist/soiled Fissures/fistulae Incontinence Poor hygiene Tight pants Threadworm Contact dermatitis e.g. perfume
Pruritis ani management
Avoid scratching, good hygiene
Avoid foods which loosen stools
Oral antihistamine for nocturnal itch
Mild topical corticosteroid if severe
What is Fissure-in-ano
Painful tear in squamous lining of lower anal canal
Spasm can constrict inferior rectal artery, causing ischaemia making healing more difficult
Fissure-in-ano causes
Usually due to hard faeces
Can be due to syphilis, herpes, trauma, Crohn’s, anal cancer, psoriasis
Fissure-in-ano management
Lactulose + high fibre diet
5% lidocaine ointment + GTN (0.2-0.4%)
2nd line Botox injection + dialtezem (2%)
Surgical lateral partial internal sphincterotomy if necessary
What is Fistula-in-ano
Skin - anal canal fistula predisposed by blockage of deep intramuscular glands which form abscesses which discharge
Fistula-in-ano causes
Perianal sepsis Abscesses Crohn's/diverticular disease TB Rectal carcinoma
Fistula-in-ano tests
MRI
Endoanal US
Fistula-in-ano management
Fistulotomy and excision High fistulae (involve anal sphincter muscles) require seton sutures which are tightened over time to maintain continence Low fistulae laid open to heal by secondary intention, doesn't affect continence
Anorectal abscess causes
Usually gut organisms, 8x more likely in female
Associated with Crohn’s, DM, malignancy, fistulae
Anorectal abscess treatment
Incise and drian under GA
What is Perianal haematoma
Clotted venous saccule under skin at anal margin, looks like 2-4mm dark blueberry
Perianal haematoma treatment
Removed under local or left to resolve spontaneously
what is Pilonidal sinus
Obstruction of natal cleft hair follicles, ingrowing of hair may cause secondary tracks to open and abscesses
10x more likely in males, more likely in asian, middle east and obese
Pilonidal sinus treatment
Excision of tracts and closure, skin flaps can be used to cover defect if large
Hygiene and hair removal advice offered
Rectal prolapse pathology
Mucosa (partial/type I) or all layers (complete/type II) protrude through anus due to lax sphincter
Prolonged straining
Causes incontinence in 75%
Rectal prolapse treatment
Abdominal approach: fix rectum to sacrum ± mesh ± rectosigmoidectomy
Perineal approach: Delorme’s procedure (resect close to dentate line and suture mucosal boundaries), anal encirclement with wire (Thiersch)
Perianal warts causes and treatments
Condylomata acuminata (viral warts), may progress to low grade non-metastasising cancers Condylomata lata 2˚ to syphilis, treated with penicillin
What is proctalgia fugax
Idiopathic stabbing/crampy rectal pain often worse at night
Proctalgia fugax treatment
Reassurance mainly
Inhaled salbutamol/topical GTN/topical diltiazem may help
Anal ulcer causes
Crohn's Anal cancer Lyphogranuloma venerum (lymphatics infection) TB Syphilis
Skin tags management
Don’t really cause trouble, easily excised if needed
Anal cancer risk factors
Anoreceptive intercourse
HIV
HPV
Anal cancer histology and prognosis
85% are squamous cell carcinoma
Anal margin tumours well-differentiated, good prognosis
Above dentate line poor diff, poor prognosis
Anal cancer spread lymph nodes
Above dentate line to pelvic nodes, below to inguinal
Anal cancer presentation
Bleeding Pain Change bowel habit Pruritis ani Masses/stricture
Anal cancer treatment
Chemoirradiation (radiotherapy + fluorouracil + cisplatin)
Less likely is anorectal excision and colostomy
Haemorrhoids definition
Disrupted and dilated anal cushions (spongy vascular tissue which normally lines anus and helps closure), not painful as generally above dentate line
Haemorrhoids causes
Constipation with prolonged straining
Less frequently congestion from pelvic tumour/pregnancy/CCF/portal hypertension
Haemorrhoids pathology
Vicious cycle where cushions protrude through tight anus, more congestion so hypertrophy to protrude more
May eventually strangulate
Haemorrhoids signs
Bright red rectal bleeding, often coat stools and drip after defecation
May be pruritis ani/mucous discharge
Haemorrhoids classifications
1st degree - remain in rectum
2nd - prolapse through anus on defecation but spontaneously reduce
3rd - 2nd degree but need digital reduction
4th - remain persistently prolapsed
Haemorrhoids treatment 1st degree
Fluid Fibre Topical analgesics Stool softener Sclerosants - 2ml of 5% phenol oil injected above dentate line, causes fibrosis
Haemorrhoids treatment 2nd degree
Sclerosants//
Rubber band ligation//
Infra red coagulation and tethering of mucosa to SC tissue//
Diathermy and electrocurrent causes fibrosis and coagulation
Haemorrhoids treatment 3rd degree
Surgical excision/stapling
Rubber band ligation
Haemorrhoids treatment 4th degree
Surgical excision/stapling
