Ahmad kachooei Assistant Professor of Qom Medical University

Ahmad kachooei
Assistant Professor of Qom Medical University
 Any patient with anal/perianal symptoms requires a
careful history and physical, including a digital rectal
 defecography, manometry, CT scan, MRI, contrast
enema, endoscopy, endoanal ultrasound, or
examination under anesthesia may be required to
arrive at an accurate diagnosis
 Hemorrhoids are cushions of submucosal tissue
containing venules, arterioles, and smooth-muscle
fibers .
 Three hemorrhoidal cushions :
1. left lateral
2. right anterior
3. right posterior
 continence mechanism
 aid in complete closure of the anal canal at rest
 Because hemorrhoids are a normal part of anorectal
anatomy, treatment is only indicated if they become
 Excessive straining
 increased abdominal pressure
 hard stools
 External hemorrhoids are located distal to the dentate
line and are covered with anoderm
 Internal hemorrhoids are located proximal to the
dentate line and covered by insensate anorectal
 Graded according to the extent of prolapse:
First-degree hemorrhoids bulge into the anal canal
and may prolapse beyond the dentate line on
Second-degree hemorrhoids prolapse through the
anus but reduce spontaneously
Third-degree hemorrhoids prolapse through the anal
canal and require manual reduction.
Fourth-degree hemorrhoids prolapse but cannot be
reduced and are at risk for strangulation
 Combined internal and external hemorrhoids straddle
the dentate line and have characteristics of both
internal and external hemorrhoids
 Hemorrhoidectomy often is required for large,
symptomatic, combined hemorrhoids.
 result from straining during labor, which results in
edema, thrombosis, and/or strangulation.
 Hemorrhoidectomy is often the treatment of choice,
especially if the patient has had chronic hemorrhoidal
 Medical Therapy:
 Bleeding from first- and second-degree hemorrhoids
often improves with the addition of dietary fiber, stool
softeners, increased fluid intake, and avoidance of
 Associated pruritus may often improve with improved
 Rubber Band Ligation
 Infrared Photocoagulation
 Sclerotherapy
 Excision of Thrombosed External Hemorrhoids
 Closed Submucosal Hemorrhoidectomy
 Open Hemorrhoidectomy
 Whitehead's Hemorrhoidectomy
 Procedure for Prolapse and Hemorrhoids/Stapled
 Postoperative pain
 Urinary retention
 fecal impaction
 Bleeding
 Infection
 Incontinence
 anal stenosis
 ectropion (Whitehead's deformity)
 A fissure in ano is a tear in the anoderm distal to the
dentate line.
 The vast majority of anal fissures occur in the posterior
midline. Ten to 15% occur in the anterior midline.
 Less than 1% of fissures occur off midline
 trauma from either the passage of hard stool or
prolonged diarrhea.
 This cycle of pain, spasm, and ischemia contributes to
development of a poorly healing wound that becomes
a chronic fissure.
 extremely common
 tearing pain with defecation and hematochezia
(usually described as blood on the toilet paper)
 painful anal spasm lasting for several hours after a
bowel movement
 can be seen in the anoderm by gently separating the
 Patients are often too tender to tolerate digital rectal
 An acute fissure is a superficial tear of the distal
anoderm and almost always heals with medical
 Chronic fissures develop ulceration and heaped-up
edges with the white fibers of the internal anal
sphincter visible at the base of the ulcer.
 There often is an associated external skin tag and/or a
hypertrophied anal papilla internally.
 A lateral location of a chronic anal fissure may be
evidence of an underlying disease such as Crohn's
disease, HIV, syphilis, tuberculosis, or leukemia.
 If the diagnosis is in doubt or there is suspicion of
another cause for the perianal pain, such as abscess or
fistula, an examination under anesthesia may be
 Therapy focuses on breaking the cycle of pain, spasm,
and ischemia
 First-line therapy to minimize anal trauma includes
bulk agents, stool softeners, and warm sitz baths
 The addition of 2% lidocaine jelly or other analgesic
creams can provide additional symptomatic relief.
 Nitroglycerin ointment (0.2%)
 Both oral and topical calcium channel blockers
(diltiazem and nifedipine)
 arginine (a nitric oxide donor)
 topical bethanechol (a muscarinic agonist)
 Medical therapy is effective in most acute fissures, but
will heal only approximately 50 to 60% of chronic
 Botulinum toxin (Botox)
Surgical therapy: traditionally has been recommended
for chronic fissures that have failed medical therapy
 Approximately 30% of the internal sphincter fibers are
divided laterally
 Healing is achieved in more than 95% of patients by
using this technique
 The majority of anorectal suppurative disease results
from infections of the anal glands (cryptoglandular
 Their ducts traverse the internal sphincter and empty
into the anal crypts at the level of the dentate line
perianal space
2. intersphincteric space
3. ischiorectal space (ischiorectal fossa)
4. supralevator spaces
perianal abscess
2. ischiorectal abscess
3. Intersphincteric abscesses
4. supralevator abscesses
 Severe anal pain
 Walking, coughing, or straining can aggravate the pain
 Palpable mass
 fever
 urinary retention
 life-threatening sepsis
 Drainage as soon as the diagnosis is established
 diagnosis is in question:an examination under
 Antibiotics :
1. extensive overlying cellulitis
2. Immunocompromised
3. diabetes mellitus
4. valvular heart disease
 Drainage of an anorectal abscess results in cure for
about 50% of patients.
 The fistula usually originates in the infected crypt
(internal opening) and tracks to the external opening,
usually the site of prior drainage.
 Patients present with persistent drainage from the
internal and/or external openings.
 An indurated tract often is palpable
 Goodsall's rule can be used as a guide in determining
the location of the internal opening .
tracks through the distal internal sphincter
and intersphincteric space to an external
opening near the anal verge
often results from an ischiorectal abscess
and extends through both the internal and
external sphincters
originates in the intersphincteric plane and
tracks up and around the entire external
originates in the rectal wall and tracks
around both sphincters to exit laterally,
usually in the ischiorectal fossa
 The goal of treatment of fistula in ano is eradication of
sepsis without sacrificing continence.
 Simple intersphincteric fistulas often can be treated by
fistulotomy (opening the fistulous tract), curettage,
and healing by secondary intention
 seton :
Cutting setons
2. noncutting seton
 endorectal advancement flap :Higher fistulas
 Fibrin glue