Pictures of surgical procedures are from youtube video. to watch full video, go to the link copied on the "references" slide.

1. ANAL &
PERIANAL
DISEASE (PART 2)
NUR HANISAH BINTI ZAINOREN

2. Contents
ANAL FISSURE
PRURITUS ANI
ANORECTAL ABSCESS
FISTULA-IN-ANO
HIDRADENITIS SUPPURATIVA
ANAL WARTS
ANAL INTRAEPITHELIAL NEOPLASIA (ANI)
ANAL STENOSIS
MALIGNANT TUMORS

3. ANAL FISSURE
A longitudinal split in the anoderm of the distal anal canal,
which extends from the anal verge proximally towards, but
not beyond the dentate line
(SYN: FISSURE-IN-ANO)

4. • Superficial, small but distressing lesion
• Fissure ends below the dentate line
• Commonly occurs in the midline, posteriorly or
anteriorly

5. • Causes
• Trauma  strained evacuation of a hard stool
(acute) Repeated passage of diarrhea (less common)
• Posterior anal fissure  perhaps relates to the
exaggerated shearing forces acting at that site during
defecation
• Anterior anal fissure  common in females (10:1) due to
lack of support to pelvic floor (following vaginal delivery)

6. • Clinical features
• Constipation
• Severe anal pain on defecation
• Passage of fresh blood (bright red)
• Chronic fissure; characterized by:
• Hypertrophied anal papilla internally & sentinel tag
exernally (both consequent upon attempts at healing and
breakdown)
• Between them, lies the slightly indurated anal ulcer
overlying the fibres of the internal sphincter
(felt as button like depression)
• Patient may have itching secondary to irritation from the
sentinel tag
• Discharge from the ulcer or asst. intersphincteric fistula

7. • Sentinel tag
• ‘Sentinel’ means guard
• Commonly associated with fissure-in-ano of chronic
type, wherein, in the lower part of fissure, skin enlarges
and appears like guarding the fissure
• Can cause perianal haematoma, abscess formation, and
discomfort
• Chronic fissure is treated along with excision of sentinel
pile

8. • Differential diagnosis
• Carcinoma anal canal
• Inflammatory bowel disease
• Venereal diseases
• Anal chancre
• Tuberculous ulcer
• Proctalgia fugax

9. • Treatment
• Conservative management:
• Adequate fluid intake (6-8 glasses of liquid)
• Fiber rich diet (vegetables, fruits, brown rice)
• Bulk forming agents (psyllium husk, bran)
• Stool softeners (lactulose)
• Local anaesthetic agents (lignocaine 5%)
• Pharmacological agents (commonly nitric oxide donors)
 Reducing spasm to relieve pain
 Increase vascular perfusion to promote healing
• Sitz bath
• Operative measures:
1. Lateral anal sphincterotomy
2. Anal advancement flap

10. Lateral Anal Sphincterotomy

11. Lateral Anal Sphincterotomy

12. Lateral Anal Sphincterotomy

13. PRURITUS ANI
Intractable itching in and around the anus

14. • Common, embarrasing condition
• Skin is reddened, hyperkeratotic, cracked & moist
• Causes:
• Poor hygiene
• Anal discharge (due to
fissure/fistula/piles/warts/polyps)
• Trichomonas vaginalis infection (females)
• Parasites
• Epidermophytosis
• Allergic cause
• Skin diseases -Dermatitis/psoriasis
• Diabetes mellitus
• Psychological cause

15. • Treatment
• Proper cause should be assessed and treated
• Symptomatic treatment includes:
• Hygiene measures: toilet papercotton wool; soapwater;
rubpat-dried; cotton underwear; calamine lotion; shaving
• Hydrocortisone: only in patients with dermatitis
• Strapping of the buttocks
*Surgery is only indicated if there’s a lesion of the
anorectum that is thought to initiate/contribute to the
pruritus

16. ANORECTAL ABSCESS
infected cavity filled with pus found near the anus or rectum

17. • Usually produces a painful, throbbing swelling in
the anal region
• Patient often has swinging pyrexia
• Subdivided according to anatomical site into
perianal, ischiorectal, submucous and pelvirectal

18. • Acute sepsis in the region of the anus is common
• Underlying conditionts include
• Fistula-in-ano (most common)
• Crohn’s disease
• Infected hematoma
• Foreign body/trauma
• Diabetes
• Immunosuppression
• Treatmentdrainage of pus + antibiotics

19. FISTULA-IN-ANO
Fistula-in-ano/anal fistula is a chronic abnormal
communication which runs outwards from the anorectal
lumen (the internal opening) to an external opening on the
skin of the perineum or buttock or vagina (women, rare)

20. • May be found in specific conditions like:
• Crohn’s disease
• Tuberculosis
• Lymphogranuloma venereum
• Actinomycosis
• Rectal duplication
• Foreign body
• Malignancy

21. Types of Anal Fistula

22. • Clinical assessment:
• Determine the:
• Site of internal opening
• Site of external opening
• Presence of secondary extensions
• Presence of other conditions complicating the fistula
• Goodsall’s ruleused to indicate the likely position of
the int. opening according to position of the ext.
opening (HELPFUL BUT NOT INFALLIBLE!)
• Probing in an awake patient is painful, unhelpful,
dangerous

24. • Full examination under anaesthesia should be repeated
before surgical intervention
• To demonstrate the site of internal opening:
• Instillation of hydrogen peroxide via the external opening
• Gentle use of probes and a finger in the anorectum
 usually delineates primary and seconday tracks
& their relation to the sphincter

25. fistulotomy

27. fistulectomy

30. Setons

32. HIDRADENITIS
SUPPURATIVA
A chronic suppurative condition of apocrine gland-bearing
skin and is a source of considerable physical and psychological
morbidity

34. • Presentation
• Not seen before puberty, rare after 4th decade of life
• 3x more common in women than men
• Obesity is a common association
• Lesion begin as multiple raised boils, with recurrent
lesion within the same area leading to sinus tract
formation
• Treatment
• In early stages, general measures:
• Weight reduction
• Antiseptic soaps
• Surgical intervention ranges from simple I&D to radical
excision of all apocrine gland-bearing skin  req.
closure by skin graft/rotation flap

35. ANAL WARTS
(CONDYLOMATA ACCUMINATA)
Most common sexually transmitted anal disease.

36. It is caused by Human Papilloma Virus(HPV)
Increase incidence in:
• sexual promiscuity (esp. anal intercourse)
• immunocompromised individual (HIV-infected
individuals, transplant recipients)

37. • Presentation
• Many are asymptomatic
• Pruritus, discharge, bleeding & pain are usual presenting
complaints
• Penile warts or female genital warts may be present
• Treatment
• Local application of 25% podophyllin cream
• Surgical excision under local/regional/general
anaesthesia

38. ANAL
INTRAEPITHELIAL
NEOPLASIA (ANI)
Multifocal virally induced dysplasia of the perianal /intra-anal
epidermis which is aassociated with HPV

39. • Prevalence: <1% of the population, with a rising
incidence esp. in area where anoreceptive
intercourse & HIV are prevalent
• At-risk group:
• HIV patients
• Immunocompromised patients
• Patients with extensive anogenital condylomata
• Women with h/o other genital intraepithelial neoplasia
(VIN & CIN)

40. ANAL STENOSIS

41. • May be spasmodic or organic
• Spasmodic:
• Anal fissure causes spasm of the anal sphincter
• Organic:
• Postoperative stricture (hemorrhoidectomy)
• Irradiation stricture (chemoradiation for anal carcinoma/
pelvic tumors)
• Senile anal stenosis
• Inflammatory bowel disease (Crohn’s/UC)
• Neoplastic
• Treatment:
• Biopsy must be taken to rule out malignancy
• Can usually be managed by regular dilatation
• Severe anal stenosis may require an anoplasty

42. MALIGNANT TUMOR
Rare!
Accounts for <2% of all large bowel cancers

43. • Rare
• Incidence rate is 0.65 per 100,000
• Usually a squamous cell carcinoma
• Associated with HPV
• More prevalence in patient with HIV infection
• May affect anal verge or anal canal
• Lymphatic spread is to inguinal LN
• Treatment: chemotherapy
• Major ablative surgery is required if the above fails

44. References
• Bailey & Love’s Short Practice of Surgery, 26th Edition
• SRB’s Manual of Surgery, 4th Edition
• Videos:
• https://www.youtube.com/watch?v=JnsWuMJJysg
(fistulotomy)
• https://www.youtube.com/watch?v=PsYnEXGxf-
M&oref=https%3A%2F%2Fwww.youtube.com%2Fwatch%3
Fv%3DPsYnEXGxf-M&has_verified=1 (fistulectomy)
• https://www.youtube.com/watch?v=qn2_Krasyr0 (anal
fissure)

45. THANK YOU