Perianal Surgery Flashcards
perianal haematoma
• Subcutaneous bleeding from a burst venule caused
by straining or the passage of hard stool.
- Tender blue lump at the anal margin
- Pain worsened by defecation or movement
pain relief, often resolves
otherwise evac under local
proctalgia fugax
diagnosis of exclusion!
Crampy anorectal pain, worse @ night
Unrelated to defecation
Assoc. ¯c trigeminal neuralgia
reassure, stress-relief, pelvic floor training
perineal warts
may be MSM
• Condylomata accuminata
(HPV)
treatment: podophyllin paint, cryo, surgical excision
• Condylomata lata
(Syphilis)
treatment: penicillin
pruritis ani
50% idiopathic
other causes: • Poor hygiene • Haemorrhoids • Anal fissure • Anal fistula • Fungi, worms • Crohn’s • Neoplasia
explain the formation of haemorrhoids
• Anal cushion = mass of spongy vascular tissue
-> where the three major arteries that feed the
vascular plexuses enter the anal canal
• Gravity + straining = engorgement and enlargement of
anal cushions
• Hard stool disrupts connective tissue around
cushions.
• Cushions protrude and can be damaged by hard stool
§ can get bright red (capillary) bleeding.
• Haemorrhoids arise above dentate line \ not painful
• May be gripped by anal sphincter → thrombosis
(strangulated piles are acutely painful)
causes of piles
constipation and prolonged straining
venous congestion:
- pregnant
- portal hypertension
- abdominal tumour
classification of haemorrhoids
1st degree: never prolapse
2nd: prolapse on defecation but spontaneously reduce
3rd: prolapse on defecation but require digital
reduction
4th: remain permanently prolapsed
symptoms of haemorrhoids
fresh blood on tissue / in pan
itching
lump
if severe pain - thrombosed
examining for piles
full abdo exam
inspect perineal area
DRE - shouldn’t be palpable unless thrombosed
rigid sigmoidoscopy or proctoscopy
treating haemorrhoids
cons: fibre and behavioural change
med: anusol, laxatives, topical pain relief
surg: inject sclerosant, banding, cryotherapy
haemorroidectomy (excise and ligate vascular pedicles)
ddx piles
Perianal haematoma
• Fissure
• Abscess
• Tumour (must exclude in all cases)
managing thrombosed piles
pain relief
stool softener
ice pack
usually all that is needed
presentation and cause of anal fissures
and exam
cause: hard stool and straining = trauma (also - Chron’s, herpes, anal ca)
presents: fresh red blood, very painful passing stool, avoidance of stool
PR too painful, may have muscosal tag or ulcer
define anal lesions using an analogue clock when describing
treating anal fissures
cons: soak in warm water, pain relief, high fluid and fibre diet
med: lactulose, fybogel, local anaesthetic, GTN ointment, diltiazem cream
surg: exam under anaesthetic (EUA) + botox
lateral partial sphicterotomy - rarely performed though
perianal fistula
abnormal connection between skin and anal canal
causes: Chron's diverticular disease rectal ca immunosuppression
high vs low anal fistula
High: cross sphincter muscles above dentate line
Low: cross sphincter muscles below dentate line
rule used to determine path of anal fistulas
Goodsall’s rule
anterior to transverse anal line = direct
posterior = curved path
presentation and o/e of anal fistula
persistent discharge and pain
pus, induration
proctoscopy may reveal internal opening
investigation and management anal fistula
MRI
endoanal ultrasound
low fistula: fistulotomy and excision
high fistula: seton suture passed through fistula and gradually tightened (scars up)
perianal abscess
assoc with Chron’s, DM, cancers
perianal - simplest, local
ischiorectal, intersphincteric, intermuscular - v painful and systemically unwell
pelvirectal / supralevator - bladder upset too
presentation perianal abscess
throbbing pain
pus discharge
can’t sit
fluctuant mass +/- septic signs
treating perianal abscess
abx may be enough
mostly get EUA, incision+drainage
may be complicated by a fistula
pilonidal sinus summary
ingrown hair in natal cleft
forms abscess
may be overweight, have poor hygiene, be sedentary
treat with shaving + good hygiene
incision and drainage otherwise
anal cancer
fairly uncommon
usually SCCs
anal margin better prognosis
anal canal worse prognosis
route of spread:
§ Above dentate line → internal iliac nodes
§ Below dentate line → inguinal nodes
HPV is a significant risk factor
presentation of anal cancer
• Perianal pain and bleeding • Pruritis ani • Faecal incontinence § 70% have sphincter involvement @ presentation • May → rectovaginal fistula
inv and management anal cancer
abdo exam, PR
EUA + biospy
CT, MRI
mostly C or R therapy
surgery only for obstruction or simple tumours not involving sphincter
rectal prolapse types
Type 1: Mucosal prolapse • Partial prolapse of redundant mucosa • Common in children: esp. ¯c CF • Essentially large piles with the same Rx
Type 2: Full thickness prolapse
• Usually elderly females with poor O&G Hx
presentation of rectal prolapse
mass felt on defecation
may need manual reduction
+/- pain/bleeding from ulceration
may get faecal soiling
associated with vaginal prolapse and urinary incontinence
exam and inv for rectal prolapse
Examination • Visible prolapse: brought out on straining • ± excoriation and ulceration • ↓ sphincter tone on PR • Assoc. uterovaginal prolapse
Ix • Sigmoidoscopy to exclude proximal lesions • Anal manometry • Endoanal US • MRI
treating rectal prolapse
Partial Prolapse
• Phenol injection
• Rubber band ligation
• Surgery: Delorme’s Procedure
Complete Prolapse
• Conservative
- Pelvic floor exercises
- Stool softeners
• Surgery
Abdominal Approach: Rectopexy
- Lap or open
- Mobilised rectum fixed to sacrum +/- mesh
Perineal Approach: Delorme’s Procedure
- Resect mucosa and suture the two
mucosal boundaries
