Define Anorectal Disorder Gain knowledge about the pathophysiology of anorectal disorders Knows about the major contributing factor in development disease. To know about nursing management of Disorders.

1. Shashi Prakash
M.Sc. Nursing 2nd year
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ANORECTAL DISORDERS

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GENERAL OBJECTIVES: After the class students able to acquire
knowledge about Anorectal Disorder & use information and develop
skills or an idea to care of the disease based management.
SPECIFIC OBJECTIVES:
 At the end of the class, the students will be able to:
 Define Anorectal Disorder
 Gain knowledge about the pathophysiology of anorectal disorders
 Knows about the major contributing factor in development disease.
 To know about nursing management of Disorders.

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5. 1. Haemorrhoids
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 Haemorrhoids result from dilation of the superior and inferior
haemorrhoidal veins.
 These veins form haemorrhoidal plexuses, or cushions, in the
submucosal layer of the lower rectum and are essential to the
normal function of the anal canal.
 Hemorrhoids are either internal or external.

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 Internal haemorrhoids arise from the superior haemorrhoidal
venous plexus above the mucocutaneous junction, or dentate line,
of the anorectal.
 They are covered with rectal mucosa and occur in three primary
locations: right anterior, right posterior, and left lateral.
 External hemorrhoids arise from the inferior haemorrhoidal
venous plexus below the mucocutaneous junction and are covered
by squamous epithelium.

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 The perianal squamous epithelium contains numerous pain
receptors.
 Internal and external hemorrhoidal plexuses freely communicate to
drain into the inferior vena cava through the internal pudendal
veins.

10. causes
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 Straining during bowel movements
 Sitting for long periods of time on the toilet
 Chronic diarrhea or constipation
 Obesity
 Pregnancy
 Anal intercourse
 Low-fiber diet

11. Pathophysiology
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Histologically, haemorrhoids consist of three important parts: the lining (rectal mucosa or
squamous epithelium), stroma (blood vessels, smooth muscle, supporting connecting tissue), and
anchoring connective tissue, which secures haemorrhoids to the sphincter apparatus.
With age or other aggravating factors, the anchoring and supporting connective tissue
deteriorates, causing haemorrhoids to bulge and descend

12. 1.Internal haemorrhoids
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 Internal haemorrhoids may be associated with discomfort, pruritus
ani, fecal soiling, or varying degrees of prolapse.
 Bleeding is the typical complaint.
 Haemorrhoidal bleeding is described as bright-red spotting,
 It most often occurs at the end of defecation and is separate from
the stool.
 Strangulation occurs secondary to prolapse with subsequent lack of
blood supply.

13. Internal haemorrhoids may be classified as
follows
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 Grade I haemorrhoids bulge into the lumen of the anorectal canal
on anoscopy but do not prolapse.
 Grade II haemorrhoids prolapse out of the anus with defecation or
straining but reduce spontaneously.
 Grade III haemorrhoids prolapse with defecation or straining and
require manual reduction.
 Grade IV haemorrhoids are irreducibly prolapsed and are at risk for
strangulation.

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15. Treatment
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 Topical agents are effective for most first- and second degree
haemorrhoids.
 A high-fiber diet and adequate fluid intake helps to promote
passage of soft bulky stools to minimize straining.
 warm sitz baths twice daily and attention to proper anal hygiene.
 Suppositories, ointments, and hydrocortisone or anesthetic-
containing preparations (benzocaine, lidocaine, pramoxine
[pramocaine], dibucaine) offer short-term relief from pruritus,
burning, and soreness

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Modality Grade Advantages Disadvantages
Rubber band ligation (RBL) I, II, some III Lowest recurrence rate
Removes redundant tissue
Discomfort. Rare local
complications especially if
immunocompromised.
Injection sclerotherapy I, II, some III Minimal discomfort Technically
easy
Rare local complications. Poor
long-term benefits.
Infrared coagulation I, II, III Minimal discomfort Several applications required.
More expensive than RBL
Laser photocoagulation I, II, III Minimal discomfort Expensive
Electrocoagulation I, II, III Long application time.
Recurrence rates: 25%–35%
Cryosurgery I, II, III None Pain and complications
common. Less patient
satisfaction

17. External haemorrhoids
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 Thrombosis of an external haemorrhoid can cause extreme pain due
to distention of overlying perianal skin and inflammation.
 Bleeding may occur after the overlying perianal skin ulcerates and
the resolving liquefied hematoma extravasates.
 External haemorrhoids should be distinguished from strangulated
internal haemorrhoids, which tend to be larger and more
circumferential, encompassing the entire anus.

18. Treatment
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 Warm sitz baths two to three times per day.
 Stool softening agents, such as psyllium, synthetic mucilloides,
and the sodium or calcium salts of dioctyl sulfosuccinate.
 Topical anesthetic ointments and witch hazel-impregnated pads
may provide additional relief.

19. Nursing management
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1. Nursing Diagnosis: Impaired Skin Integrity related to Haemorrhoidal surgery and
procedures, Alteration in activity, Changes in mobility, Aging process, Loss of elasticity
of the skin.
Intervention
 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
 Instruct patient and/or family in comfort measures to use with the presence of
haemorrhoids

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2.Constipation related to Low residue diet, Lack of dietary bulk,
Hemorrhoidal pain, Medications
 Intervention
 Determine the patient’s bowel habits, lifestyle, ability to sense an urge to
defecate, painful hemorrhoids, and history of constipation.
 Assess patient’s stool frequency, characteristics, presence of flatulence,
abdominal discomfort or distension, and straining at stool.
 Auscultate bowel sounds of presence and quality.
 Monitor diet and fluid intake.

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 Monitor for complaints of abdominal pain and abdominal distention.
 Monitor patient’s mental status, syncope, chest pain, or any transient
ischemic attacks. Notify the physician if these symptoms occur.
 Provide bulk, stool softeners, laxatives, suppositories, or enemas as
warranted.
 Provide a high-fiber diet, whole grain cereals, bread, and fresh fruits.
 Monitor medications that may predispose patient to constipation.
 Instruct patient in activity or exercise programs within limits of the
disease process.

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3.Nursing Diagnosis
Acute pain related to haemorrhoidal condition
Intervention
 Administer analgesics as ordered.
 Provide warm baths or heating pad to aching muscles.
 Provide cool compress to head prn.
 Instruct patient or SO in deep breathing, relaxation techniques,
guided imagery, massage and other non-pharmacologic aids.

23. 2. Anorectal varices
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 Rectal varices represent enlarged portosystemic collaterals
 It develop from haepato fugal portal venous flow through the inferior
mesenteric vein to the superior haemorrhoidal veins.
 Anorectal varices are usually discrete, serpentine, submucosal
veins, which, in contrast to external hemorrhoids, are
compressible and refill rapidly.
 Nearly 45% of patients with cirrhosis have anorectal varices on
endoscopic examination

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25. Treatment
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 The optimal management of anorectal varices is unknown.
 Absorbable suture achieves primary control in most cases and
has a low rate of morbidity.
 Ultimately, surgical or transjugular intrahepatic portosystemic
shunting may be required.

26. 3. Anorectal abscess and fistula
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 Anorectal abscess and fistula represent the acute and chronic
manifestations of suppurative anorectal infection.
 An anorectal abscess is an undrained collection of perianal pus,
whereas a fistula is an abnormal communication between the
anorectal canal and the perianal skin.

27. Anorectal abscess
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 The most common cause of anal sepsis is an infection of the anal
glands and duct.
 Secondary to fecal bacterial plugging of the ducts and obstruction
(i.e., the cryptoglandular theory).
 These glands arise from the anal canal at the level of the crypts of
Morgagni, and often penetrate into the inter-sphincteric space.
 Anal trauma, diarrhea, hard stools, or foreign bodies may predispose
to glandular obstruction or sepsis. Anal sepsis most frequently
affects people in the third and fourth decades.

28. Etiology
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 The most common bacterial isolates are Escherichia coli,
Enterococcus species, and Bacteroides fragilis.
 Anal sepsis include Crohn’s disease, malignancy, tuberculosis,
actinomycosis, lymphogranuloma venereum, radiation-induced
proctitis, leukemia, and lymphoma.
 Suppurative anorectal conditions are infected pre-sacral epidermal
inclusion cysts, hidradenitis suppurative , pilonidal disease, and
Bartholin abscesses.

29. Clinical manifestation
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 Slow, gradual onset of pain, increasing in intensity to the
sensation of pressure and fullness.
 The pain may be exacerbated by sitting, movement, or
defecation.
 Localized swelling, hyperemia, induration or fluctuance, and perianal
tenderness.
 Purulent discharge reflects spontaneous drainage.
 Necrosis and tissue breakdown may proceed rapidly with extension
into the genitalia and pelvis.

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 Diagnostic tests
 Physical examination
 Sigmoidoscopy to identify the internal opening and associated
disease (i.e., inflammatory bowel disease or neoplasms).
 Pelvic magnetic resonance imaging (MRI), endoanal ultrasound, and
surgical examination

31. Treatment
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 A small incision close to the anal verge is made and a Mallenkot
drain is advanced into the abscess cavity.
 Antibiotics should be used as adjunctive therapy in special
circumstances only (i.e., valvular heart disease,
immunosuppression, extensive associated cellulitis, and diabetes).
 Antibiotics that provide gram-negative aerobic and anaerobic
coverage.

32. Anorectal Fistula
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 A communication of an abscess cavity with an identifiable internal
opening within the anal canal.
 It located at the dentate line where the anal glands enter the anal
canal.
 These fistulas are classified by their relationship to the anal
sphincter muscles, with 70% being intersphincteric, 23%
transsphincteric, 5% suprasphincteric, and 2%
extrasphincteric.

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Clinical feature
 The classical symptoms are increasing pain, slight fever, and pain
on defecation followed by mucopurulent drainage and a reduction in
pain.
 Chronic discharge may irritate the skin and cause pruritus. Most
patients have a previous history of anorectal suppuration.

35. Diagnostic tests
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 Sigmoidoscopy to identify the internal opening and associated
disease (i.e., inflammatory bowel disease or neoplasms).
 Pelvic magnetic resonance imaging (MRI), endoanal ultrasound,
and surgical examination under anesthesia were of comparable
accuracy (87%–91%) for classifying perianal fistulae.

36. Management
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 Medical Management:
 Antibiotics should be used as adjunctive therapy (i.e., ticarcillin/
clavulanate, piperacillin/tazobactam, or a broad-spectrum
cephalosporin) are recommended.
 Wound isolates are usually polymicrobial with Escherichia coli,
Proteus vulgaris, Bacteroides species, streptococci, and
staphylococci predominating

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 A seton, a vessel loop or silk tie placed through the fistula tract,
which maintains the tract open and quiets down the surrounding
inflammation that occurs from repeated blockage of the tract.
 A simple fistulotomy can be performed for intersphincteric and low
(less than onethird of the muscle) transsphincteric fistulas without
compromising continence. For a higher trans sphincteric fistula,
an anorectal advancement flap in combination with a drainage
catheter or fibrin glue may be used.
 Patients should be maintained on stoolbulking agents, nonnarcotic
pain medication, and sitz baths following surgery for a fistula

38. 4. Rectal Prolapse
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 Abnormal descent of the rectal mucosa.
 Complete rectal prolapse, or procidentia, indicates intussusception
of all layers of the rectal wall through the anus.
 Occult rectal prolapse refers to internal intussusception without
protrusion through the anus.
 A pouch of Douglas hernia originates in the cul de sac of Douglas
and protrudes, via the anterior rectal wall, through the anus.

40. 1. Mucosal prolapse–hemorrhoids
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 Initially, the mucosal prolapse is small, occurs only after defecation,
and reduces spontaneously.
 Later, the protrusion becomes larger and may require manual
reduction or becomes irreducible, causing seepage of mucus and
staining of the underclothes.
 Erosion and ulceration of the protruding mucosa lead to bleeding.

41. 2.Procidentia
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 Etiology and pathophysiology
 Rectal procidentia begins with circumferential intussusception of the
rectum that progressively increases over time
 Factors that may predispose to procidentia include excessive
straining during defecation,
 Anatomical factors (i.e., abnormally low descent of the peritoneum
covering the anterior rectal wall, loss of posterior fixation of the
rectum to the sacral curve, and lengthening and downward
displacement of the sigmoid and rectum).
 Rectal procidentia is rare in men older than 45 years and in women
younger than 20 years.

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 Symptoms :
 Feeling of bearing down, or of incomplete evacuation, and often of
passage of mucus and bleeding. A majority of patients have
constipation, diarrhea, or both.

43. Diagnosis
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 At physical examination
 Findings: full-thickness prolapse can be identified, Denervation of
striated musculature on electromyogram, perineal descent, and
absence of the anocutaneous reflex are also common findings.

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 Procto-sigmoidoscopy reveals congestion and edema of the
distal rectal mucosa, sometimes associated with a rectal ulcer
 Treatment
 Combined abdominal proctopexy and sigmoid resection eliminates
two of the presumed causes of rectal prolapse

45. 5. Anal fissure
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 An anal fissure is a tear in the lining of the distal anal canal below
the dentate line, occurring most commonly in the posterior midline.
 It can affect individuals of all ages and both genders.
 Clinical symptoms include anal pain during and after defecation,
often accompanied by bright-red rectal bleeding and pruritus ani.

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 Acute fissures have sharply demarcated, fresh mucosal edges and
may have granulation tissue in the base.
 Fissures may also occur secondary to an underlying disease such
as inflammatory bowel disease (especially Crohn’s disease),
HIV/AIDS, leukemia, anal carcinoma, and, rarely, syphilis or
tuberculosis. Secondary fissures are usually found in a more lateral
“off the midline” position.

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Pathophysiology
The elliptical arrangement of the anal sphincter fibers offers less
muscular support to the anal canal posteriorly
This predisposes the posterior anal canal to traumatic tears during
passage of a large, hard stool
Anoderm receives part of its blood supply from arterioles
Elevated anal resting pressure could reduce perfusion to the anoderm
and lead to local ischemia

49. Treatments
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 Acute anal fissures: High-fiber diet, stool softeners, and warm sitz
baths following bowel movements may provide symptomatic relief .
 Chronic anal fissures:
 1. Topical nitrates: Nitric oxide is a critically important
nonadrenergic, noncholinergic neurotransmitter that mediates
relaxation of the IAS(Internal Anal Spinctor).
 It decrease resting anal pressures and increase anodermal blood
flow.
 2. Calcium channel blockers: Calcium channel blockers also
reduce IAS tone but have fewer side effects than do topical nitrates.

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3. Botulinum toxin: Botulinum toxin (20 units into the IAS), which
inhibits acetylcholine release from nerve endings, or saline injection
but are contraindicated in pregnancy and during breast-feeding.
4. Surgery: Lateral internal anal sphincterotomy (LIS), involving
division of the IAS from its most distal end for a distance equal to that
of the fissure or to the dentate line.

51. 6. Anal stenosis
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 Anal stenosis is defined as narrowing of the anal canal. It result from
a true anatomical stenosis (stricture) or a functional (i.e., muscular)
stenosis.
 The most common cause is (80%) is haemorrhoidectomy.
 Excessive excision of anoderm and haemorrhoidal rectal mucosa
during haemorrhoidectomy leads to scarring and a progressive
stricture.

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 Others causes: Recurrent anal fissure, recurrent abscess and fistula
requiring surgical treatment, anal Crohn’s disease, radiation,
excision of perianal skin lesions as in Paget or Bowen disease,
tuberculosis, actinomycosis, lymphogranuloma, and congenital
abnormalities . Malignant causes of anal stenosis include anal and
rectal cancers, and, less commonly, transmural invasion of the
anorectum by a urogenital malignancy.

53. Sign & Symptom
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 Difficult evacuation of stool is the most troublesome symptom.
 Other symptoms include narrow stools, painful defecation, anal
digitation during defecation, bleeding from recurrent anal tears, and
constipation or obstipation.
 Digital rectal examination may reveal the stricture, or cause
considerable discomfort to the patient.

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 Treatment
 Medical therapy combines bulking of the stool with anal dilation
 Surgical treatments of anal stenosis include LIS, an advancement
flap, or a colostomy.

55. Fecal incontinence
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 Fecal incontinence (FI) is defined as recurrent uncontrolled passage of fecal material in
an individual with a developmental age of at least 4 years.
Common causes of fecal incontinence
 Anal sphincter weakness Traumatic: obstetric, surgical (e.g., hemorrhoidectomy,
internal sphincterotomy)
 Nontraumatic: scleroderma, internal sphincter degeneration of unknown etiology,
pudendal neuropathy
 Disturbances of pelvic floor Rectal prolapse, descending perineum syndrome
 Inflammatory conditions Radiation proctitis, Crohn’s disease, ulcerative colitis
 Central nervous system disorders Dementia, stroke, brain tumors, multiple sclerosis,
spinal cord lesions

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 Diagnostic testing:
 Endoscopy
 Anal manometry
 Endoanal ultrasound
 Evacuation proctography (defecography)
 Pelvic magnetic resonance imaging (MRI)
 Pudendal nerve terminal motor latency (PNTML)
 Needle electromyography (EMG)

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 Management
 1.Bowel habit modification
1. Modifying bowel habits is often central to managing FI effectively.
2.Loperamide reduces diarrhea and slightly increases IAS tone,
thereby reducing FI [138]. It is important that adequate doses are
given (i.e., 2–4 mg, 30 min before meals, up to 16 mg/day)
 2.Direct pharmacological approaches
 Topical application of the α1-adrenergic agonist phenylephrine to the
anal canal increases anal resting pressure.

58. 8. Pruritus ani
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 Pruritus ani is an annoying itchy sensation of the anus and
perianal skin that is often associated with burning and soreness.
 It affects 1%–5% of the population, with a male-to-female
predominance of 4:1

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Causes of pruritus ani
Anorectal disorders:
 Diarrhea, Anal incontinence, Hemorrhoids, Fissures, Fistulae, Rectal
prolapse.
 Malignancy: Bowen disease, epidermoid cancer, perianal Paget
disease
 Fungal: candidiasis, dermatophytes
 Parasitic: pinworms, scabies
 Venereal: herpes, gonococcus, syphilis, condylomata acuminate

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Local irritants Moisture: obesity, excessive perspiration
 Soaps: hygiene products
 Toilet paper: perfumed, dyed
 Underwear: irritating fabrics, detergents Anal creams, suppositories
 Dietary: coffee, beer, acidic foods
 Drugs: mineral oil, ascorbic acid, hydrocortisone sodium succinate,
quinidine, colchicine
 Dermatological diseases: Psoriasis Atopic dermatitis Seborrheic
dermatitis

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 Treatment
 Anorectal disorders that impede good perianal hygiene
 Fecal leakage or incontinence must be aggressively managed
 Foods or beverages that produce diarrhea or pruritus should be
discontinued.
 A 1% hydrocortisone cream may be applied sparingly twice daily
during the acute phase of pruritus ani but should not be used for
longer than 2 weeks to avoid skin atrophy.
 Applying a protective ointment (zinc oxide) over the anti
inflammatory agent may facilitate healing.

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63. Nursing Diagnosis
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 Fluid electrolyte imbalance
 Altered bowel pattern
 Potential to develop complications related to the disease condition
& surgery
 Altered nutritional pattern
 Altered self body image related to the colostomy
 Knowledge deficit of the parent related to the disease condition
 Feeding modifications related to GI surgery
 Abdominal distension related to obstruction

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Summary & Conclusion

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Thank you

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 References:
 A text book of gastroenterology “Tadatak Yamada ” 5th edition
volume one Willy Blackwell publisher