a basic review of causes, clinical assessment, investigation of benign perianal disease; fistula in ano, anal fissure, hemorrhoids

1. BENIGN PERIANAL DISEASES
Dr Winston Makanga, M.B.Ch.B., M.Med. (Surg)
Consultant General and Laparoscopic Surgeon

2. Objectives of the lecture
• Definitions
• Anatomy of the perianal region
• Common presentation
• Hemorrhoids
• Fistula in ano and ano-rectal abscess
• Pilonidal sinus
• Fissure in ano
• Rectal prolapse
• Pruritus ani

3. Definitions
• Anal verge
• Anorectal ring
• Anal canal
• Benign anal disease

4. Anatomy and physiology
• Canal proper
• Sphincter anatomy and function
• Venous plexuses and function

5. Common presentation
• Wetness
• Discharge from a papule
• Itch
• Swelling
• Bleeding
• Painful defecation

6. Hemorrhoids
• Enlargement of anal cushions due to dilatation and congestion of
submucosal venous plexus
• Classification: internal, external, intero-external
• Grading: I-IV
• Causes: Pregnancy, constipation, rectal tumor, ?PHTN
• Presentation: hematochezia, prolapsing mass, itch, wetness
• Diagnosis: C/E, proctoscopy, ?DRE, colonoscopy
• Rx: Dietary, medical, Surgical: hemorrhoidectomy, band ligation,
sclerotherapy, stapling

7. Anal abscess
• Pus collection in the perianal region
• Results from cryptogladular colonization
• Classified by site
• Usually a forerunner to anal fistula
• Present: Painful swelling, fever,
discharge
• Diagnosis: C/E, FHG
• Treatment: Drainage

8. Fistula in ano
• Abnormal communication between anal
canal and perianal skin
• Usually after a resolved abscess
• Classification: based on sphincter
• Presentation: pus discharge, perianal swelling,
wetness, pain
• Diagnosis: C/E, fistulogram, MRI
• Rx: fistulotomy, fistulectomy, Seton, Flaps,
fibrin glue, plugs

9. Pilonidal disease
• Either an cyst, abscess or sinus resulting from infection of hair follicles
in the natal cleft (far) superior to anal verge
• Results from hair penetration of the SC tissues causing a
granulomatous reaction
• Causes:male, hirsute, sitting occupations, deep natal cleft, hair within
the natal cleft, familial, obesity
• Diagnosis: C/E, ?Ultrasound
• Rx: I&D if abscess, Wide excision for multiple recurrent sinuses

10. Fissure in ano
• Break in the anoderm extending to the anal verge exposing deeper
sphincter muscles
• Initially caused by minor trauma but sustained by ischemia due to
sphincter hypertonicity
• Classified by site and acuteness
• Present: painful defecation, hematochezia
• Diagnosis : C/E, proctoscopy. Must rule out
underlying malignancy
• Rx: Medical, Surgical – sphincterotomy
(open/closed), Botulinum

11. Rectal prolapse
• Evagination of part (mucosal) or whole of rectal wall
through the anus
• Common in children and eldery multiparous ladies
• Causes: diarrhea, constipation, pelvic floor weakness,
incontinence
• Diagnosis: C/E, confirm if full thickness, defecography
• Rx: self limiting, manual reduction, control primary
etiology, rectopexy (with/out mesh)

12. Pruritus
• Intractable itching
• Causes
• Local: poor hygiene, excess sweat, hemorrhoids, fistula, pinworms
• Skin diseases: scabies, fungal, pediculosis
• Systemic diseases: Hodgkins, Obstructive jaundice, DM
• Idiopathic

13. Review
• Definitions
• Anatomy of the perianal region
• Common presentation
• Hemorrhoids
• Fistula in ano and Ano-rectal abscess
• Pilonidal sinus
• Fissure in ano
• Rectal prolapse
• Pruritus ani

14. Thank you