The document discusses the embryological development, classification, clinical features, investigations, and management of benign anorectal diseases such as imperforate anus, anorectal malformations, and rectal prolapse. It describes the normal development of the anorectum and various congenital anomalies that can occur. Evaluation methods including invertograms and defecography are outlined, as well as surgical techniques for repair of anomalies like posterior sagittal anorectoplasty.

1. BENIGN
ANORECTAL
DISEASE-2
Moderator: Dr. H.S.Jolly
Presentor: Dr. Azhar

2. Embryology
• Cloaca is a common chamber in early embryonic
life which divides into dorsal (rectum) and ventral
(urogenital sinus) by down growth of a septum.
• The dorsal membrane is k/a anal membrane,
which is composed of outer ectoderm and inner
endoderm and get resorbed by 8th week gives rise
to anal canal.

3. Development of the anorectum is complete by
the 9th week of intrauterine life and consists of:
–a) cloaca formation
–b) division of the cloaca into urogenital sinus
anteriorly and rectum posteriorly by the
urorectal fold
–c) development of the anal canal

4. allantois
Cloacal
membrane
Cloaca
Urorectal
membrane

5. primitive urogenital
sinus
perineal area
anus
urorectal septum
rectum

6. • Two lateral folds of cloacal tissue join the
urorectal septum to complete the separation of
the urinary and rectal tracts.
• Any deviation in this normal development can
lead to anorectal malformations

7. Congenital Anomalies
• Imperforate anus
• Post-anal dermoid
• Post-anal dimple (synonyme: fovéa coccygea)
• Pilonidal sinus ?

8. Anorectal Malformation/Imperforate
anus
• Includes agenesis and atresia of the rectum
and anus
• Etiology: unknown
• Incidence: 1 in 4,500 to 5000
• SEX: 60% male

9. Classification
Wingspread classification - based on the
anatomical relation of the blind rectal pouch to
the Levator ani muscle.
When the blind pouch is
 above the levator ani muscle, it is a high
anomaly.
 below the level of levator ani muscle it is a low
anomaly.
 partially within the muscle, the anomaly is an
intermediate anomaly

10. Classification
Males
1. Cutaneous (perineal
fistula)
2. Rectourethral fistula
A. Bulbar
B. Prostatic
3. Recto–bladder neck fistula
4. Imperforate anus without
fistula
5. Rectal atresia
Females
1. Cutaneous (perineal fistula)
2. Vestibular fistula
3. Imperforate anus without fistula
4. Rectal atresia
5. Cloaca
A. Short common channel
B. Long common channel
6. Complex malformations

11. Low-type ARMs
scrotal perineum
have an external anocutaneous opening in the scrotum
(1) or perineum (2, 3) in males.

12. Bucket Handle Malformation
• ‘low’ type of anorectal
malformation
• Here the rectum opens
to the skin through a
small opening anterior
to the normal position
of the anal sphincter

13. Low-type ARMs
• have an external opening in the perineum (1) or
vestibular area (2) in females.

14. Vestibular anus
Anterior ectopic anus

15. Intermediate- and high-type
ARMs
extend anteriorly to the base of the penis (1), the
bulbar (2) or prostatic (3) or the urinary bladder
(4) in males.

16. Rectobulbar fistula
•Rectum opens into the bulbar urethra.
•Presence of anal pit in perineum.
•Long common wall of rectum and urethra.
•Voluntary sphincter muscle complex is well
developed.

17. Rectoprostatic urethral fistula
• Rectum opens into prostatic urethra
• Sacral deformity is more severe than in bulbar
fistula
• Passing meconium through urethra
• Flat perineum with hypoplastic voluntary
sphincter muscles

20. Recto vesical fistula
• Rectum opens into urinary bladder
• Relatively uncommon; no common wall between
rectum and bladder
• Flat perineum with hypoplastic voluntary sphincter
muscles
• Severe Sacral deformity

21. Anorectal Anomaly with no
fistula
• Rectum ends blindly behind the urethra
• Blind end usually extends to a well formed anal
pit
• Presence of well developed voluntary sphincter
muscle complex
• Typical presentation in a Down’s syndrome

22. Anorectal Anomaly with no fistula

23. Rectal Atresia(same in male &
female)
• Normal looking anal opening ending just above
dentate line
• Proximal blind ending rectum is very much
dilated
• Voluntary sphincter muscle complex is well
developed
• Local vascular abnormality is the cause

24. Intermediate- and high-type
ARMs
• In females –
1. Recto vestibular
2. Recto vaginal fistula

25. Cloacal anomaly
• Is a complex anatomic disorder that manifests
as a unique external perineal opening with a
short or long common canal for the genital,
urinary, and digestive systems. Isolated
rectovaginal fistulas are extremely rare and are
considered a variant of cloacal anomaly.

27. Cloacal Anomaly with < 3 cms
common channel
• Urinary tract, vagina and rectum join in a common
channel
• The orientation and anatomy of cloaca are
extremely variable
• Urinary tract abnormalities like obstructive
uropathy is common
• Vaginal & uterine duplications with Neonatal
Hydrocolpos occur in 50%

29. Cloacal Anomaly with > 3 cms
common channel
• Babies with long channel tend to have poor
sphincter
• Agenesis of Mullerian structures is common
• Severe sacral anomalies

31. Associated anomalies
• V – vertebral : Predominantly lumbosacral
• A – anorectal
• C - cardiac : TOF, VSD
• T - tracheo
• E - esophageal
• R – renal: VUR, UDT, Hypospadias
• L – limb: Radial ray anomalies

32. Clinical features
• In general, boys with anorectal malformations
present with intestinal obstruction (abd
distension, failure to pass meconium,
vomiting)in the newborn period.
• Girls present with h/o passing meconium/stools
from an abnormal site. (within the fourchette)

33. • High-
1. Flat perineum & buttocks
2. No pigmentation or dimple at site of anus
3. Meconium per urethra in males
• Low-
1. Stenotic opening
2. Bulged membrane seen at normal location of
anus
3. Well formed perineum & buttocks

34. Currarino triad
• ASP Triad
• Anorectal malformation or congenital anorectal
stenosis
• Sacrococcygeal osseous defect
• Presacral mass
–e.g anterior sacral meningocoele
–and/or tumors like teratoma, hamartoma

35. Investigations
• If the anomaly can be classified clinically there is
no need to do Invertogram
• Invertogram
• USG abdomen (kidneys)
• Echo (cardiac status)
• X ray spine (sacral spine abnormalities)
• CT/MRI to reveal sphincter muscle integrity

36. Invertogram
• A coin/metal piece is placed over the expected
anus and the baby is turned upside down (for a
minimum 3 minutes).
• Distance of gas bubble in rectum from the metal
piece is noted:
a) >2 cm: denotes high type
b) <2 cm: denotes low type

38. Prone cross table lateral X ray
• -the patient in prone position
– -If air in the rectum is located below the coccyx, and
the patient is in good condition with no significant
associated defects, one may consider performing a
posterior sagittal operation with or without a
protective colostomy
– -if the rectal gas does not extend beyond the
coccyx, or the patient has meconium in the urine,
an abnormal sacrum, or a flat bottom, a colostomy
should be done.

39. • Fluoroscopy: contrast study
 to detect recto-urinary, recto-vaginal or rectoperineal
fistula the fistula is considered low (below levator ani
plane) if it is below the puboccygeal line (PCL) and
considered high fistula if above the PCL.
• Ultrasound
 the anus may be seen as an echogenic spot at the level
of the perineum and in an atresia this echogenic spot
may be absent -may show bowel dilatation

40. MANAGEMENT
• Single stage for low ARMS
• Staged for intermediate & high ARMS

41. Surgery for low ARM
• Imperforate anus: Anoplasty
• Cruciate incision is made at the proposed site
of anal opening and four skin flaps are raised.
• The blind pouch is identified, opened by a
cruciate incision and the mucosal and skin flaps
are sutured after interdigitating them.

43. • Anocutaneous fistula: Cutback anoplasty
• Anterior Ectopic Anus: repositioning of the
anus at the normal site by Anterior Sagittal
AnoRectalPlasty(ASARP)

44. Intermediate & High anomalies:
• Staged surgical procedure
a) preliminary colostomy
b) A pullthrough operation
c) closure of colostomy

45. Pullthrough procedures:
• a) Any fistulous communication to the urinary
or genital tract should be divided.
• b) The blind rectal pouch, after adequate
mobilisation, should be brought down to the
proposed anal site within the sphincter
complex.

46. Posterior Sagittal Anorectoplasty
(PSARP)
• It is a definitive repair performed at 8-12
weeks

47. Rectal Prolapse
•Rectal Prolapse is circumferential descent of
rectum (bowel) through the anal canal.
•Common in infants, children & elderly
•Common in females (6:1)

48. Rectum-Anatomy
1. 18-20 cm long: from rectosogmoid junction to
anorectal junction and follows curve of
sacrum.
2. Three lateral curvatures: upper and lower are
convex to right while middle one is convex to
left.
3. On mucosal side-they correspond to
semicircular folds (Houston’s valve).
4. Part of rectum between middle and lower
valve is widest-ampulla of rectum.

49. 1. Upper 1/3rd: Peritoneal covering all around,
Middle 1/3rd: Peritoneal covering anteriorly
and laterally, Lower 1/3rd: No peritoneal
covering
2. Lower rectum separated from other organs by
fascial condensation: Anterior-Fascia of
DenonVilliers and Posterior-Fascia of
Waldeyers

50. Factors preventing Prolapse:
• Curvature of sacrum (under developed sacral
curve)
• Tilt of pelvis
• Serpentine course of rectum
• Levator ani muscles-fixes rectum
• Puborectalis sling-Tilt and elevate lower end of
rectum

51. Types of Prolapse
1. Partial or Rectal mucosal Prolapse: Protusion of
the rectoanal mucosa & submucosa
2. Complete prolapse or Procidentia: Include
mucosa, submucosa & muscles
3. Internal prolapse or intussusception:
Occult rectoanal intussusception
Prolapse does not protude from the anus
Not always pathologic/symptomatic

52. Mucosal vs Full Rectal Prolapse

53. Mucosal vs Full Rectal Prolapse

54. Difference Between Rectal
Prolapse & Hemorrhoids
Rectal Prolapse
Circumferential
Double Rectal Wall
Decreased
Hemorrhoids
Radial
Hemorrhoidal Plexus
Normal
Tissue Folds
Abnormality on
Palpation
Resting and Squeeze
Pressures

55. Difference Between Rectal
Prolapse & Hemorrhoids

56. Etiology
• Extreme of age
• Children: first three years (male=female)
Cystic fibrosis, malnutrition, diarrhea, severe cough,
parasites
–Constipation (component of colonic dysmotility)
–Weakening/malfunctioning of pelvic floor/sphincters
–Anismus – spastic pelvic floor
–Pudendal neuropathy (obstetric injuries, aging)
–Sphincter dysfunction (trauma, aging)
–Decreased sacral curvature, Multipara female, Diarrhea, cough,
malnutrition
–Decreased ischiorectal fossa fat
• Mental illness (depression, autism)

57. Pathophysiology
• Rectum passes through opening in pelvic floor
funnel
• Lateral & rectosigmoid attachments relax
• Mesorectum lengthens
•Anal sphincters stretch
• Rectal prolapse

58. Pathophysiology
• Associated pelvic anatomic abnormalities
Deep anterior cul de sac
Redundant sigmoid colon
Patulous anal sphincter
Loss of posterior rectal fixation

59. Clinical Features
• Something coming out of anal canal during
straining, coughing, lifting weights
• Constipation (58%)
• Mucus discharge
• Feeling of incomplete evacuation
• Itching

60. • Fecal incontinence:
a) More common in long standing complete
prolapse
b) Due to stretching of pudental and perineal
nerves
c) Dilatation of anal canal and relaxation of anal
sphincters.
• Bleeding (rare)-of massive or irreducible

61. Differential Diagnosis
• 1.Prolapsed haemorrhoid
• 2.Large polypoidal lesion protruding
through anus

62. Evaluation
• Ask patient to produce the prolapse
• If not obvious:
a) straining in sitting position (toilet)
b) phosphate enema or glycerine
suppositories (children) to induce strain
• Look for associate vaginal prolapse (15-30%)

63. Examination
• Concentric rings and grooves
• Perianal skin excoriation and maceration
• Chronic prolapse: Inflamed, edematous and
irregular surface & Biopsies to rule out neoplasia
• Digital examination: Sphincter pressures

64. Investigations
• Colonoscopy or barium enema: Exclude tumor,
biopsy of ulcers and mass lesions
• Defecography: Megarectum, incontinence,
nonrelaxing puborectalis, abnormal perineal
descent, rectocele, mucosal prolapse

65. • Anal manometry can help assess sphincters:
Long standing prolapse may damage internal
sphincter.
• Pudendal nerve latency study: Pudendal nerve
terminal motor latency (1.8-2.2msec)

66. Non operative management
• Treat constipation
● Fiber supplements
● Stool softeners
• Reduce incarcerated rectal prolapse
● Table sugar

67. • Adhesive strapping of buttocks
• Manual anal support during defecation
• Correction of constipation
• Perineal exercises (kegel’s exercise)
• Electrical stimulation
• Submucosal injection of phenol in almond oil
• Infrared coagulation

68. Management of acute irreducible
rectal prolapse:
• Reduction under anaesthesia to relax sphincter
• Tapping the buttocks together
• Trendelenberg position
• Placement of sugar/salt topically to reduce
edema
• Injection of hyaluronidase
• If prolapsed rectum is not viable-resection of
part

69. Surgical Treatment
• Pertial Rectal prolapse
–Improve nutrition, correct constipation
–Submucosal injection of 10ml of 5% phenol in
almond oil, tetracycline, hypertonic saline
–Thiresch wiring
–Goodsall’s operation(excision of prolapsed
mucosa at three different places)
–Stapled transanal rectal resection
surgery(STARR

70. Complete Rectal Prolapse
• Perineal procedures: Resection, reefing, and
encirclement
• Abdominal procedures: Fixation, colon
resection or combination of both

71. Choosing Type of Surgery
Abdominal
1. Recurrence low
(<10%)
2. ↑ constipation
50%
3. Mesh placement –
stricture, migration,
Perineal
1. Recurrence (20%)
2. Constipation rate unchanged
3. Persistent incontinence worse
rate due to removal of rectal
resevoir
4. Correction of associated
abnormalities (rectoceole,
sphincter)
5. No pelvic dissection –
preserves sexual function

72. Perineal Procedures
•Perineal Proctosigmoidectomy – Altemeir
• Mucosal Sleeve Resection - Delorme
• Anal Encirclement - Thiersch Wire Technique
• Perineal suspension/fixation - Wyatt

73. Thiersch repair:
Anal canal
tightened by
passing a
silver/nylon/
silicone
rubber in
perinium.

74. Delrome procedure:
•Prolapse part is fully
denuded of its
mucosa
•Underlying rectal
musculature plicated
•Defect of mucosa
repaired

75. Altmeir procedure:
•Rectosigmoidecto
my through
perineal route.

76. Abdominal Procedures
•Anterior rectopexy or Ripstein procedure/
sutured rectopexy: Anterior wrapping of the
rectum and fixation to sacrum section.
• Posterior rectopexy- Wells procedure /Ivalon
sponge (Polyvinyl alcohol)
● Synthetic mesh
● Sutures alone

77. • Goldberg rectopexy/resection rectopexy /
Fuykwan: Anterior rectopexy + sigmoid
resection
•Sigmoid colectomy with sutured rectopexy
Low recurrence
Low morbidity
Improves constipation

78. Materials used for Mesh
Rectopexy
• Natural: Fascia Lata
• Non-absorbable Synthetic: Nylon,
Polypropylene, Marlex, Polyvinyl Alcohol and
Polytef
• Absorbable Synthetic: Polyglactin and
Polyglycolic Acid

79. Laparoscopic Rectopexy
• Largely replacing open abdominal procedures
• Ease of performing rectopexy and colon
resection simultaneously with shorter hospital
stay
• Morbidity and mortality no different than open
controls
• Recurrence rate lower but not statistically
significant

80. Laparoscopic Rectopexy
• Laproscopic posterior mesh rectopexy:
Posterior as well as anterior mobilisation of
rectum done, mesh placed in presacral region
and sutured to rectal wall and presacral fascia
• Laproscopic sigmoid resection and rectopexy:
Done in rectal prolapse with constipation,
excess redundant sigmoid colon with kinking

81. Complications
• Injury to hypogastric nerve causing impotence
• Bladder dysfunction
• Bleeding from sacral venous plexus
• Injury to rectum & colon causing fistula
• Constipation after rectopexy
• Recurrence
• Infection

82. Recurrence
• Can happen after either perineal or abdominal
procedure: Overall 15% recurrence rate (range is
0-60%)
Abdominal operations – up to 10%
Perineal operations – up to 20%

83. Recurrence - Etiology
• Surgical factors:
a. Inadequate mobilization of rectum
b. Inadequate fixation of the rectum to the sacrum
c. Incomplete resection of a redundant
rectosigmoid
• Nonsurgical factors:
a. Vigorous physical activity or childbirth –
disruption of pexy
b. Continued constipation with persistent straining

84. •Pathophysiologic factors:
a. Disordered defecation
b. Intestinal dysmotility

85. Thank You For
Guidance