This document discusses various anorectal disorders including hemorrhoids, anal fissures, anal abscesses, anal fistulas, fecal incontinence, and rectal prolapse. It describes the signs, symptoms, causes, diagnosis, and treatment options for each condition. The treatment approaches include conservative measures, office-based procedures, and surgery depending on the severity of the case. Nursing care focuses on pain management, bowel regimen, dietary changes, hygiene, monitoring for complications, and patient education.

1. Anorectal Disorders
Anorectal disorders are conditions that affect the anus and rectum
area.

2. Types of anorectal disorders
• There are many types of anal and rectal disorders, ranging from
relatively minor issues such as itching or warts to more significant
concerns like pain and incontinence:
• Anal or rectal abscess;
A cavity in the anus or rectum that becomes infected and filled
with pus. Can also lead to anal fissures.

3. • Anal fissure
• Tears or cracks in the anus that result from stretching the anal
canal beyond its normal capacity.
• Anal fistula
• An opening in the skin near the anus that leads into a blind
pouch or may connect through a tunnel with the rectal canal.
Most anal fistulas form in reaction to an anal gland that has
developed an abscess.

4. • Hemorrhoids
• Red and swollen veins or blood vessels in the lower rectum.
Hemorrhoids can be internal or external.
• Fecal incontinence
• Also known as bowel incontinence, fecal incontinence is the
lack of control over bowel movements.
• Rectal prolapse
• Diagnosed when the rectum falls from its normal position and
partially exits the anus. A prolapsed rectum can lead to fecal
incontinence.

5. Hemorrhoid
• Hemorrhoids also known as piles, are vascular structures in
the anal canal.
• In their normal state, they are cushions that help
with stool control.

7. • They become a disease when swollen or inflamed
• Many people feel embarrassed when facing the problem and
often seek medical care only when the case is advanced.

8. • The exact cause of hemorrhoids is unknown.
A number of factors are believed to play a role including
irregular bowel habits (constipation or diarrhea),
lack of exercise,
nutritional factors (low-fiber diets),
increased intra-abdominal pressure (prolonged straining, ascites, an
intra-abdominal mass, or pregnancy),
genetics
aging.

9. Types
• External hemorrhoids
• Internal hemorrhoids

10. Diagnosis
• Physical examination.
A visual examination of the anus and surrounding area may
diagnose external or prolapsed hemorrhoids
• Colonoscopy or sigmoidoscopy is reasonable to confirm the
diagnosis and rule out more serious causes.
• anoscopy

11. Signs and symptoms
External hemorrhoids
• If not thrombosed, external hemorrhoids may cause few problems.
• when thrombosed, hemorrhoids may be very painful.
• swelling.
• Symptoms frequently get better after a few days.
• A skin tag may remain after healing.
• issues with hygiene,
• irritation of the surrounding skin, and thus
• itchiness around the anus.
• If bleeding occurs, it is usually darker

12. A thrombosed external hemorrhoid

13. Internal hemorrhoids
originate above the pectinate line.
• painless,
• bright red rectal bleeding during or following a bowel movement.
• The blood typically covers the stool (a condition known as hematochezia),
is on the toilet paper, or drips into the toilet bowl.
• mucous discharge,
• perianal mass if they prolapse through the anus,
• itchiness,
• fecal incontinence.
• Internal hemorrhoids are usually painful only if they become thrombosed
or necrotic.

14. Internal hemorrhoids were classified in 1985 into four grades based on the
degree of prolapse:
• Grade I:No prolapse, just prominent blood vessels
• Grade II: Prolapse upon bearing down, but spontaneous
reduction
• Grade III: Prolapse upon bearing down requiring manual
reduction
• Grade IV: Prolapse with inability to be manually reduced.

16. Prevention
• A number of preventative measures are recommended, including
• Avoiding straining while attempting to defecate,
• Avoiding constipation and diarrhea either by eating a high-fiber diet
and drinking plenty of fluid or by taking fiber supplements and
• Getting sufficient exercise.
• Spending less time attempting to defecate, avoiding reading while on
the toilet
• losing weight for overweight persons
• Avoiding heavy lifting are also recommended.

17. Management
• conservative management
• increasing fiber intake,
• drinking fluids to maintain hydration,
• NSAIDs to help with pain, and rest.
• Medicated creams may be applied to the area, but their
effectiveness is poorly supported by evidence.
• A number of minor procedures may be performed if symptoms are
severe or do not improve with conservative management.[6]
• Surgery is reserved for those who fail to improve following these
measures.

18. Office-based procedures
1.Rubber band ligation
2.Sclerotherapy
3.cauterization
Surgery
Excisional hemorrhoidectomy

19. Nursing Interventions: for patient with
hemorrhoids
1.After thrombosis or surgery, assist with frequent repositioning using
pillow support for comfort.
2.Provide analgesics, warm sitz baths, or warm compresses to reduce
pain and inflammation.
3.Apply witch-hazel dressing to perianal area or anal creams or
suppositories, if ordered, to relieve discomfort.
4.Observe anal area postoperatively for drainage and bleeding.
5.Administer stool softener or laxative to assist with bowel movements
soon after surgery, to reduce risk of stricture.

20. 6.Teach anal hygiene and measures to control moisture to prevent
itching.
7.Encourage the patient to exercise regularly, follow a high fiber diet,
and have an adequate fluid intake (8 to 10 glasses per day) to avoid
straining and constipation, which predisposes to hemorrhoid formation.
8.Discourage regular use of laxatives; firm, soft stools dilate the anal
canal and decrease stricture formation after surgery.
9.Tell patient to expect a foul-smelling discharge for 7 to 10 days after
cryodestruction.
10.Determine the patient’s normal bowel habits and identify
predisposing factors to educate patient about preventing recurrence of
symptoms.

21. Anal fissure

22. • An anal fissure is a break or tear in the skin of the anal canal.
• may be noticed by bright red anal bleeding on toilet paper and
undergarments, or sometimes in the toilet.
• If acute they are painful after defecation, but with chronic fissures,
pain intensity often reduces.
• Anal fissures usually extend from the anal opening and are usually
located posteriorly in the midline, probably because of the relatively
unsupported nature and poor perfusion of the anal wall in that
location.
• Fissure depth may be superficial or sometimes down to the
underlying sphincter muscle.
• Untreated fissures develop a hood-like skin tag (sentinel piles) which
cover the fissure and cause discomfort and pain.

23. Causes
• Stretching of the anal mucous membrane beyond its capability.
• In adults, fissures may be caused by constipation, the passing of large,
hard stools, or by prolonged diarrhea.
• In older adults, anal fissures may be caused by decreased blood flow to
the area.
• childbirth trauma in women
• anal sex
• Crohn's disease
• Ulcerative colitis

24. • Superficial or shallow anal fissures look much like a paper cut,
and may be hard to detect upon visual inspection; they will
generally self-heal within a couple of weeks.
• However, some anal fissures become chronic and deep and will
not heal. The most common cause of non-healing
is spasming of the internal anal sphincter muscle which results
in impaired blood supply to the anal mucosa. The result is a
non-healing ulcer, which may become infected by fecal bacteria.

25. Diagnosing
• By visual inspection.
• Proctoscope
• Digital rectal examination

26. Prevention
• Avoiding straining when defecating. This includes
• Treating and preventing constipation by
eating food rich in dietary fiber,
drinking enough water,
occasional use of a stool softener, and
avoiding constipating agents.
• prompt treatment of diarrhea may reduce anal strain.
• Careful anal hygiene after defecation, including using soft toilet paper and cleaning with
water, plus the use of sanitary wipes.
• In cases of pre-existing or suspected fissure, use of a lubricating ointment (It is important
to note that hemorrhoid ointment is contraindicated because it constricts small blood
vessels, thus causes a decrease in blood flow, which prevents healing).

27. Treatment
• Non-surgical treatments are recommended initially for acute
and chronic anal fissures.
• These include topical nitroglycerin or calcium channel
blockers (e.g. diltiazem), or injection of botulinum toxin into the
anal sphincter.
• Other measures include warm sitz baths,
• Topical anesthetics,
• High-fiber diet
• Stool softeners

28. Surgery
• lateral sphincterotomy
where the internal anal sphincter muscle is incised aim to
decrease sphincter spasming and thereby restore normal blood
supply to the anal mucosa. Surgical operations involve a general
or regional anesthesia.
• Anal dilation
• Fissurectomy

29. Anal fistula
• Anal fistula is a chronic abnormal communication between
the epithelialized surface of the anal canal and usually the perianal
skin.
• Anal fistulae commonly occur in people with a history of anal
abscesses. They can form when anal abscesses do not heal
properly.
• Anal fistulae originate from the anal glands, which are located
between the internal and external anal sphincter and drain into
the anal canal.
• If the outlet of these glands becomes blocked, an abscess can form
which can eventually extend to the skin surface.
• The tract formed by this process is a fistula.

31. Signs and symptoms
• skin maceration
• pus, serous fluid
• feces discharge — can be bloody or purulent
• pruritus — itching
• Pain
• Swelling
• Tenderness
• fever
•unpleasant odor
• Thick discharge, which keeps the area wet

32. Diagnosis
• Diagnosis is by examination, either in an outpatient setting or
under anesthesia (referred to as EUA or Examination Under
Anesthesia).
• The fistula may be explored by using a fistula probe (a narrow
instrument).
• Anoscopy.
• Fistulogram,
• Proctoscopy
• Sigmoidoscopy.
Treatment;
• Repair of the fistula

33. • Assessment:
1.Pain (more so with external hemorrhoids),
sensation of incomplete fecal evacuation,
constipation, and anal itching..
2.Bleeding may occur during defecation; bright
red blood on stool caused by injury of mucosa
covering hemorrhoid.
3.Visible and palpable masses at anal area.
• Diagnostic Evaluation:
1.External examination with anoscope or
proctoscope shows single or multiple
hemorrhoids.
2.Barium edema or colonoscopy rules out more
serious colonic lesions causing rectal bleeding

34. • Therapeutic Interventions:
1.High-fiber diet to keep stools soft.
2.Warm sitz baths to ease pain and combat
swelling.
3.Reduction of prolapsed external hemorrhoid
manually.
• Pharmacologic Interventions:
1.Stool softeners to keep stools soft and
relieve symptoms.
2.Topical creams, suppositories or other
preparation,
3.Preparation ,

35. • Surgical Interventions:
1.Injection of sclerosing solutions to produce
scar tissue and decrease prolapse is an office
procedure.
2.Cryodestruction (freezing) of hemorrhoids is
an office procedure.
3.Surgery may be indicated in presence of
prolonged bleeding, disabling pain, intolerable
itching, and general unrelieved discomfort

36. • Here are three (3) nursing care plans (NCP) and nursing
diagnosis for patients with anorectal condition:
1.Impaired Tissue Integrity
2.Constipation
3.Acute Pain

37. 1. Impaired Tissue Integrity
Nursing Diagnosis
• Impaired Skin Integrity
• May be related to
• Hemorrhoidal surgery and procedures
• Alteration in activity
• Changes in mobility
• Aging process
• Loss of elasticity of the skin
• Possibly evidenced by
• Disruption of skin tissue from incisional sites

38. • Destruction of skin layers
• Thrombosed hemorrhoids
• Internal prolapsed hemorrhoids
• Pain
• Swelling
• Drainage

39. Nursing Interventions
• Assess patient for the presence of hemorrhoids, discomfort or pain
associated with hemorrhoids, diet, fluid intake, and presence
of constipation.
• Administer topical medication as ordered.
• Provide “donut cushion” for the patient to sit on if needed.
• Administer stool softeners as ordered.
• Assist with procedures for the treatment.
• Instruct patient and/or family regarding all procedures required.
• Instruct patient and/or family in dietary management.
• Increasing bulk, fiber, fluids, and eating fruits and vegetables can
help by maintaining soft stools to avoid straining at bowel
movements.

40. • Instruct patient and/or family regarding the use of bulk
producing agents, such as psyllium husk. Bulk-forming laxatives
help absorb water to increase moisture content in the stool,
increases peristalsis, and helps promote soft bowel movements.
• Instruct patient and/or family in comfort measures to use with
the presence of hemorrhoids. Use of rubber donuts remove
pressure directly placed on the hemorrhoid. Warm sitz baths or
suppositories containing anesthetic agents can help to alleviate
pain temporarily.

41. • Constipation
• Nursing Diagnosis
• Constipation
• May be related to
• Low residue diet
• Lack of dietary bulk
• Hemorrhoidal pain
• Medications

42. • Possibly evidenced by
• Passage of hard, formed stool
• Decreased bowel sounds
• Inability to evacuate stool
• Severe, exquisite rectal pain
• Abdominal pain

43. • Abdominal distention
• Ileus
• Absent bowel sounds
• Frequency of stool is less than normal
• Less than the usual amount of stool
• Palpable mass
• A feeling of rectal fullness
• Flatulence

44. • Nursing Interventions
• Determine patient’s bowel habits, lifestyle, ability to sense urge to defecate, painful hemorrhoids, and history
of constipation.
• Rationale: Assists with identification of an effective bowel regimen and/or impairment, and need for assistance. GI function
may be decreased as a result of decreased digestion. Functional impairment related to muscular weakness and immobility
may result in decreased abdominal peristalsis and difficulty with identification of the urge to defecate.
• Assess patient’s stool frequency, characteristics, presence of flatulence, abdominal discomfort or distension,
and straining at stool.
• Rationale: Aging, such as decreased rectal compliance, pain, impairment of rectal sensation can lead to constipation.
• Auscultate bowel sounds of presence and quality.
• Rationale: Abnormal sounds, such as high-pitched tinkles, suggests complications like ileus.
• Monitor diet and fluid intake.
• Rationale: Adequate amounts of fiber and roughage provide bulk and adequate fluid intake of at least 2 L per day is
important in keeping the stool soft.
• Monitor for complaints of abdominal pain and abdominal distention.

45. • Rationale: Gas, abdominal distention, or ileus, could be a factor. Lack of peristalsis from impaired digestion
can create bowel distention and worse to the point of ileus.
• Monitor patient’s mental status, syncope, chest pain, or any transient ischemic attacks. Notify the
physician if these symptoms occur.
• Rationale: Undue straining may have harmful effects on arterial circulation that can result in cardiac, cerebral,
or peripheral ischemia.
• Assess for rectal bleeding.
• Rationale: Excessive straining may produce hemorrhoids, rectal prolapse, or anal fissures, with resultant pain
and bleeding.
• Provide bulk, stool softeners, laxatives, suppositories, or enemas as warranted.
• Rationale: May be used to stimulation evacuation of stool.
• Provide high-fiber diet, whole grain cereals, breads, and fresh fruits.
• Rationale: Improves peristalsis and promotes elimination.
• Monitor medications that may predispose patient to constipation

46. • Rationale: Analgesics, anesthetics, anticholinergics, diuretics, and other drugs are
some medications that are known to cause constipation.
• Instruct patient in activity or exercise programs within limits of disease
process.
• Rationale: Activity promotes peristalsis and stimulates defecation. Exercises help to
strengthen the abdominal muscles that aid in defecation.

47. • Nursing Diagnosis
• Acute Pain
• May be related to
• Hemorrhoidal pain
• GI bleeding
• Gastric mucosal irritation
• Inflammation
• Infection
• Constipation
• Spasm
• Surgery
• Possibly evidenced by
• Verbalization of pain
• Fever
• Malaise
• Rectal pain
• Elevated WBC
• Surgical wound

48. • Nursing Interventions
• Assess patient for complaints of headaches, sore throat, general malaise or body
weakness, muscle aches and pain.
• Rationale: Caused by inflammation or elevated temperature.
• Assess VS for changes from baselines
• Rationale: VS are usually increased as result of autonomic response to pain.
• Administer analgesics as ordered.
• Rationale: Pharmacologic therapy to control pain and aches by inhibiting brain prostaglandin synthesis.
• Provide restful, quiet environment.
• Rationale: Reduces stimuli that may increase pain.
•

49. • Provide warm baths or heating pad to aching muscles.
• Rationale: Warmth causes vasodilation and decreases discomfort.
• Provide cool compress to head prn.
• Rationale: Promotes comfort and treats headache.
• Provide backrubs prn.
• Rationale: Promotes relaxation and relieves aches.
• Encourage gargling with warm water; provide throat lozenges as necessary.
• Rationale: Reduces throat discomfort.

50. • Instruct patient or SO in deep breathing, relaxation techniques, guided
imagery, massage and other nonpharmacologic aids.
• Rationale: Helps patient to focus less on pain, and may improve efficacy of analgesics
by decreasing muscle tension.
• Instruct patient or SO regarding use of acetaminophen and to avoid use of
aspirin.
• Rationale: Acetaminophen may relieve pain and headache, but should be used
cautiously in patients with liver dysfunction because of acetaminophen metabolism in
the liver. Aspirin can potentially cause hemorrhage and ulceration, therefore, must be
avoided.