Perianal issues

Question 1

Pruritis ani causes

Answer 1

Anus is moist/soiled
Fissures/fistulae
Incontinence
Poor hygiene
Tight pants
Threadworm
Contact dermatitis e.g. perfume

Question 2

Pruritis ani management

Answer 2

Avoid scratching, good hygiene
Avoid foods which loosen stools
Oral antihistamine for nocturnal itch
Mild topical corticosteroid if severe

Question 3

What is Fissure-in-ano

Answer 3

Painful tear in squamous lining of lower anal canal

Spasm can constrict inferior rectal artery, causing ischaemia making healing more difficult

Question 4

Fissure-in-ano causes

Answer 4

Usually due to hard faeces

Can be due to syphilis, herpes, trauma, Crohn’s, anal cancer, psoriasis

Question 5

Fissure-in-ano management

Answer 5

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

Question 6

What is Fistula-in-ano

Answer 6

Skin - anal canal fistula predisposed by blockage of deep intramuscular glands which form abscesses which discharge

Question 7

Fistula-in-ano causes

Answer 7

Perianal sepsis
Abscesses
Crohn's/diverticular disease
TB
Rectal carcinoma

Question 8

Fistula-in-ano tests

Answer 8

MRI

Endoanal US

Question 9

Fistula-in-ano management

Answer 9

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

Question 10

Anorectal abscess causes

Answer 10

Usually gut organisms, 8x more likely in female

Associated with Crohn’s, DM, malignancy, fistulae

Question 11

Anorectal abscess treatment

Answer 11

Incise and drian under GA

Question 12

What is Perianal haematoma

Answer 12

Clotted venous saccule under skin at anal margin, looks like 2-4mm dark blueberry

Question 13

Perianal haematoma treatment

Answer 13

Removed under local or left to resolve spontaneously

Question 14

what is Pilonidal sinus

Answer 14

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

Question 15

Pilonidal sinus treatment

Answer 15

Excision of tracts and closure, skin flaps can be used to cover defect if large
Hygiene and hair removal advice offered

Question 16

Rectal prolapse pathology

Answer 16

Mucosa (partial/type I) or all layers (complete/type II) protrude through anus due to lax sphincter
Prolonged straining
Causes incontinence in 75%

Question 17

Rectal prolapse treatment

Answer 17

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)

Question 18

Perianal warts causes and treatments

Answer 18

Condylomata acuminata (viral warts), may progress to low grade non-metastasising cancers
Condylomata lata 2˚ to syphilis, treated with penicillin

Question 19

What is proctalgia fugax

Answer 19

Idiopathic stabbing/crampy rectal pain often worse at night

Question 20

Proctalgia fugax treatment

Answer 20

Reassurance mainly

Inhaled salbutamol/topical GTN/topical diltiazem may help

Question 21

Anal ulcer causes

Answer 21

Crohn's
Anal cancer
Lyphogranuloma venerum (lymphatics infection)
TB
Syphilis

Question 22

Skin tags management

Answer 22

Don’t really cause trouble, easily excised if needed

Question 23

Anal cancer risk factors

Answer 23

Anoreceptive intercourse
HIV
HPV

Question 24

Anal cancer histology and prognosis

Answer 24

85% are squamous cell carcinoma
Anal margin tumours well-differentiated, good prognosis
Above dentate line poor diff, poor prognosis

Question 25

Anal cancer spread lymph nodes

Answer 25

Above dentate line to pelvic nodes, below to inguinal

Question 26

Anal cancer presentation

Answer 26

Bleeding
Pain
Change bowel habit
Pruritis ani
Masses/stricture

Question 27

Anal cancer treatment

Answer 27

Chemoirradiation (radiotherapy + fluorouracil + cisplatin)

Less likely is anorectal excision and colostomy

Question 28

Haemorrhoids definition

Answer 28

Disrupted and dilated anal cushions (spongy vascular tissue which normally lines anus and helps closure), not painful as generally above dentate line

Question 29

Haemorrhoids causes

Answer 29

Constipation with prolonged straining

Less frequently congestion from pelvic tumour/pregnancy/CCF/portal hypertension

Question 30

Haemorrhoids pathology

Answer 30

Vicious cycle where cushions protrude through tight anus, more congestion so hypertrophy to protrude more
May eventually strangulate

Question 31

Haemorrhoids signs

Answer 31

Bright red rectal bleeding, often coat stools and drip after defecation
May be pruritis ani/mucous discharge

Question 32

Haemorrhoids classifications

Answer 32

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

Question 33

Haemorrhoids treatment 1st degree

Answer 33

Fluid
Fibre
Topical analgesics
Stool softener
Sclerosants - 2ml of 5% phenol oil injected above dentate line, causes fibrosis

Question 34

Haemorrhoids treatment 2nd degree

Answer 34

Sclerosants//
Rubber band ligation//
Infra red coagulation and tethering of mucosa to SC tissue//
Diathermy and electrocurrent causes fibrosis and coagulation

Question 35

Haemorrhoids treatment 3rd degree

Answer 35

Surgical excision/stapling

Rubber band ligation

Question 36

Haemorrhoids treatment 4th degree

Answer 36

Surgical excision/stapling