Prolapse Of The Rectum And Chronic Proctologic Diseases

Question 1

Rectal prolapse syndrome (prolapse of the rectum)

Answer 1

Protrusion, through the anal canal, of the rectal tissue layers or protrusion of abnormal formations/elements located in distal rectum.

In the presence of the rectal prolapse syndrome, physical examination, digital rectal and perianal area examinations allow to formulate clinical diagnosis and define treatment approach.

The most commonly it is reported for the rectal prolapse and chronic hemorrhoids.

Question 2

Definition: Rectal prolapse

Answer 2

Protrusion of either the rectal mucosa or the entire wall of the rectum through the anal canal.

Question 3

Types of protrusion of the rectum through the anal canal:

Answer 3

А) Mucosal prolapse or full-thickness rectal prolapse

B) Prolapse of hemorrhoids through the anal canal.

Question 4

Clinical signs of the rectal prolapse:

Answer 4

A) Complaints:

• protrusion of different in size formations through the anal canal;
• rectal bleeding and mucus discharge through the anal canal.

B) Anamnesis:

• hard manual labor;
• parturition in women;
• constipations.

C) Objective signs:

а) physical examination: (performed when patient is straining in the squatting position)

• visual assessment of the protruded bowel dimensions;
• presence of changes in the rectal mucosal membrane (erosions, uclers, mucus, blood);

b) palpation:
- digital rectal examination;
- palpation of the prolapsing part of the rectum.

Question 5

Diagnosis of the rectum prolapse:

Answer 5

Clinical signs:

a) complaints
b) case history;
c) objective signs.

A) Physical examination and palpation of the prolapsing rectum:

• during the examination a patient is squatting or positioned on the left side with the knees close to the chest (the patient is asked to strain and the prolapsed rectum dimensions are visually assessed);
• palpation of the protruded rectum is performed;
• the bowel is manually reducted and digital examination of the anal sphincter (its passive and active tone) is performed.

B) Instrumental methods of examination:

• sigmoidoscopy;
• proctography;
• radiography of sacrum and coccyx.
• Rectal speculum examination.

Question 6

The rectal prolapse treatment principles:

Answer 6

A) Surgery is indicated for treatment of the rectum prolapse or prolapse of the rectal mucosapathologic
elements.

B) Extent of surgery is depended on the nature of the pathology.

Question 7

Causes of the rectal prolapse:

Answer 7

А) Elevated intraabdominal pressure:

• hard manual labor;
• difficult delivery;
• constipation.

B) Damage of ligamentous apparatus of the rectum caused by traumas.

С) Disturbance and weaking of connection between mucous membrane and muscular layer of the rectum, as a result of inflammatory processes.

D) Anatomic and constitutional peculiarities of pelvis, rectum and ligamentous apparatus of the rectum:

• flattening of sacrococcygeal curvature;
• lenghthened sigmoid colon (pelvic colon) and mesosigmoid;
• mesorectum;
• pelvic floor muscle weakness.

Question 8

Types of the rectum prolapse

Answer 8

А) Prolapse of the anal canal mucosal membrane (three degrees of severity):

• first degree the mucosa is protruding during the defecation and self-reducted;
• second degree the mucosal membrane is protruding during defecation and significant straining efforts, requires manually assisted reduction;
• third degree the mucosal membrane is protruding during lightintensity physical activities and requires manual reduction.

B) Prolapse of the rectum (three degrees of severity):

• first degree - rectal segment, up to 5cm long, is protruding during defecation; self reducted; little erosions in the mucosal membrane; diminished sphincter tone;
• second degree - 6-10 cm long rectal segment is protruding during physical activity; requires manual reduction; the mucosal membrane is edematous and eroded, local ulcers occur; sphincter relaxed;
• third degree - rectal segment longer than 10cm is protruding in a vertical/upright position of a patient; the bowel is not self reducted and protruding again after manual reduction in upright position, the mucosal membrane is ulcered and bleeding; anus is incompletely closed.

Question 9

Clinic-statistical classification of the rectal prolapse:

Answer 9

ICD10 Diagnosis Code К62.2 Anal prolapse
Layout of clinical diagnosis: {SXdegree} prolapse of the rectal mucosal prolapse

Degree of severity:
S1 1st degree
(Selfreducted protrusion of the rectal mucosa during defecation)

S2 2nd degree
(Protrusion of the rectal mucosal membrane during defecation and vigorous physical activities, not self-reducted, requires manually assisted reduction)

S3 3rd degree
(The mucosal membrane is protruding during light-intensity physical activities and requires manual reduction)

К62.3 Rectal prolapse
Layout of clinical diagnosis: {SXdegree} rectal prolapse {, due to EX} {complicated
with CX}

Degree of severity:

S1 1st degree
(Protrusion of the rectum during defecation, up to 5cm long; selfreducted; little erosions in the mucosal membrane; diminished sphincter tone)

S2 2nd degree
(Protrusion of the rectum during physical activities, 6-10cm long; manually reducted; the mucosal membrane is edematous and eroded, with local ulcers; anal sphincter relaxed)

S3 3rd degree
(Protrusion of the rectum in vertical/upright position of the patient, longer than 10cm; the bowel is not self-reducted and protruding again after manual reduction when recovering upright position; the mucosal membrane is ulcered and bleeding; anus is
incompletely closed)

Causes of the disease:
E1 elevated intraabdominal pressure
E2 pelvic floor muscle insufficiency
E3 insufficiency of ligamentous apparatus of the rectum

Complications:
C1 stangulation of the rectum
C2 strangulation and necrosis of the rectum
C3 rupture of the rectum

Question 10

Management of the rectal prolapse:

Answer 10

A) Treatment of rectal mucosal prolapse:

• normalization of diet (elimination of constipations and diarrhoeas);
• sphincterolevatoroplasty, in case of anal sphincter insufficiency (fecal incontinence);
• circular excision of rectal mucosa with suturing, in case of rectal mucosal prolapse and necessity
  of its manual reduction.

B) Treatment of rectal prolapse - surgical:

• fixation of the rectum to the sacral periosteum by means of alloplastics, in case of any severity of rectal prolapse with preserved function of the anal sphincter;
• fixation of the rectum by means of alloplastics is supplemented with sphincterolevatoroplasty, in case of rectal prolapse and insufficiency of the anal sphincter

Question 11

Definition: Chronic hemorrhoids

Answer 11

Enlarged or dilated cavernous bodies of the rectum that protrude through the anal canal and require manual reduction.

Question 12

Risk factors:

Chronic hemorrhoids

Answer 12

A) Congenital insufficiency of connective tissue in submucosal layer of the rectum, forming internal hemorrhoids.

B) Hard manual labor.

C) Works that require a lot of standing.

D) Pregnancy.

E) Chronic constipation.

Question 13

Classification of hemorrhoids

Chronic

Answer 13

A) External hemorrhoids.

B) Internal hemorrhoids.

C) Mixed or combined hemorrhoids (presence of both external and internal hemorrhoids).

Question 14

Clinical signs of chronic hemorrhoids

Answer 14

(depend on degree of severity):

• First degree of severity:

a) complaints:
- perianal itching;
- discomfort, sometimes feeling of foreign body in the rectum;
- possible bleeding during or straight after defecation;

b) visual examination, palpation:
- hemorrhoids are identified in the rectal cavity;
- soft-elastic consistency of the formations;
- painless on palpation.

• Second degree of severity:

а) complaints:

• hemorrhoids are protruding during defecation and capable of being spontaneously reduced;
• bleedings become almost continuous;
• exacerbation of the disease is possible after alcohol and hot and spicy food intake;

b) visual examination, palpation:
- hemorrhoids are protruding during straining efforts and manually reduced;
- soft-elastic consistency and painless on palpation.

• Third degree of severity:
a) complaints:
- hemorrhoids are protruding during straining efforts,
defecation, physical activity and manually reduced;
- mucus discharge from the rectum;

b) visual examination, palpation:
- hemorrhoids are protruding during straining efforts, defecation, physical activity and manually reduced;
- maceration and perianal inflammations;
- diminished rectal sphincter tone.

• Fourth degree of severity:
а) complaints:
- hemorrhoids are protruding with the slightest physical activity and irreducible (protruding again straight after manual reduction);
- incontinence of flatus and faeces;

b) visual examination, palpation:
- hemorrhoids are protruding with the slightest physical activity and irreducible (protruding again straight after manual reduction);
- protrusion of the piles is accompanied by protrusion of the mucosal membrane of the anal canal;
- anal sphincter tone decrease

Question 15

Preliminary diagnosis based on the clinical findings

chronic hemorrhoids

Answer 15

Provisional diagnosis is based on the patient complaints, anamnesis and objective signs of disease confirmed by physical methods of examination.

Question 16

Diagnosis

chronic hemorrhoids

Answer 16

Instrumental methods of examination:

• rectal speculum examination;
• sigmoidoscopy.

Question 17

Differential diagnosis of chronic hemorrhoids:

Answer 17

Differentiation from rectal diseases:

• rectal tumor;
• rectal polypus;
• rectal mucosal membrane prolapse

Question 18

Clinic-statistical classification of chronic hemorrhoids:

Answer 18

ICD10 code I84 Hemorrhoids
Layout of clinical diagnosis: Chronic {LX} hemorrhoids {in stage of ХX}, {complicated with OX}

Localization:
L1 internal
L2 external
L2 mixed

Course of disease:

Х1 remission {SX degree of severity}
Degree of severity:

S1 1st degree (no prolapse, hemorrhoids stay inside the anal canal)

S2 2nd degree (hemorrhoids protrude on straining efforts, defecation; spontaneously reducible)

S3 3rd degree (hemorrhoids protrude on straining efforts, defecation and light physical activity; require manually assisted reduction)

S4 4th degree (hemorrhoids protrusion at rest, spontaneously irreducible, piles protrude straight after manual reduction)

Х2 exacerbation {QX}

Clinical signs:
Q1 trombosed hemorrhoids without inflammation
Q2 trombosed hemorrhoids with inflammation
Q3 necrotic hemorrhoids, inflammation of skin and subcutaneous tissue

Complications:
O1 chronic bleeding, {hemorrhage TX}
O2 acute bleeding, {hemorrhage TX}

Question 19

Management of chronic hemorrhoids:

Answer 19

А) Conservative treatment (1-2 degree of severity):

a) normalization of digestive system functioning (regulation of intestinal contents consistency and its large intestinal transit);
b) toilet of perianal area after each defecation act;

c) local treatment:
- phlebotropic drugs (detralex, deflon, diomin, hesperidin);
- anesthetics (suppositories and ointments – ultraproct, posterisan, proctoglyvenol, nefluan).

B) Surgical treatment:

• for 1-2 degree hemorrhoids: minimally invasive surgical methods:

• rubber band ligation of hemorrhoids;
• infrared coagulation of hemorrhoids;
• cryotherapy of hemorrhoids;
• sclerotherapy of hemorrhoids;
• bipolar electrocoagulation of hemorrhoids;

• for 3-4 degree hemorrhoids: hemorrhoidectomy

Question 20

Work capacity examination and rehabilitation of patients:

chronic hemorrhoids

Answer 20

A) Work capacity restoration in 15-20 days after surgery.

B) Patients suffering from chronic hemorrhoids and operated in that regard require normalization of the factors that contribute to disease progression or relapse.

Question 21

Chronical pain syndrome in the area of the anal canal

Answer 21

Conditioned by a range of chronic slowly developing proctologic diseases or as consequence of past acute pathologic processes.

Analysis of clinical signs of the disease and examination of the perianal area and rectum allows to formulate clinical diagnose and choose treatment approach.

The most commonly this condition is observed in case of 1st-2nd degree chronic hemorrhoids, chronic rectal fissure, rectal fistulas, epithelial coccygeal ducts.

Question 22

Definition: pain syndrome in the area of the anal canal

Answer 22

The conditions are referred to chronical proctologic pathology and characterized by the pain syndrome and discomfort in the rectal area, anal canal and perianal areas.

Question 23

Clinical signs of chronic diseases of the anal canal and perianal area:

Answer 23

А) Complaints:

• pain in the anal canal and perianal areas;
• pain increase after defecation;
• rectal bleeding and mucus discharge from the rectum.

B) Anamnesis:

• assessment of clinical course of the disease;
• acute conditions of the anal canal and perianal area in past history.

C) Objective signs:

a) visual examination:
- visual change of the skin around the anal canal;
- visual detection of fistulous openings, hemorrhoids, skin maceration, tumorlike masses;

b) palpation:
- digital examination of the rectum;
- palpation of soft tissues of the perianal area

Question 24

Diagnosis

chronic diseases of the anal canal and perianal area

Answer 24

– rectal speculum examination;

– sigmoidoscopy;

– colonoscopy;

– in case of rectal fistula, epithelial coccygeal ducts – probe investigation of the fistulas, contrast radiography of fistulas (fistulography).

Question 25

Treatment program for chronic proctologic diseases of the anal canal and perianal area:

Answer 25

Choice of treatment method is conditioned by nature of the identified pathology.

Question 26

Definition: Anal fissures

Answer 26

Defects of mucosal membrane of the anal canal of linear or trigonous shape with indurated edges

Question 27

Causes of chronic anal fissure development:

Answer 27

A) Mechanical causes:
- traumatization of the mucosal membrane caused by fecal masses.

B) Infectious causes:

• nonspecific inflammation of the anal glands located in the rectal crypts, with development of fibrous tissue, decrease in elasticity of tissues and formation of fissures;
• specific inflammation with formation of fissures (syphilis, tuberculosis).

Question 28

Clinical signs of chronic anal fissure:

Answer 28

A) Complaints:

а) pain:

• increases during or after defecation;
• irradiates into perineum, genitals, urinary bladder;
• accompanied by dysuric disorders in men and dysmenorrhea in women;

b) anal sphincter spasm;

c) blood in faeces is possible:
- during or after defecation;
- bright red blood color;
- small amount of blood emerging as blood stripes in faeces in accordance with location of the fissure.

B) Anamnesis:

a) continual occurrence of the fissure;

b) defecation disorders (constipations,
diarrheas) ;

c) alcohol abuse.

C) Objective signs:

а) visual examination:

• performed in knee-elbow position with slight straining efforts of the patient (anus goes down that allows visual examination of external part of the fissure);
• physician opens the anal orifice with the help of napkins for better examination of the anal canal.

Question 29

Preliminary diagnosis

Anal Fissure

Answer 29

Preliminary diagnosis is based on the patient complaints, anamnesis and objective signs of disease confirmed by physical methods of examination

Question 30

Diagnosis:

Anal Fissure

Answer 30

A) Laboratory examination:

a) CBC;
b) urinnalysis.

B) Instrumental examination:
a) rectal speculum examination of anal canal and rectum.

Question 31

Differential diagnosis:

Anal Fissure

Answer 31

Includes diseases of the rectum:

• coccygodynia
• anal form of ulcerative colitis;
• Crohn’s disease;
• anal form of rectal cancer

Question 32

clinic-statistical classification of anal fissure:

Answer 32

ICD10 Diagnosis Code К60.1 Anal fissure
Layout of clinical diagnosis: {XX} anal fissure, {FX,} {LX localization,} {QX,}
{complicated by OX}

Course of disease:
X1 Acute
X2 Chronic

Stage of the process:
F1 newly diagnosed
F2 recurrent

Localization:
L1  anterior
L2  posterior
L3  leftsided
L4  rightsided
L5  multiple

Clinical signs:
Q1 with anal sphincter spasm
Q2 without anal sphincter spasm

Complications:
O1 periproctitis/perirectitis/paraproctitis
O2 anemia

Question 33

Management of chronic anal fissure:

Answer 33

А) Conservative treatment:

a) normalization of digestion (elimination of constipations, diarrheas);
– elimination of spicy, salty and smoked foods;
– ingestion of foods that normalize defecation;

b) drug therapy:
– spasmolytics;
– anaesthetics;
– fatty microenemas, antiseptics (rectal administration);
– suppositories (containing belladonna, anesthesin);

c) physiotherapy:
– thermal procedures (baths, hotwater bags);
– d’arsonvalization, UHF therapy, diathermy, laser therapy.

B) Surgical treatment:

a) indications for surgical treatment:
– ineffectiveness of drug therapy;
– bleeding;
– fistulas;

b) surgical methods:
– excision of the fissure in longitudinal direction and suture of the defect in transverse direction

Question 34

Work capacity examination and rehabilitation of patients:

Anal Fissure

Answer 34

A) Disability to work lasts 7–10 days until healing of fissure by conservative measures; ability to work is restored in the course of three weeks after surgery.

B) Dieting and normalization of defecation (prevention of constipations)

Question 35

Definition: Rectal fistula

Answer 35

The presense fistula tract between rectum and perianal area in consequence of endured inflammatory process in perirectal fat.

Question 36

Causes of rectal fistulas development:

Answer 36

A) Chronic proctologic pathology accompanied by traumatization of the rectal wall.

B) Acute paraproctitis.

Question 37

Types and localization of rectal fistulas

Answer 37

1) rectal ampulla;
2) intrasphincteric (submucous) fistula;
3) transsphincteric fistula;
4) extrasphinteric fistula;
5) extrasphincteric complex fistula;
6) anal sphincter

Question 38

Clinical signs of rectal fistulas:

Answer 38

A) Complaints:

a) occurrence of fistulous openings in perianal area:
- purulent discharge from the fistula;
- periodical closing of the fistula with subsequent exacerbation of inflammatory process;

b) perianal itching.

B) Visual examination:

a) fistulas in perianal area;
b) asymmetry of perianal area.

C) Palpation:

a) palpation allows to detect direction of fistulous tract and potential localization of its internal opening;
b) pus discharge from fistula is possible under pressing in projection of fistulous tract;
c) on digital rectal examination approximate localization of internal fistulous opening may be discovered.

Question 39

Preliminary diagnosis:

rectal fistulas

Answer 39

Preliminary diagnosis is based on the patient complaints, anamnesis and objective signs of disease confirmed by physical methods of examination.

Question 40

Diagnosis:

Rectal fistulas

Answer 40

Instrumental methods of examination:

• rectal speculum examination;
• sigmoidoscopy;
• color test with 1% methylene blue solution (the rectum is tamponed and staining agent is injected into external fistulous opening; location of the staining agent on the tampon determines localization of internal fistulous opening);
• probing of the rectal fistula with metal probe to determine fistulous tract direction in relation to sphincter
• contrast fistulography.

Question 41

Differential diagnosis:

Rectal fistulas

Answer 41

• pilonidal sinuses;
• congenital cysts of paraproctium;
• Corhn’s disease;
• fistulas of specific etiology (tuberculosis, syphilis, actinomycosis).

Question 42

Clinic-statistical classification of the rectal fistulas:

Answer 42

Clinicstatistical classification of the rectal fistulas:
ICD10 Diagnosis Code К60.4 Rectal fistula
Layout of clinical diagnosis: {BX {RX}} rectal fistula

Type:

B1 complete / amphibolic
B2 internal
B3 blind

Prevalence of the process:

R1– simple {Lх}
Localization:
L1 (intrasphincteric)
L2 (transsphincteric)

R2 complex extrasphincteric ({TX degree. })

Degree of severity:

(T1) 1 degree
(narrow internal opening without surrounding cicatricial process, abscesses and infiltrations in the perianal fatty spase)

(T2) 2 degree
(narrow or wide internal opening, but without inflammatory changes in fatty spases)

(T3) 3 degree
(narrow internal opening without cicatrical process around fistula but with occurrence of purulent inflammatory changes in the perirectal fat)

(T4) 4 degree
(wide internal opening with inflammatory infiltration or purulent cavities)

Question 43

Treatment of the rectal fistulas

Answer 43

Surgical.

Choice of surgical method depends on relation of the fistula to sphincteric apparatus:

• for transsphincteric or extraspincteric fistulas ligature method is applied;
• for subdermalsubmucosal fistulas- fistulectomy (excision of the fistula) on probe according to Gabriel.

Question 44

Work capacity examination and rehabilitation of patients:

rectal fistulas

Answer 44

А) Temporary incapacity to work comes to 3-4 weeks after surgery till the wound healing.

B) Dieting and defecation normalization (prevention of constipations).

Question 45

Definition: Pilonidal sinuses

Answer 45

Located in intergluteal region above sacrum and coccyx and made up of tubular formations paved with stratified squamous epithelium and opened by one or several fistulous openings in skin.

Question 46

Causes of occurrence of pilonidal sinuses

Answer 46

congenital development defects:

• abnormal hair ingrowth;
• remnant of spinal chorda;
• disorder of reduction of coccygeal vertebras.

Question 47

Clinical signs depend on the disease course:

pilonidal sinuses

Answer 47

А) Without clinical signs (accidental finding of sinus openings during medical examination):

а) visual examination:

• one or two sinus openings in distal part of intergluteal fold near apex of coccyx above border of anal region
• diameter of openings from 1 to 3 mm;
• hair growth from openings is possible;
  b) palpation: under pressing above fistula turbid or purulent fluid discharge from the opening is possible.

B) Acute course of disease:

a) common features of inflammation: body temperature 39-40 °C, fever;

b) local signs of inflammation:
- pain in intergluteal region, intensive, radiating into the rectum;
- swelling and infiltration in intergluteal region;
- hyperemia of skin above infiltration;
- possible fluctuation above infiltration;
- possible spreading of inflammatory process into perirectal fat.

C) Chronic course of disease:

• recurrent course;
• purulent discharge from fistula.

Question 48

Preliminary diagnosis

pilonidal sinuses

Answer 48

Preliminary diagnosis is based on the patient complaints, anamnesis and objective signs of disease confirmed by physical methods of examination.

Question 49

Diagnosis:

pilonidal sinuses

Answer 49

А) Rectal speculum examination.

B) Sigmoidoscopy.

C) Contrast fistulography

Question 50

Differential diagnosis:

pilonidal sinuses

Answer 50

• congenital cysts of pararectal fat;
• chronic periproctitis;
• fistulas of specific etiology (tuberculosis, syphilis, actinomycosis).

Question 51

Clinics-tatistical classification

pilonidal sinuses

Answer 51

ICD10 Diagnosis Code L05.0 Pilonidal sinuse
Formula of clinical diagnosis: Pilonidal sinuse {ХX} {complicated by OX}

Course of disease:
Х1 without clinical signs
Х2 acute
Х3 chronic

Complications:
O1 abscess of intergluteal region
O2 phlegmon of intergluteal region
O3 phlegmon of perirectal fatty spases.

Question 52

Treatment of pilonidal sinus:

Answer 52

Surgical treatment:

а) pilonidal sinuses without clinical signs - elective surgery: excision of pilonidal sinuses;

b) pilonidal sinuses, acute course - urgent operation: drenage of the abscess ;
c) pilonidal sinuses, chronic course - elective surgery: excision of pilonidal sinuses after sanation of chronic purulent focci.

Question 53

Work capacity examination and rehabilitation of patients:

pilonidal sinuses

Answer 53

Temporary disability lasts 10-15 days until wound healing.

Question 54

Causes of the pain syndrome development in perianal area:

Answer 54

A) Chronic hemorrhoids.

B) Chronic rectal fissure.

C) Rectal fistulas.

D) Epithelial coccygeal ducts.

E) Perianal condylamas