This document provides guidance on the assessment and management of various anorectal conditions, including anal fissures, hemorrhoids, pilonidal disease, inguinal hernias, anorectal abscesses, fistulas, and diabetic foot ulcers. Assessment involves examination, imaging studies if needed, and identifying any infection or complications. Management depends on the severity and type of condition, and may involve nonsurgical approaches like lifestyle changes or surgical procedures like excision or drainage. The appropriate dressing is also important to promote wound healing and control infection.

1. By
MAHMOUD ZAGHLOUL RASLAN, MD
CONSULTANT SURGEON, MGH
MEDINA

2. ANAL FISSURE & ANAL
HEMORRHOIDS
 PR & proctoscopy should be done for patients with any
perianal complaint.
 Acute anal fissure: Treated by WASH regimen:
 Warm water
 Analgesics
 Stool softeners
 High fiber diet

3.  Chronic anal fissure:
 WASH regimen should be tried first.
 Non responders need to be treated by internal
sphinctrotomy and excision of the fisure.

4. 2. Anal hemorrhoids:
2.1. Thrombosed external hemorrhoids:
2.1.1. Seen within 3 days: Do excision
2.1.2. Seen after 3 days: WASH regimen

5. 2.2. Internal hemorrhoids:
2.2.1. Try WASH regimen first
2.2.2. It may be enough in 1st degree
2.2.3. 2nd and 3rd degrees may improve. But
complete resolution may require
hemorrhoidectomy
2.2.4. Acute gangrenous or thrombosed 4th
degree need urgent
hemorroidectomy

6. PILONIDAL DISEASE
1. Thorough anorectal examination: is required to
detect any associated fistula-in-ano, Crohn’s disease or
any anorectal pathology.
2. Nonoperative treatment: (if no found abscess)
2.1. Hair shaving or depilation.
2.2. Avoid sedentary life, weight reduction.
2.3. Phenol (not used due to its toxicity)
2.4. Fibrin glue (not to be used bec. It did not
prove to be effective)

7. 3. Operative treatment:
3.1. Asymptomatic patients should not undergo any
surgical treatment.
3.2. Acute PN abscess: Incision & drainage.
3.3. Chronic PN disease:
3.3.1. Pit picking
3.3.2. Sinusectomy
3.3.3. Excision with open wound healing
3.3.4. Excision with midline closure
3.3.5. Flap-based off-midline procedures

8. 4. Antibiotics:
4.1. Not required in acute PN abscess except if there is
surrounding cellulitis.
4.2. A single dose of antibiotic prophylaxis is used
empirically in chronic cases.
5.Wound drainge:
5.1. Needed in off-midline flap procedures.
6.Postoperative shaving or depilation:
6.1. Is not be recommended.

9. INGUINAL HERNIA IN ADULTS
1. Diagnosis:
1.1. Physical examination
1.2. Dynamic US in doubtful cases
1.3. Herniography: an alternative to dynamic US if
local expertise is available
1.4. MRI: In case of persistent inguinal pain &
negative dynamic US.

10. 2. Who requires surgery:
2.1. Asymptomatic hernias can be treated by
“watch and wait” policy. They may require surgery
in the future.
2.2. Symptomtic hernias: surgical repair should
be offered.
2.3. Inform the pt about the possibility of chronic
postoperative groin pain. This can be lessened
by laparoscopic repair.

11. 3. Open vs laparoscopic repair:
3.1. Laparoscopic repair in:
3.1.1. Patients at risk of chronic pain e.g.
young pt, and in case of marked pain with
small hernia.
3.1.2. Female patients
3.1.3. Bilateral inguinal hernias
3.1.4. Recurrent hernia after open repair

12. 3.2. Open repair in:
3.2.1. Patients at low risk of chronic pain
e.g. older pt and patients with mild groin
pain.
3.2.2. Recurent cases after laparoscopic
repair.

13. 4. Surgical treatment of inguinal hernia:
4.1. Tension free open mesh repair
(Lichtenchtein)
4.2. Laparoscopic TAPP or TEP
4.3. Choice of treatment option should be based
on:
4.3.1. Surgeon’s expertise
4.3.2. Local resources
4.3.3. Patient- and hernia-related factors

14. ANORECTAL ABSCESS & FITULA-IN-
ANO
1. Diagnosis:
1.1. MRI: may be needed for occult anorectal
abscess, recurrent fistula-in-ano and perianal
Crohn’s disease.
1.2. Fistulography: useful alternative if MRI is
not available

15. 2. Treatment:
2.1. Anorectal abscess:
2.1.1. Intersphincteric: drain via internal
sphinctrotomy
2.1.2. Supraelevator:
2.1.2.1. As extension of ischiorectal
abscess: drain through perianal skin
2.1.2.2. As extension of
intersphincteric abscesss: drain
transanally with drain insertion

16. 2.1.3. Horseshoe abscess: drained by
internal sphinctrotomy and seton insertion
2.1.4. With fistula formation: drain with
seton insertion
2.1.5. Antibiotics:
2.1.5.1. Only with cellulitis, systemic
illness or immmunocompromized
2.1.5.2. Should cover MRSA

17. 2.2. Fistula-in-ano:
2.2.1. Fistulotomy: For simple fistulas
2.2.2. Fistulectomy: may be followed by
incontenance
2.2.3. Endoanal advancement flap
2.2.4. Ligation of intersphincteric fistula
tract (LIFT): with prior seton
2.2.5. Seton insertion:
2.2.5.1. followed by definitive surgery
2.2.5.2. with gradual tightening
2.2.6. Fistula plug & fibrin glue: not proved to
be effective

18. DIABETIC FOOT ULCERS
DIABETIC FOOT ASSESSMENT:
1. Assessment of the ulcer
2. Assessment for sensory loss
3. Assessment for the vascular status
4. Identifying infection
5. Assessment of bone involvement
6. Inspection for foot deformities

21. DFU MANAGEMENT:
1. Treatment of the underlying disease
2. Ensuring adequate blood supply
3. TIME optimum wound care (recommended by EWMA)
3.1. Tissue debridement
3.2 Inflammation & infection control
3.3. Moisture balance (optimum dressing selection)
3.4. Edge of the wound
4. Advanced therapy:
4.1. Negative pressure wound therapy NPWT
4.2. Hyperbaric oxygen therapy
4.3. Bioengineered skin equivalents & growth factors
5. Offloading
6. Amputation

22. PrecautionsIndicationsActionsType
_Not used in dry necrotic
wounds
_Not used in friable
tissues
_Do not pack the wound
tightly
_Moderate to high exudative
wounds
_Special cavity presentations
e.g. ribbon
_May be silver impregnated
_Absorb exudate
_Promote autolytic
debridement
_Moisture control
Alginates
e.g. Silvercel
_Not used in dry necrotic
wounds
_Not used in wounds with
minimal exudate
_Moderate to high exudative
wounds
_Special cavity presentations
e.g. ribbon
_ Absorb exudate
_Moisture control
_Antimicrobial if is silver
impregnated
Foams
e.g. Mepilex Ag
_Known sensitivity_Low to moderate exudative
wounds
_Infected sloughy wounds
_Rehydrate the wound bed
_Promote autolytic
debridement
_Antimicrobial action
Honey
e.g. Apinate Medihoney
_Not used in highly
exudative wounds
_Not used if anaerobic
infection is suspected
_May cause maceration
_ Dry/low to moderate
exudative wounds
_Rehydrate the wound bed
_Promote autolytic
debridement
_Moisture control
Hydrogel
e.g. NU-gel and Purilon
gel

23. PrecautionsIndicationsActionsType
_Not used on dry/necrotic
tissue
_Known sensitivity to iodine
_Not used for long term
(risk of systemic absorption)
_Low to high exudative wounds
_Clinical signs of infection
_Antimicrobial actionIodine
e.g. Iodosorb
_Not used in dry wounds_Malodorous wounds due to
excess exudate or increased
bioburden
_Odour absorptionOdour control
e.g. Activated charcoal
with silver (Actisorb
silver 220)
_Not used in dry wounds_Not improving clean wounds
despite correction of underlying
cause, exclusion of infection and
optimum wound care
_Active or passive control of
wound protease level
Protease modulating
e.g. Colactive plus
and Colactive plus Ag
_Not used in case of gross
slough
_Wound thin slough_ Debridement of thin slough
_Cleansing of the peri-lesional
area
Wound debridement
e.g. UCS debridement
wipe
_Known sensitivity_Moderate to high exudative
wounds
_Protect the peri-wound skinPeri-wound skin
barrier e.g. Cavilon
cream