CHAPTER 54

ANATOMY AND PHYSIOLOGY EXAMINATION OF THE ANUS CONGENITAL ABNORMALITIES PILONIDAL SINUS ANAL INCONTINENCE ANAL FISSURE HYPERTROPHIED ANAL PAPILLA PROCTALGIA FUGAX HAEMORRHOIDS INTERNAL HAEMORRHOIDS TREATMENT TREATMENT OF COMPLICATIONS EXTERNAL HAEMORRHOIDS PRURITIS ANI ANORECTAL ABSCESSES FISTULA IN ANO TYPES OF ANAL FISTULAS NONMALIGNANT STRICTURES MALIGNANT TUMOURS

ANATOMY AND PHYSIOLOGY

Surgical anatomy The anal canal commences at the level where the rectum passes through the pelvic diaphragm and ends at the anal verge (the external or distal boundary of the anal canal). The muscular junction between the rectum and anal canal can be felt with

the finger as a thickened ridge the anorectal bundle or ring. Anal canal musculature (Fig. 54.1) The internal Sphincter is a thickened continuation of the circular muscle coat of the rectum. This involuntary muscle commences where the rectum passes through the pelvic diaphragm, and ends at the anal orifice, where its lower border can be felt. The internal anal sphincter is 2.5 cm long and 2 to 5 mm thick. When exposed during life, it is pearly white in colour, and its individual transversely placed fibres can be seen clearly. Spasm and contracture of this muscle play a major part in fissure and other anal affections. The longitudinal muscle is a continuation of the longitudinal muscle coat of the rectum intermingled with fibres from the puborectalis. Its fibres fan out through the lowest part of the external sphincter, to be inserted into the true anal and perianal skin. The longitudinal muscle fibres that are attached to the epithelium provide pathways for he spread of perianal inimons, and mark out tight compartments that are responsible for the intense pressure and pain that accompany many localised perianal lesions. Fig. 54.1 The musculature of the anal canal. Beneath the anal skin lie the scanty fibres of the corrugator culls ani muscle. The external sphincter, formerly subdivided into a deep, superficial, and subcutaneous portion is now considered lobe one muscle (Goligher). Some of its fibres are attached posteriorly to the coccyx, while anteriorly they are inserted into the midperineal paint in the male, whereas in the female they fuse with the sphincter vaginae. In life the external sphincter is pink in colour, and homogeneous. Unlike the pale internal sphincter muscle, which is involuntary, the red external sphincter is composed of voluntary (somatic) muscle. Between the internal (involuntary) sphincter and the external (voluntary) sphincter muscle mass is found a potential space the intersphinc.teric plane. This plane is important as it contains the basal parts of 8-12 apocrine glands, which can cause infections, and it is also a route for the spread of pus. It can also be opened up by a surgeon to provide access for operations on the sphincter muscles. The puborectalis plays a key role in maintaining the angle between the anal canal and rectum and, hence, is essential for the preservation of continence (Fig 54.2). There is a close association between the puborectalis portion of the levator ani and the external sphincter muscle. The mucous membrane. The pink columnar epithelium lining the rectum extends

through the anorectal ring into the surgical anal canal. The mucosa of the upper anal canal is attached loosely to the underlying structures, and covers the internal rectal plexus. Passing downwards where it clothes the series of 812 longitudinal folds known as the columns of Morgagni, the mucous membrane becomes cubical, and red in colour (Fig. 54.3); above the anal valves the mucous membrane becomes plum coloured. Just below the level of the anal valves there is an abrupt, albeit wavy, transition to squamous epithelium, which is parchment colour. This wavy junction constitutes the dentate line. The squamous epithelium lining the lower anal canal is thin and shiny, and is known as the anoderm. This squamous epithelium differs from the true skin in that it has no epidermal appendages. i.e. hair and sweat glands. The anoderm passes imperceptibly into the pigmented skin of the anus. At the dentate line the anoderm is attached very firmly indeed to deeper structures. FIg. 64.2 The disposition of the puborectalis muscle. Note how it maintains the rectoanal angle. FIg. 64.3 The lining membrane of the anal canal with duct opening into a crypt of Morgagni. Fig. 64.4 Anal gland.. The dentate line is a most important landmark both morphologically and surgically. It represents the site of fusion of the proctodaeum and post-allantoic gut, and the position of the anal membrane, remnants of which may frequently be seen as anal papillas situated on the free margin of the anal valves. The dentate line separates: above cubical epithelium autonomir nerves (insensitive) portal venous system below from squamous epithelium from spinal nerves (very sensitive) from systemic venous system. The anal valves of Ball are a series of transversely placed semilunar folds linking the columns of Morgagni. They lie along and actually constitute the waviness of the dentate line. They are functionless remnants of the fusion of the postallantoic gut with the proctodaeuxn. The crypts of Morgagni (syn. anal crypts) are small pockets between the inferior extremities of the columns of Morgagni. Into several of these aypts. mostly those

situated posteriorly, opens one anal gland by a narrow duct. This duct bifurcates, and the branches pass outward to enter the internal sphincter muscle, in 60 per cent of people (Fig. 54.4). Issuing from this ampulla there are 3-6 tubular sub-branches that extend into the intermuscular connective tissue, where they end blindly. In some lower animals, these glands secrete an odoriferous substance during the rutting season; in humans, their function, if any, is obscure. Some of their cells have been shown to give a positive staining reaction for mucin, but as the lining epithelium is mainly cubical, the mucus-secreting propensity of the anal glands must be extremely small. Infection of an anal gland can give rise to an abscess, and in the opinion of a number of surgeons, infection of an anal gland is the most common cause of anorectal abscesses and fistulas. The anoredtal ring marks the junction between the rectum and the anal canal. It is formed by the joining of the puborectalis muscle (Fig. 54.2), the deep external sphincter, conjoined longitudinal muscle, and the highest part of the internal sphincter. The anorectal ring can be clearly felt digitally, especially on its posterior and lateral aspects. Division of the anorectal ring results in permanent incontinence of faeces. The position and length of the anal canal, as well as the angle of the anorectal junction, depends to a major extent on the integrity and strength of the puborectalis muscle sling. Arterial supply. The anal canal is supplied by branches from the superior, middle and inferior haemorrhoidal arteries. The most important is the superior haemorrhoidal, whose left branch supplies tlte left half of the canal by a single terminal branch, while its right has two terminal branches. All the arteries contribute to a rich submucous and intramural plexus, so that interruption of the arterial supply from above by division of the superior and middle rectal arteries does not deprive the anus of its blood supply. Venous drainage. The anal veins are distributed in similar fashion to the arterial supply. The superior and middle haemorrhoidal veins drain via the inferior mesenteric vein into the portal system, having become the superior rectal vein en route. The superior haemorrhoidal vein drains the upper half of the anal canal. The inferior haemorrhoidal veins drain the lower half of the anal canal and the subcutaneous perianal plexus of veins: they eventually join the external iliac vein on each side. Lymphatic drainage. Lymph from the upper half of the anal canal flows upwards to drain into the postrectal lymph nodes and from there goes to the para-aortic nodes via the inferior mesentenc chain. Lymph from the lower half of the anal canal drains on each side first into the superficial and then into the deep inguinal group of lymph glands. However, if the normal flow is blocked, e.g. by tumour, the lymph can be diverted into the alternative route.

Surgical physiology of the anal muscles and pelvic floor The function of the anal canal and pelvic floor muscles is to not only contain the contents of the rectum, but to allow effortless, unimpeded voiding at defaecation. Interference with the integrity of the anatomy or physiology of the muscles of the anus and pelvic floor can lead to the extremes of intractable constipation or incontinence. If the muscles of the pelvic floor become too floppy, the entire anorectal mechanism can drop down (pertneal descent), or alternatively can gape open, so allowing intussusception and prolapse of the rectum. If the puborectalis and anorectal ring of muscles fail to relax appropriately (socalled inappropriate function or anismus) to allow the rectum to empty at defaecatioti, obstructed defaecation ensues: this can usually be overcome by excessive voluntary straining efforts, but frequently ends in intractable constipation. Excessive straining can cause both partial and complete rectal prolapse. When a patient presents with incontinence caused by weak or damaged anorectal musculature, or if bizarre or extreme complaints of constipation are elicited, it is now possible to investigate these symptoms to obtain objective data on which to base a management protocol (Swash and Henry). The length, resting tone and the power to relax and contract the anal sphincter muscles can be assessed by manometry and electromyography (Figs 54.5, 54.6 and 54.7): these studies can be combined with delineation of rectal sensibility and function by balloon distension and radiology (defaecatory proctography) and the abnormalities identified. In addition to the intrinsic defects, mechanical deviations can also be mapped: the level and angle of the anorectal junction can be established by clinical observation, and by an appliance (perineometer) . Furthermore, it is possible to take radiographs of the acts of straining and evacuation while simultaneously recording electromyographs of the sphincter musdes and intrarectal pressure (Williams) (Fig. 54.8). This integrated dynamic proctography, together with the other techniques of investigation, provides information which enables many patients with incontinence and constipation to be treated effectively. Fig. 54.5 A typical, normal pull-through manometric study of the anal canal (35 cm long; maximal pressure 60 cm H20 approx.). Fig. 54.6 A typical, normal electromyographic study of the external sphincter during various activities. FIg. 54.7 An electromyographic study of the external sphincter showing prolonged inhibition on straining and absent cough reflex. This is typical of a denervated patulous sphincter.

EXAMINATION OF THE ANUS

This requires careful attention to circumstances. The examining couch should be of sufficient height to allow easy inspection and access for any necessary manoeuvres. A good light is mandatory. The Sims (left lateral) or the lithotomy position are satisfactory: the latter is less convenient for an elderly patient and can cause social embarassment to young women. A protective glove should be worn. The patient should be relaxed and able to co-operate. A few quiet words from the doctor can prevent many loud ones from the patient. Inspection. With the buttocks opened, the anus is inspected. Note is made of any lesions, e.g. infla~matory skin changes. haemorrhoids, fissure (sentinel pile), or fistula. The patient is asked to strain down before inspection is concluded. Digital examination with the index finger. A good lubricant is necessary neither too little nor too much. Any secretions should be sampled before applying lubricant to the anal verge. Extreme gentleness should be the rule so that pain is not caused. Painful spasm of the anal sphincters is confirmation of a hidden fissure if the history is suggestive. The examination should check normal, as well as abnormal, structures according to the following plan: intraluminal normal: faeces abnormal: polyp or carcinoma intramural normal: sphincter muscles and anorectal angle abnormal: leiomyoma or carcinoma extramural normal: perianal structures abnormal: abscess. FIg. 64.8 Integrated dynamic proctography. (a) At rest; (b) during evacuation. Vlsualisation of the rectum as achieved by using barium impregnated synthetic stool. The effects of straining and evacuation on the EMG activity of the sphincter muscles arid intrarectal pressure can be simultaneously recorded (Williams). At the same examination, the rectum is examined according to the same system. Before withdrawing the finger, the patient is asked again to strain down, and a note is made regarding the prostate in a male patient and the cervix, uterus and pouch of Douglas in a female.

Discharge. After withdrawal, the finger is examined for mucus, pus, blood and abnormal faecal material. FIg. 64.9 An Hlumanated practoscope. Fig. 54.10 Knee-elbow positron for proctoscopy. Proctoscopy (Fig. 54.9). This examination is of great importance. Either the Sims position with the buttocks elevated on a small cushion, or the kneeelbow position (Fig. 54.10) may be used. The lower third of the rectum, the anorectal junction and the anal canal can be inspected as the instrument is withdrawn slowly. The patient should also be asked to strain during withdrawal as by so doing an internal intusussception may be made visible. Minor procedures can be carried out through this instrument, e.g. treatment of haemorrhoids by injection or banding (see below) and biopsy. Sigmoidoscopy (Chapter 53). Although this is strictly an examination of the rectum and lower sigmoid colon, it should be carried out even when an anal lesion has been confirmed. Rectal pathology, e.g. colitis or carcinoma, is frequently the cause of an anal lesion, e.g. fissure or haemorrhoids. Not infrequently, rectal pathology is found that is independent of the anal lesion and which requires treatment. Special investigations. These are discussed above and are not used routinely.

CONGENITAL ABNORMALITIES
Early in embryonic life there is a common chamber the cloaca into which open the hind gut and the allantois. The c.loaca becomes separated into the bladder and postal]antoic gut (rectum) by the downgrowth of a septum. About this time an epiblastic bud, the proctodaeum, grows in towards the rectum. Normally fusion between these two structures occurs during the third month of intrauterine life. Imperforate anus. (The term is used as a well-recognised description. Strictly it should be agenesis and atresia of the rectum and anus.) One infant in 4500 is born with an imperforate anus, or with imperfect fusion of the postallantoic gut with the proctodaeum. The condition is divided into two main groups: the high and the low, depending on whether the termination of the bowel is above or below the pelvic floor. The low varieties are easy to diagnose, relatively simple to treat, and the outlook is good. The high varieties often have a fistula into the urinary tract

together with a deficient pelvic floor, and are difficult to treat. Low abnormalities (Fig. 54.11). Covered anus: the underlying anal canal is covered by a bar of skin with a track running forward to the perineal raphe. The track should be opened with scissors, followed by routine dilatation of the anus. Ectopic anus: the anus is situated anteriorly and may open in the perineum in boys, or more commonly in the vulva in girls, or rarely into the vagina. A plastic cut-back operation is required (Pena). Stenosed anus: the anus is microscopic, but careful examination usually reveals a minute opening which responds to regular dilatation. Membranous stenos is: here the anus is normally sited, but is covered with a thin membrane which bulges with retained meconium. It is rare, and an incision will cure the condition. Fig. 64.11 Low abnormalities of the anus: (a) covered anus, (b) vutval ectopic anus, (c) anal stenosis, and (d) anal membrane. High abnormalities (Fig. 54.12). These are often associated with a fistulous connection between the blind rectal stump and the bladder, or other abnormalities of the pelvic structures. Anorectal agenesis. A blind rectal pouch lies just above the pelvic floor its anterior aspect in the male is attached to the bladder and often there is a rectovesical fistula manifested by the passage of gas or meconium in the urine. In the female, the fistula is usually into the posterior fornix. Rectal atresia. The anal canal is normal but ends blindly at the level of the pelvic floor. The bowel also ends blindly above the pelvic floor without a fistulous opening. This anomaly is rare but must be treated by mobilisation of the rectum and excision of the stricture. After that, end-to-end anastomosis of the anus and rectum must be attempted. More conservative measures are followed by an intractable stricture. Cloaca. This occurs only in females and here the bowel, urinary and genital tracts all open into a common wide cavity. Commonly severe malformations of the area are associated with other developmental abnormalities, e.g. tracheobronchial fistula. FIg. 54.12 Hiph abnormalities: (a) anorectal agenesis with rectourethrsi flstula, and (b) rectal atresia. Clinical management. As congenital abnormalities are frequently multiple, very careful general examination of the baby must be made to exclude any other

anomalies. It is urgent and important to determine whether the abnormality is high or low, and a radiograph will help. Radiological examination. Six hours after birth sufficient air may have collected in the large intestine to cast an x-ray shadow. With a metal button or a coin strapped to the site of the anus, or a metal bougie inserted into the blind anal canal, the infant is held upside down for 3-4 minutes and radiographed in the inverted position (Fig. 54.13). The gas in the rectum will rise to the top and indicate the distance between the site of the metal indicator and the blind end of the rectum. If the distance is over 2~5 an, the abnormality is high. This method, though useful, is sometimes vitiated by a plug of meconium in the rectum causing an apparent gap far in excess of that actually present. It may be necessary to wait until the baby is 24 hours old before rectal gas appears. Fig. 54.13 Radiograph of neonate whilst held upside down to show gas in the rectum. Anal dimple is marked by a piece of lead shot. Where a high lesion is suspected, an effort must be made to obtain a specimen of urine the presence of proteus or pyocynaneus usually signifies that a fistula is present. An i.v. urogram is recommended by some, even though there is a definite radiation risk. There may be gas in the bladder. A diagnostic perineal exploration is usually unwise it may prejudice the chances of further surgery. Treatment. In the low abnormalities, this is usually simple and has been outlined when each condition was described above. The high abnormalities present a very difficult problem and each case must be considered on its merits. On the whole, newborn babies stand surgery very well, provided compatible blood is available and a dear airway is maintained postoperatively and inhalation of vomit prevented by nasogastric suction. The presence of other congenital abnormalities is also a most important factor to consider. The possibilities are: laparotomy, division of rectourethral fistula, and transverse colostomy. A rectal pull-through operation can be done later; laparotomy. division of fistula. and pull-through operation in one stage; division of the flstula and rectal pull-down operation through the 1) penneal or 2) sacral route (this method is now rarely used); colostomy only (for the cloacal variety). For the pull-through operation the lower bowel is mobilised, and a new passage is created through the pelvic floor by passing a pair of curved forceps through it, keeping close to the urethra, to the site of the future anus. This is dilated by

Hegars dilators so that the bowel can be pulled down.and its mucosa stitched to the skin of the newly formed anus. In general, daily dilatation will be required for at least 3 months and it may be necessary for years. In a high percentage of cases, imperforate anus is associated with other congenital abnormalities, especially of the urinary organs, and nearly half the deaths in cases of imperforate anus are due to other malformations. Sacrococcygeal teratoma, although rare, is among the most common of the large tumours seen during the first 3 months of life. The frequency of the precoccygeal region for the development of a teratoma is explained by the fact that this area is the site of the primitive knot, a group of totipotent cells that retain their totipotenliality longer than any others save the sex anlage. Females are more often affected than males. The tumour, which arises between the sacrum and the rectum, is firmly attached to the coccyx and, occasionally, to the last piece of the sacrum. At the time of birth some of these tumours are huge, and in 20 per cent of cases the infant is stillborn. The tumour tends to be large (Fig. 54.14), but it can be small enough to pass unnoticed until it enlarges or a complication ensues. It is this variety that is prone to become malignant, usually at about 10 months of age. Treatment. Removal soon after birth; delay is liable to result in fatal ulceration, infection, rectal or urinary obstruction, or malignant change. Operation: excision is undertaken through a longitudinal elliptical incision, the coccygeal attachment being left until the last. The coccyx must always be excised; occasionally the last piece of the sacrum must be removed also. There may be a fistula between the tumour and the rectum, but as a rule this is small, and can be closed safely without performing a colostomy. The dead space in the pelvis is drained, the skin is united, and a pressure dressing applied. When the operation is undertaken soon after birth, the prognosis is good. Postanal dermoid. The space in front of the lower pact of the sacrurn and coccyx is occupied by a soft, cystic swelling a postanal dermoid cyst which is regarded as a simple form of teratoma. Hidden in the hollow of the sacrum, it is unlikely to be discovered unless a sinus communicating with the exterior is present, or develops as a result of inflammation. Such a cyst usually remains symptomless until adult life, when it is prone to become infected. Exceptionally, by its very size, it gives rise to difficulty in defaecation. The cyst is easily palpable on rectal examination. Differential diagnosis. Especially in a child, an anterior sacral meningocele must

be excluded. The latter enlarges when the child cries, and is frequently associated with paralysis of the lower limbs, and incontinence. When a discharging sinus is present, a postanal dermoid will probably be mistaken for a pilonidal sinus, unless pressure over the sacrococcygeal region with a finger in the rectum causes a flow of sebaceous material, and injection of contrast and radiography reveals a bottlenecked cyst in front of the coccyx. Treatment is complete excision of the cyst, and sinus if present. In the case of large cysts it is necessary to remove the coccyx in order to gain access. Postanal dimple (syn. fovea coccvgea). A dimple, sometimes amounting to a short, blind pit, in the skin beneath the tip of coccyx, is noticed from time to time in the course of a clinical examination.

PILONIDAL SINUS
Pilonidal means hair nest and Pilonidal sinus refers to a chronic sinus in the intergluteal cleft, of the associated with entrapped tufts of hair. Aetiology. Some authers supports the congenital theory of pilonidal sinus is a developmental defect results in ectodermal inclusions in the gluteal cleft. The majority support the acquired theory of pilonidal sinus due to: -Interdigital pionidal sinus is an occupational disease of hairdressers. Also pilomdal sinuses of the axilla and umbilicus have been reported. -The age of appearance of pilonidal sinus is not seen before puberty. -Hair follicles have almost never been demonstrated in the walls of the sinus. -The hairs projecting from the sinus are dead hairs, with their pointed ends directed towards the blind end of the sinus. -The disease mostly affects men. -Recurrence is common, even though adequate excision of the track is carried out. FIg. 54.14 Sacrococcygeal teratoma The mode of origin of a pilonidal sinus is now believed to be as follows: on sitting, the buttocks take the weight of the body, and move independently, or together. Hairs broken off by friction against clothing, and shed short hairs, whether originating from the nape of the neck, back, or buttocks, tend to collect in the cleft of the nates and/or a postanal dimple. Furthermore, it is suggested that the

use of toilet paper may contribute to hair entangled in faecal matter being swept into the cleft; pilonidal sinus is extremely rare in those races that employ ablution after defaecation. By reason of the shearing action of the buttocks, which is increased by sitting on a hard seat, and especially by vibration of a vehicle, loose hair travels down the intergluteal furrow, to penetrate the skin or the open mouth of a sudoriferous gland, such glands being more active in early manhood. It is not yet dear whether the initial entry of hairs through the skin is a primary event, or follows the softening of the skin due to pustular or other forms of dermatitis. Once a sinus has formed, intermittent negative pressure of the area may suck other loose hairs into the pit. So common was pionidal sinus among jeep riders in the 1935 45 war, that it became known as jeep bottom. Pathology. The sinus extends into the subcutaneous planes as an infected track. Branching side channels are not infrequent. A stratified squamous epithelial lining, of varying degrees of integrity, is found in about half the cases. Hair shafts are found either lying loose in the sinus, embedded in granulation tissue, or deep in mature scar tissue in three-quarters of the cases. Foreign-body giant cells are common. The primary sinus may have one, or as many as six openings, all of which are strictly in the midline between the level of the sacrococcygeal joint and the tip of the coccyx. Unlike a fistula in ano, the sinus passes upwards and forwards towards the sacrum. It does not reach bone, but ends blindly near the bone. When an abscess forms it may discharge through a primary sinus; more frequently it points and bursts, or is incised to one side of the midline (usually the left), thus forming a secondary sinus. Clinical features. -There is a chronic sinus in the midline at the level of the first piece of the coccyx. Typically, a tuft of hairs projects from its mouth. -The discharge from the sinus is often bloodstained, contains foul sebum, and sometimes hairs. -Secondary openings may be present on either side of the midline, often far out on to the buttocks or in the perineum. -Pain, or a tender swelling at the bottom-of the spine -A history of repeated abscesses in the region that have discharged spontaneously or have been incised Incidence symptoms usually commence during the third decade. Males to females ratio is 4 to 1. Patients are usually obese. The condition is practically confined to white races.

Treatment Conservative treatment. Patients for the first time with mild symptoms can sometimes be cured by cleaning out the track, removing all hairs from the area, followed by frequent washing of the parts with a detergent and water, and applying equal parts of witch hazel (liq. ext. hamamelis) and alcohol. Long sitting, e.g. driving a car, is avoided if possible. Treatment of an acute exacerbation (abscess). If rest, baths, local antiseptic dressings, and the administration of a broad-spectrum antibiotic fail to bring about resolution, the abscess should be opened through a comparatively small incision. Provided all hairs and granulation tissue are removed from the abscess cavity, there is some prospect of curing the lesion (Millar). After it has been cleaned out, the track can be destroyed by careful instillation of pure phenol solution (Maurice). In all other circumstances, an elective operation must be planned. Chronic pilonidal sinus: The patient is placed on the operating table, for preference in the jack-knife position. Methylene blue is injected into the sinus to colour all the tracks. Variations in operative technique include the following. Marsupialisation: Lay open the tracks, remove all debris and hair, and suture the edges to the skin. Excise all the tracks, as stained by blue dye, meticulously secure haemostasis by diathermy and catgut ligature and, using sutures, coapt the subcutaneous fat and skin very accurately and institute a drain and suction (i.e. Redivac) for 48 hours to remove blood and serum. In cases of extensive sinus formation, primary cover may be achieved by rotating a flap of skin and fat. Excise all the tracks as stained by the blue dye and, after securing haemostasis as above, pack the wound. The following day the whole dressing is removed, and daily baths and moist dressings are instituted until the wound heals by granulation. A elastic elastomer pack is particularly useful for dressing the wound as it can be removed, washed and reinserted by the patient, and ensures that the wound heals from below. Epithelialisation can sometimes be speeded up by skin grafting. Recurrent pilonidal sinus. Three possibilities account for this disappointment: a diverticulum of the main channel has been overlooked at the primary operation; new hairs enter the skin or the scar; when the natal fold is deformed by scarring, the least trauma causes teasing of the scar, and the resulting crevice becomes contaminated with colilorm and cutaneous bacteria.

ANAL INCONTINENCE
The origins of anal incontinence causes relating to: descent perineal descent prolapsing haemorrhoids rectal prolapse destruction malignant tumours irradiation debility illness old age deficiency congenital abnormalities damage wounds surgical procedures childbirth denervation spinal injuries neurosurgical procedures spina bifida dementia senility psychological abnormality Of these causes, geriatric, traumatic, and obstetric cases predominate with anal surgical procedures an important contributor to the traumatic group. Another major cause in women is pudendal nerve neuropathy may derive from, which results from chronic straining, perineal descent and a traction injury to the nerve. This type of incontinence used to be termed idiopathic but neurophysiological studies have determined its true nature. Once the cause of the incontinence has been precisely defined by a careful history and meticulous examination, supported by special investigations as indicated (see above), treatment may be possible. Surgical procedures have been developed to repair and support damaged or weak sphincter muscles. These may be classified as follows. Operations to reunite divided sphincter muscles.

The sphincter muscles may have been divided as a result of direct trauma, operations for fissure and fistula or by obstetrical injury. The ends of the divided muscle are found and reunited by a double overlap repair (Fig. 54.15) Fig. 54.15 Direct sphincter repair in which (a) the sphincter defect is excised and (b) the remaining muscle is overlapped. (Redrawn from Mann. C.V. and Glass, R.E., Surgical Treatment of Anal Incontinence, published by Springer-Verlag. 1991.) Operations to reef the external sphincter and puborectalis muscle. If the sphincter muscles are stretched and patulous (as they often are in old age and cases of rectal prolapse) they may be tightened by a postanal repair. These operations use dams of absorbable material to narrow down and plicate the external sphincter and the puborectalis sling . (Fig. 54.16). They restore length to the anal canal, strength to the anal sphincter and angulation to the anorectal junction. The approach is usually through the intersphincteric plane. Fig. 54.16 Postanal repair in which (a) the sphincter muscle is plicated posterior to the anal canal, thus restoring the anorectal angle; (b) the completed repair. Operations to support the anal canal. If the anal canal is gaping and has feeble musdes that cannot be strengthened by direct means, support can be given by encircling stitches or Mersilene strands after the Thiersch operation pattern (Chapter 53). However, these techniques are not popular since the sutures may erode into the anal canal or cause an impediment to satisfactory evacuation and have now been abandoned. Recently, attempts have been made to create a new anal sphincter by transposing the gracilis muscle around the anal canal and stimulating it electrically by a pacemaker (Williams) (Fig. 54.17). This appears a promising technique and is effective in approximately 60 per cent of patients who have previously had more conventional operations. All these procedures achieve best results if the bowel habit is regulated and a normal defaecatory pattern established over the pre- and postoperative periods. The operations should be covered by antibiotics active against both aerobic and anaerobic organisms to reduce the risk of septic complications. If any of these procedures fail or are contraindicated, the patient may require a permanent colostomy. FIg. 54.17 Electrically stimulated gracilis neosphincter in which the gracilis muscle is transposed around the anal canal and the muscle is stimulated visa totally

implanted pacemaker. In this way, the muscle is converted from a fast-twitch fatiguable muscle to a slow-twitch nonfatiguable muscle. The stimulator can be turned off by use of a magnet. (Redrawn from Wtlltams etal.. Development of an electronically stimulated neoanal sphincter, by The Lancet Ltd. 338. p. 1167, 1991, by permissIon.)

ANAL FISSURE
Definition. An anal fissure (syn. fissure in ano) is an elongated ulcer in the long axis of the lower anal canal. Location. The site of election for an anal fissure is the midline posteriorly (90 per cent overall). The next most frequent situation is the midline anteriorly. Aetiology. The cause of anal fissure, and particularly the reason why the midline posteriorly is so frequently affected, is not completely understood. A probable explanation is as follows: the posterior wall of the rectum curves forwards from the hollow of the sarmm to join the anal canal, which then turns sharply backwards. During defsecaUon the pressure of a hard faecal mass is mainly on the posterior anal tissues, in which event the overlying epithelium is greatly stretched and, being relatively unsupported by muscle, is placed ins vulnerable position when a scybalous mass is being expelled. Possibly some cases are due to tearing down of an anal valve of Ball. An anterior anal fissure is much more common in women, particularly in those who have borne children. This can be explained by the lack of support of the anal mucous membrane by a damaged pelvic floor and an attenuated perineal body. Some causes of anal fissure are certain: an incorrectly performed operation for haemorrhoids in which too much skin is removed. This results in anal stenosis and tearing of the scar when a hard motion is passed; inflammatory bowel disease particularly Crohns disease; sexually transmitted diseases. Pathology. An anal fissure is either acute or chronic. The upper internal end of the fissure stops at the dentate line. Because the fissure occurs in the stratified sensitive epithelium of the lower half of the anal canal, pain is the most prominent symptom (see below). Acute anal fissure is a deep tear through the skin of the anal margin extending into the anal canal. There is little inflammatory induration or oedema of its edges.

There is accompanying spasm of the anal sphincter muscle. Chronic anal fissure is characterised by inflamed indurated margins, and a base consisting of either scar tissue or the lower border of the internal sphincter muscle. The ulcer is canoe-shaped, and at the inferior extremity frequently there is a tag of skin, usually oedematous. This tag is known picturesquely as a sentinel pile sentinel because it guards the fissure. There may be spasm of the involuntary musculature of the internal sphincter. In long-standing cases, this muscle becomes organically contracted by infiltration of fibrous tissue. Infection is common and may be severe, ending in abscess formation. A cutaneous fistula may follow. Chronic fissure in ano may have a specific cause often a granulomatous infection, e.g. Crohns disease or syphilis. Biopsy examination is advisable of any tissue removed at operation for a chronic fissure. Specific fissures of this type are often less painful than the appearances of the lesion would suggest. Clinical features. The condition is more common in women, and generally occurs during the meridian of life. It is uncommon in the aged, because of muscular atony; on the other hand, anal fissure is not rare in children, is sometimes encountered during infancy, and may cause acquired megacolon (Chapter 50). Pain is the symptom sharp, agonising pain starting during defaecation, often overwhelming in intensity and lasting an hour or more. As a rule, it ceases suddenly, and the sufferer is comfortable until the next action of the bowel. Periods of remission occur for days or weeks. The patient tends to become constipated rather than go through the agony of defaecation. (One patient accustomed himself to take a generous dose of senna on Saturday night, and retire to the toilet on Sunday morning with a boffle of whisky and the newspaper.) Bleeding this is usually slight and consists of bright streaks on the stools or the paper. Discharge. A slight discharge accompanies fully established cases. On examination. In cases of some standing, a sentinel skin tag can usually be displayed. This, together with a typical history and a tightly closed, puckered anus, is almost pathognomonic of the condition. By gently parting the margins of the anus, the lower end of the fissure can be seen (Fig. 54.18). Because of the intense pain it causes, digital examination of the anal canal should not be attempted at this stage unless the fissure cannot be seen, or it seems imperative to exclude major intrarectal pathology. In these circumstances, the local application of a surface anaesthetic such as 5 per cent Xylocaine on a pledget of cotton wool, left in place for about 5 minutes, will enable the necessary examination to be made. In early cases, the edges of the fissure are impalpable; in fully established cases, a characteristic crater which feels like a vertical buttonhole can be palpated. The

diagnosis must be established beyond doubt, for which a general anaesthetic may be required. Fig. 54.18 The appearances of an anal fissure, If the buttocks are gently parted, the presence of an anal fissure can usually be detected as an ulcer of variable depth with a skin tag and an anal papilla. Differential diagnosis Carcinoma of the anus in its very early stages easily simulates a fissure. If real doubt exists, the lesion must be excised under general anaesthesia and submitted to histological examination. Multiple fissures in the perianal skin are commonly seen as a complication of skin diseases, scratching and inflammatory bowel disease. Also homosexual practices (sodomy, listing and the use of anorectal sex toys, Fig. 53.8) and anorectal sexually transmitted disease can cause multiple fissures in both sexes. Anal chancre is becoming more common and may present as a painful rather than a painless ulcer. The serous discharge contains spirochaetes. A glass pipette is used to aspirate a few drops which are placed on a slide for examination by dark-ground illumination. Lubricating gel from the fingerstall may prevent adequate aspiration of serum from a chancre. All patients with anal sexually transmitted disease, and admitted homosexuals, should be tested for a positive serological response to HTV as they max have AIDS (Chapter 7). Tuberculous ulcer has an undermined edge. Proctalgia fugax (see below) causes severe episodic pain. Treatment The pain of an anal fissure is so great that usually the patient demands relief, and consequently many patients with an acute fissure present early. The object of all treatment for this condition is to obtain complete relaxation of the internal sphincter. Provided the complications are dealt with, the fissure will slowly heal as soon as all spasm has disappeared. Conservative treatment. In cases where the fissure is acute and superficial and where the inflammation is minimal, simple conservative measures will usually give relief. Xylocaine 5 per cent in a watersoluble lubricant is introduced with a fine nozzle into the anal canal. After waiting a few minutes for the surface anaesthetic to act, relaxation may be sufficient to permit the passage of a well-lubricated finger into the canal. Following this, a small anal dilator may be passed and, if the anaesthesia is adequate, it may be

possible to introduce the largest dilator. Anal dilators are commonly made in three sizes, and it may not be possible to use the largest dilator until several days have passed. The patient is supplied with xylocaine lubricant and instructed to pass a dilator twice a day for a month, by which time the fissure is usually healed. Laxatives are prescribed to ensure that the motions are soft, but the stools should not be made watery: Celevac tablets give a soft stool of good bulk, which is ideal. Operative measures. The simplest procedure is wide, yet gentle, dilatation of the sphincter. Under general anaesthesia, the index and middle finger of each hand are inserted simultaneously into the anus and carefully pulled apart dilating the anus so that its diameter is no greater than four finger breadths. Great care and judgement should be exercised, so that the anal sphincter is not overstretched. The patient can go home the same day, but should be warned that there may be some minor faecal incontinence lasting possibly for a week or 10 days. This manoeuvre is contraindicated in any patient with a weak sphincter. Should these measures prove ineffective, or if the fissure is chronic with fibrosis, a skin tag, or a mucous polyp, then surgical measures are advisable. General anaesthesia is best, though some surgeons use a local anaesthetic in the form of Xylocaine or lignocaine introduced into the ischiorectal fossa on each side, in order to anaesthetise the nerves passing towards the rectum. In other situations, a caudal anaesthetic is suitable. Lateral anal sphincterotomy (Notaras). In this operation, the internal sphincter is divided away from the fissure itself usually either in the right or the left lateral positions. The procedure can be done by an open or a dosed method. Healing is usually complete within 3 weeks. The operation is more successful for acute than chronic fissures. Seventy-five per cent of cases are suitable for treatment by this method, which can be done as an outpatient procedure under local anaesthesia by an experienced surgeon. Dorsal Jl ssurectomy and sphincterotomy. The essential part of the operation is to divide the transverse fibres of the internal sphincter in the floor of the fissure. If a sentinel pile is present, this is excised. The ends of the divided muscle retract and a smooth wound is left. The after-treatment consists of attention to bowels, a daily bath, and the passage of an anal dilator until the wounds have healed, which usually takes about 3 weeks. Despite the presence of the wound, there is little or no pain and the results are good. The disadvantage of this operation is the prolonged healing time usually not less than 3 weeks and often longer and, occasionally, a mild, persistent and permanent mucus discharge. It is now reserved only for the most chronic or recurrent anal fissures, the majority being treated by lateral sphincterotomy.

HYPERTROPHIED ANAL PAPILLA

Anal papilas occur at the dentate line, and are remnants of the ectodermal membrane that separated the hindgut from the proctodaeum. As these papillas are present in fully 60 per cent of patients examined proctologically, they should be regarded as normal structures. Anal papiflas can become elongated, as they frequently do in the presence of an anal fissure. Occasionally, an elongated anal papilla may be the cause of pruritus. An elongated anal papilla associated with pain andior bleeding at detaecation is sometimes encountered in infancy. Haemorrhage into a hypertrophied anal papilla can cause sudden rectal pain. A prolapsed papills may become nipped by contraction of the sphincter mechanism after defaecation. Occasionally, a red oedematous papilla is encountered with local pain and a purulent discharge from the associated crypt. This condition of cryptitis may be cured by laying open the mouth of the infected anal gland and removing the papilla. Treatment. Using a slotted proctoscope, elongated papillas withOut haemorrhoids should be crushed and excised after injecting the base with local anaesthetic. When large papillae complicate internal haemorrhoids, this is an indication for operative treatment of the haemorrhoids, as well as excision of the elongated papillas.

PROCTALGIA FUGAX
This disease is characterised by attacks of severe pain arising in the rectum, recurring at irregular intervals and apparently unrelated to organic disease. The pain is described as cramp-like, often occurs when the patient is in bed at night, usually lasts only a few minutes, and disappears spontaneously. It may follow straining at stool, sudden explosive bowel action or ejaculation. It seems to occur more commonly in patients suffering from anxiety or undue stress, and also it is said to afflict young doctors. The pain may be unbearable it is possibly due to segmental cramp in the pubococcygeus muscle. It is unpleasant, incurable, but fortunately harmless and gradually subsides. A more chronic form of the disease has been termed the levator syndrome and can be associated with severe constipation. Biofeedback techniques have been used to help such patients: same surgeons have been willing to sever the puborectalis muscle, but this can cause incontinence.

HAEMORRHOIDS
syn. piles Haemorrhoids (Greek haima = blood, rhoos = flowing) are veins occurring in relation to the anus. Such haemorrhoids may be external or internal, i.e. external or internal to the anal orifice. The external variety are covered by skin, while the internal variety lie beneath the anal mucous membrane. When the two varieties are associated, they are known as interoexternal haemorrhoids. The veins which form internal haemorrhoids become engorged as the anal lining descends and is gripped by the anal sphincters. The mucosal lining is gathered prominently in three places (the anal cushions), which can be in the areas of the three terminal branches of the superior haemorrhoidal artery, but this is exceptional (Thomson). The anal cushions are present in embryonic life and are necessary for full continence. Straining causes these cushions to slide downwards, and internal haemorrhoids develop in the prolapsing tissues. Haernorrhoids may be symptomatic of some other condition, and this important fact must be remembered. Symptomatic haemorrhoids may appear: in carcinoma of rectum. This, by compressing or causing thrombosis of the superior rectal vein, gives rise to haemorrhoids (Fig. 54.19) sufficiently often to warrant examination of the rectum and the rectoaigtnoid junction for a neoplasm in every case of haemotrhoids; during pregnancy. Pregnancy piles are due to compression of the superior rectal veins by the pregnant uterus and the relaxing effect of progesterone on the smooth muscle in the walls of the veins, plus an increased pelvic circulating volume; from straining at micf urit ion consequent upon a stricture of the urethra or an enlarged prostate; from chronic constipation. The common people call them piles, the aristocracy call them haemorrhoids, the French call them figs what does it matter so long as you can cure them? column of blood unassisted by valves produces a high venous pressure in the lower rectum. unparallelled in the body. Except in a few fat old dogs, haemorrhaids are exceedingly rare in animals. Anatomical. The collecting radicles of the superior haemorrhoidal vein lie unsupported in the very loose submucous connective tissue of the anorectum. These veins pass through muscular tissue and are liable to be constricted by its contraction during defaecation. The superior rectal veins, being tributaries of the

portal vein, have no valves. Ertacerbatingfacf ova. Straining accompanying constipation or that induced by overpurgation is considered to be a potent cause of haemorrhoids. Less often, the diarrhoea of enteritis, colitis, or the dysenteries aggravates latent haemorrhoids. In both instances, descent and swelling of the anal cushions is a prominent feature. Fig. 54.19 Carcinoma of the rectum associated with haemorrhoids. A not infrequent diagnostic pitfall. NB. Contrary to the usual belief, in 128 consecutive cases of portal hypertension, Macpherson did not encounter a single example of haemorrhoids that could be attributed to portal cirrhosis, although bleeding oesophageal varices often complicate portal hypertension. The great majority of haemorrhoids are not symptomatic. The description that follows concerns symptomatic haemorrhoids that are not secondary to an underlying cause.

1. INTERNAL HAEMORRHOIDS
Definition. Internal haemorrhoids is a dilatation of the internal venous plexus within an enlarged displaced anal cushion. Because of the communication between the internal and external plexuses, if the former becomes engorged, the latter is liable to become involved also. Aetiology. Hereditary. The condition is so frequently seen in members of the same family as a congenital weakness of the vein walls or an abnormally large arterial supply to the rectal plexus. Varicose veins of the legs and haemorrhoids often occur concurrently. Morphological. In quadrupeds. gravity aids, or at any rate does not retard, return of venous blood from the rectum. Consequently venous valves are not required. In humans, the weight of the Pathology. Internal haemorrhoids are frequently arranged in three groups at 3, 7, and 11 oclock with the patient in the lithotomy position (in which patients used to be put for the classic operation of cutting for bladder stone via the urethral or the

perineal route (Chapter 55)). This distribution has been ascribed to the arterial supply of the anus whereby there are two subdivisions of the right branch of the superior rectal artery, but the left branch remains single (Fig. 54.20), but this is now known to be atypical. In between these three primary haemorrhoids there may be smaller secondary haemorrhoids. Each principal haemorrhoid can be divided into three parts: The pedicle is situated at the anorectal ring. As seen through a proctoscope, it is covered with pale pink mucosa. Occasionally, a pulsating artery can be felt in this situation. The internal haemorrhoid, which commences just below the anorectal ring. It is bright red or purple, and covered by mucous membrane. It is of variable size. An external associated haemorrhoid lies between the dentate line and the anal margin. It is covered by skin, through which blue veins can be seen, unless fibrosis has occurred. This associated haemorrhoid is present only in well-established cases. Fig. 54.20 Disposition of anal vasculature illustrating why hsemorrEdinburgh. Scotland. holds are classically sited at 3, 7 and 11 oclock. Entering the pedicle of an internal haemorrhoid may be a branch of the superior rectal artery. Very occasionally there is a haemangiomatous condition of this artery an arterial pile which leads to ferocious bleeding at operation. Degrees of hemorrhoids -First-degree haemorrhoid Haemorrhoids that bleed but do not prolapse outside the anal canal. -Second-degree haemorrhoid Haemorrhoids that prolapse on defaecation but return or need to be replaced manually and then stay reduced. -Third -degree haemorrhoid Haemorrhoids that are permanently prolapsed. Clinical features. -Bleeding is bright red rectal bleeding and occurs during defaecation is the earliest symptom -Prolapse great discomfort & feeling of heaviness in the rectum. -Discharge. A mucoid discharge from the engorged mucous membrane. -Pruritus will almost certainly follow this discharge. -Pain is absent unless complications as abscess or anal fissure. -Anaemia is rare due to persistent profuse bleeding from haemorrhoids.

Diagnosis -On inspection: When the patient strains, internal haemorrhoids may come into view transiently or, if they are of the third degree, they are, and remain, prolapsed. -Digital examination. Internal haemorrhoids cannot be felt unless they are thrombosed. -Proctoscopy reveals bluish mucosal bridges in classical 3,7,11 positions. -Sigmoidoscopy should be done to exclude higher lesions. -Barium enema should be performed if there is any suspicion of colonic pathology. Deferential diagnosis Rectal prolapse, pruritis, anorectal carcinoma, or inflammatory bowel disease. Fig. 54.22 An attack of piles. Prolapsed strangulated piles, as commonly seen, on the left. A less common mass on the right with a flbrofatty covering. TREATMENT Bowel education habit: about consuming a high-fiber diet with adequate liquid intake, and often a psyllium seed product for stool softening is advisable. Patients must avoid straining and decrease excessive time spent on the toilet. Conservative treatment: The bowel habits are regulated by introducing bran into diet + mild laxative. Astringent ointments & anaesthetic creams can be inserted into the rectum from a collapsible tube fitted with a nozzle, at night and before defaecation. Suppositories are also useful. Injection treatment: its aim is to produce submucosal fibrosis in the region of the base of the pile, with subsequent venous obliteration & adhesion of the mucous membrane to the underlying the muscle. The injection is made by a proctoscope at the point above main mass of each haemorrhoid. The solution spreads in the submucosa upwards to the pedicle, and downwards to the internal haernorrhoid and to secondary haemorrhoids if present, but it is prevented by the intermuscular septum from reaching the external haeniorrhoid. Banding treatment: treatment is available by slipping tight elastic bands on to the base of the pedicle of each haemorrhoid with Barrons apparatus. The bands cause ischaemic necrosis of the piles, which slough off within a few days. Cryosurgery. The application of liquid nitrogen as the extreme cold (196C) of the application causes coagulation necrosis of the piles which subsequently separate and drop off. The procedure is painless and can be done in the outpatient department. Photocoagulation. The application of infrared coagulation by a specially designed

instrument for the treatment of haemorrhoids that do not prolapse. This is said to be an effective and painless method of treatment. FIg. 54.23 Correct site for injecting a haemorrhoid. Fig. 54.24 Gabriels syringe (a) has now been replaced by disposable syringes (b). The instrument shown is poduced. by Rocket of London. Fig. 54.25 Barrons banding apparatus with the appearance of a typical banded haemorrhoid. Haemorrhoidectomy Indications for haemorrhoidectomy: third-degree haemorrhoids; failure of nonoperative treatments of second degree haemorrhoids; fibrosed haemorrhoids; interoexternal haemorrhoids when the external haemorrhoid is well defined. Preoperative treatment: An aperient is given on the evening before the operation and a soap-and-water enema is administered. The anal region is shaved. On the morning of the operation the rectum is evacuated with the aid of a disposable enema. Operation: Haemorrhoidectomy can be performed using an open or closed technique. The open technique is most commonly used in the UK, and is known as the Milligan Morgan operation named after the surgeons who described it. The closed technique is the popular technique in the USA. Both involve ligation and excision of the haemorrhoid, but in the open technique the anal mucosa and skin are left open to heal by secondary intention, and in the closed technique, the wound is sutured. Postoperative complications may be early or late. Early Pain, Retention of urine, haemorrhage Late Reactionary kaemon*age FIg. 54.26 Ligation and excision of haemorrhoids. Open technique: (a) the skin is cut to the left lateral haemorrhoid; ~) transflxion of the pedicle; (c) ligation. Fig. 54.27 The appearance of the anus at the conclusion of the operation. (NB. To avoid stricture formation It is necessary to ensure that a bridge of skin and mucous membrane remains between each wound.) FIg. 54.28 Closed technique of luemontsoidsctomy. (~ The haemorrhoudini tissue us exdmed ~ bleec~g is continued by dathermy; (c) the detect is closed with a continuoaa sutr,,re after 18st wrdem*~ng the anodstm on each side ~edawn torn

&age-y of the Anon, Cobs aid Recft,m, 3rd edt. pt.tlshed by W.B. Saunders. 1993. by pemsisaion). Complications of haemorrhoids 1.Profuse haemorrhage 2.Strangulation 3.Thrombosis 4.Ulceration 5.Gangrene occurs with tight 6.Fibrosis after thrombosis 7.Suppuration is uncommon 8.Pylephlebitis (=portal pyaemia) Treatment of complications -Strangulation piles may sometimes be reduced digitally after dilating the anal sphincter under anaesthesia. -Thrombosis and gangrene antibiotics then surgical excision. -Severe haemorrhage due to the use of anticoagulants local adrenaline compress + morphine & blood transfusion.

EXTERNAL HAEMORRHOIDS
Unlike internal haemorrhoids, external haemorrhoids consist of a conglomerate group of distinct clinical entities. A thrombosed external haemorrhoid is commonly termed a perianal haematoma. It is a small dot occurring in the perianal subcutaneous connective tissue, usually superficial to the corrugator cutis ani muscle. The condition is due to back pressure on an anal venule consequent upon straining at stool, coughing, or lifting a heavy weight. The condition appears suddenly and is very painful, and on examination a tense, tender swelling which resembles a semiripe blackcurrant is seen. The haematoma is usually situated in a lateral region of the anal margin. Untreated it may resolve, suppurate, flbrose, and give rise to a cutaneous tag, or burst and extrude the dot, or continue bleeding. In the majority of cases resolution or fibrosis occurs. Indeed, this condition has been called a 5-day, painful, self-curing lesion (Mulligan). Provided it is seen within 36 hours of the onset, a perianal haematoma is best treated as an emergency. Under local anaesthesia the haemorrhoid is bisected and the two halves are excised together with 1-25 cm of adjacent skin. This leaves a pear-shaped wound, which is allowed to granulate. The relief of pain is immediate

and a permanent cure is certain. On the rare occasions in which a perianal haematoma is situated anteriorly or posteriorly, it should be treated conservatively because of the liability of a skin wound in these regions to become an anal fissure. Associated with internal haemorrhoids = interoexternal haemorrhoids. These have been discussed. Dilatation of the veins of the anal verge becomes evident only if the patient strains, when a bluish. cushion-like ring appears. This variety of external haemorrhoid is almost a perquisite of those who lead a sedentary life. The only treatment required is an adjustment in habits of the patient. A sentinel pile is associated with an anal fissure (see above). Genital warts (Chapter 60).

PRURITUS ANI
This is intractable itching around the anus. Usually the skin is reddened hyperkeratotic and may become cracked and moist. The causes are numerous. A useful mnemonic is: pus, polypus, parasites, piles, psyche. Lack of cleanliness, excessive sweating, and wearing rough or woollen underclothing are common causes. An anal or perianal discharge which renders the anus moist. The causative lesions include an anal fissure, fistula in ano, prolapsed internal or external haemorrhoids, genital warts and excessive ingestion of liquid paraffin. A mucous discharge is an intense pruritic agent and a polyp can be the cause. A ye nat discharge, especially due to the Trichomonas vaginalis. arasitic causes. Threadworms should be excluded, especially in young subjects. Children suffering from threadworms should wear gloves at night, lest they scratch the perianal region and are ted with ova by nail biting Parasites lost, parasites regained. Scabies and pediculosis pubis may infest the anal region. Epidermophytosis is a common cause especially if the skin between the toes is also infected. Microscopic and cultural exarninations are essential. Half-strength Whitfields ointment quickly gives relief and is the sheet anchor of treatment. Allergy is sometimes the cause, in which case there is likely to be a history of other allergic manifestations, such as urticaria, asthma, or hay fever. Antibiotic therapy may be the precipitating factor. Skin diseases localised to the perianal skin psoriasis, lichen pIanos and contact dermatitis.

 Bacterial infection. lntertrigo due to a mined bacterial infection. Erthrasma due to Corynebocterium minutissimum is responsible for some cases and its presence is detected by ultraviolet light which induces a pink fluorescence. A psychoneurosis. It is alleged that in a few instances neurotic individuals become so Immersed in their complaint that a pain pleasure complex develops, the pleasure being the scratching. Possibly this is true, but such a syndrome should not be assumed without firm grounds for coming to this conclusion. Treatment. The cause is treated. Other methods include: Hygienic measures. Cotton wool should be substituted for toilet paper. Soap is avoided, and replaced by a detergent. These measures alone, combined with wearing cotton cellular underwear and applications of calamine lotion, are all that is necessary to cure some cases. If there is much anal hair trapping the moisture and discharge, shaving can be very helpful. Hydrocortisone. In cases with dermatitis, and only in cases with dermatitis, prednisolone, applied topically in a cream of 1 per cent is often beneficial; sometimes after discontinuation of the therapy, the pruritus is liable to return, in which event 5 per cent Xylocaine ointment can be substituted for a time. Strapping the buttocks apart is a most useful procedure, especially when the pruritus is acute, and in chronic cases when the opposing surfaces are moist. The strapping is worn so long as the patient finds it beneficial. Operative treatment. This may be necessary for a concomitant lesion of the anorectum which is thought to initiate or contribute to the pruritis. Otherwise, surgery is not indicated and the older operations described for this condition are no longer performed.

ANORECTAL ABSCESSES
In 60 per cent of cases the pus from the abscess yields a pure culture of Escherichia coli; in 23 per cent a pure culture of Staphylococcus aureus is obtained. In diminishing frequency, pure cultures of Bacteroides, a Streptococcus, or Proteus strain are found. In many cases the infection is mixed. In a high percentage of cases some estimate it as high as 90 per cent the abscess commences as an infection of an anal gland (Figs 54.29 and 54.30). Other causes are penetration of the rectal wall, e.g. by a fish bone, a blood-borne infection, or an extension of a cutaneous boil. Underlying rectal disease, such as neoplasm and

particularly Crohns disease, may be the cause. Similarly patients with generalised disorders, such as diabetes and more recently AIDS, may present with an anorectal abscess. The latter patients usually have abscesses which run an aggressive course. Fig. 54.29 To illustrate the spread of infection from the primary anal gland abscess (A) to the perianal region (B) and the ischiorectsl fossa (C). Fig. 54.30 The four types of anorectal abscess: (A) perianal, (B) ischiorectal, (C) submucous, and (D) pelvirectal. A large percentage of artorectal abscesses coincide with a fistula in ano. For this reason, anorectal abscess becomes a highly important subject. Moreover, as antibiotics cannot reach the contents of art abscess in adequate concentration, no reliance can be placed on antibiotic therapy alone. A fistula is much more likely if bacterial culture of the pus discloses bowel (as opposed to skin) organisms (Grace). Differential diagnosis. The only conditions with which an anorectal abscess is likely to be confused are an abscess connected with a pionidal sinus. Bartholins gland, or Cowpers gland. Classification A clear understanding of suppuration in this area is dependent on a concise knowledge of the anatomy (Figs 54.29 and 54.30). There are four main varieties: perianal, ischiorectal, submucous, and pelvirectal. Perianal (60 per cent). This usually occurs as the result of suppuration in an anal gland, which spreads superficially to lie in the region of the subcutaneous portion of the external sphincter (Fig. 54.30(A)). It may also occur as a result of a thrombosed external pile. If the haematoma is not evacuated, it may become infected and a perianal abscess results. This is the most common abscess of the region. Persons of all ages are affected, and the condition is not uncommon, even in infancy and childhood. The constitutional symptoms and the pain are less pronounced than in the ischiorectal abscess because the pus can expand the walls of this part of the intermuscular space comparatively easily. Early diagnosis is made by inspecting the anal margin, when an acutely tender, rounded, cystic lump about the size of a cherry is seen and felt at the anal verge below the dentate line. Treatment. No time should be lost in evacuating the pus. Operation. Thorough drainage is achieved by making a cruciate incision over the abscess and excising the skin edges this completely removes the roof of the abscess. Healing commonly occurs within a few days.

Ischiorectal abscess (30 per cent). Commonly, this is due to an extension laterally through the external sphincter of a low intermuscular anal abscess (Fig. 54.30(B)). Rarely, the infection is either lymphatic or blood borne. The fat, which fills the ischiorectaI fossa (Fig. 54.31), is particularly vulnerable because it is poorly vasculansed; consequently it is not long before the whole space becomes involved. The ischiorectal fossa communicates with that of the opposite side via the postsphincteric space, and if an ischiorectal abscess is not evacuated early, involvement of the contralateral fossa is not uncommon. Should an internal opening into the anal canal ensue, a horseshoe abscess develops enveloping the whole of the posterior part of the circumference of the anal canal (cf. horseshoe fistula). Fig. 54.31 The ischiorectal fossa. An ischiorectal abscess gives rise to a tender, brawny induration palpable on the corresponding side of the anal canal and the floor of the fossa. Constitutional symptoms are severe, the temperature often rising to 380C.-390C. Men are affected more often than women. Treatment. Operation should be undertaken early as soon as it is certain that an abscess is present in this area remembering that antibiotic therapy often masks the general signs. Operation. Stage 1. A cruciate incision (Fig. 54.32 inset) is made into the abscess. A portion of skin is sometimes excised (Fig. 54.32) but deroofing is not necessary in every case. Stage 2. As soon as the acute infection has subsided, the wound should be reexamined, preferably under general anaesthesia. A careful search is made for a fistulous opening communicating with the anal canal. If such is found, the treatment should be 55 for flstula. If no fistula is found, the cavity should be lightly packed with gauze wrung out in any weak antiseptic favoured by the operator. A T-bandage Is applied. When the cavity has become covered with granulation tissue skin grafting may help to expedite final epithelialisation. Fig. 54.32 lrtcision of an ischiorectal abscess. The cavity is explored and, if septa exist, they should be broken down gently with a finger, and the neccotic tissue lining the walls of the abscess should be removed by the finger wrapped in gauze. It is wise to biopsy the wall and send the pus for culture. Nothing further is done at this stage. Submucous abscess (5 per cent) occurs above the dentate line (Fig. 54.30(C)).

When it occurs after the injection of haemorrhoids, it always resolves. Otherwise, it can be opened with sinus forceps when adequately displayed by a proctoscope. Pelvirectal abscess is situated between the upper surface of the levator ani and the pelvic peritoneum (Fig. 54.30(D)). It is nothing more or less than a pelvic abscess and as such, is usually secondary to appendicitis, salpingitis, diverticulitis, or parametritis. Abdominal Crohns disease is an important cause of pelvic disease that can present as perianal sepsis (cf. fistula in ano). A relevant point to remember is that, rarely, a supralevator abscess/fistula may be due to overenthusiastic attempts to drain an ischiorectal abscess or to display a fistula, when a probe is forced through the levator anil rectal wall from below. Fissure abscess. This is the name given to a subcutaneous abscess lying in immediate association with an anal fissure. Drainage, is achieved at the same time as the fissure is treated by sphincterotomy.

FISTULA IN ANO
A fistula in ano1 is a track, lined by granulation tissue, which connects deeply in the anal canal or rectum and superficially on the skin around the anus. It usually results from an anorectal abscess which burst spontaneously or was opened inadequately (Fig. 54.29). The fistula continues to discharge and, because of constant reinfection from the anal canal or rectum, seldom, if ever, closes permanently without surgical aid. An anorectal abscess may produce a track the orifice of which has the appearance of a fistula, but it does not communicate with the anal canal or the rectum. By definition this is not a fistula, but a sinus. TYPES OF ANAL FISTULAS These are divided into two groups, according to whether their internal opening is below or above the anorectal ring. Low level. These open into the anal canal below the anorectal ring. High level. These open into the anal canal at or above the anorectal ring. As an alternative to the common anatomical classification illustrated in Fig. 54.33,

Parks produced another based on the origin of the fistula from an abscess in an anal gland situated in the plane between the internal and external sphincters (the anal intersphincteric plane) (Fig. 54.34). FIg. 54.33 Types of anal ftstula (standard classification): (1) subcutaneous, (2) submucous, (3) low anal, (4) high anal, and (5) pelvirectal. Fig. 54.34 Types of anal fistula: (1) intersphincteric, (2) transsphincteric (which may be high or low), and (3) supralevator. (After Sir Alan Parks.) The importance of deciding whether a fistula is a low- or a high-level type is that a low-level fistula can be laid open without fear of permanent incontinence (from damage to the anorectal bundle), while a high-level fistula can be treated only by staged operations, often with the use of a protective colostomy to prevent septic complications and to shorten healing time between the stages. In probing a high fistulous track, great care must be taken not to create an internal opening into the rectum where none existed previously. Such a disaster could convert a relatively straightforward intersphincteric track into a high pelvirectal fistula that might prove very difficult to cure. By the standard dassification, a high fistula refers to both a high anal (Fig. 54.33(4)) and a pelvirectal fistula (Fig. 54.33(5)). By the Parks dassification, both a high transsphincteric or a supralevator fistula would qualify as high, with the intersphincteric falling into either category depending on whether an internal opening was present at all, and at what level it entered the anal canal (see Fig. 54.33(1)). Low-level fistulas Clinical features. Commonly, the principal symptom is a persistent seropurulent discharge that irritates the skin in the neighbourhood and causes discomfort. Often the history dates back for years. So long as the opening is large enough for the pus to escape, pain is not a symptom, but if the orifice is occluded pain increases until the discharge erupts. Frequently, there is a solitary external opening, usually situated within 3.54 cm of the anus, presenting as a small elevation with granulation tissue pouting from the mouth of the opening. Sometimes superficial healing occurs, pus accumulates and an abscess reforms and discharges through the same opening, or a new opening. Thus there may be two or more external openings, usually grouped together on the right or left of the midline but, occasionally, when both ischiorectal fossas are involved, an opening is seen on each side, in which case there is often intercommunication between them (Fig. 54.35). As a rule there is much induration of the skin and subcutaneous tissues

around the fistula. Goodsalls rule. Fistulas with an external opening in relation to the anterior half of the anus tend to be of the direct type (Fig. 54.36). Those with an external opening or openings in relation to the posterior half of the anus, which are much more common, usually have curving tracks, and may be of the horseshoe variety. Note that posteriorly situated fistulas may have multiple. external openings which always connect to a solitary internal orifice, usually midline (Fig. 54.36). Fig. 54.35 Horseshoe fistula In ano. Bath ischiorectal fossas involved. Usually there is only one internal orifice. Fig. 5.4.36 Goadsalls rule. Fig. 54.37 Retrograde probing of an anal canal sometimes reveals the internal orifice of the fistula. Digital examination. Not infrequently an internal opening can be felt as a nodule on the wall of the anal canal. Irrespective of the number of external openings, there is almost invariably only one internal opening. Proctoscopy sometimes will reveal the internal opening of the fistula. A hypertrophied papilla is suggestive that the internal orifice lies within the crypt related to the papilla (Fig. 54.37). Probing. In the past, it was the universal practice to probe a fistula in the ward or the outpatient department. Such manoeuvres accomplish nothing, are painful, and are liable to reawaken dormant infection. Furthermore, if probing is performed without the utmost gentleness, or if the patient, experiencing pain, makes a sudden jerk, a false passage may result which complicates the condition still further. Probing should be postponed until the patient is under an anaesthetic in the operating theatre. The injection of lipiodol, or other opaque medium, along the sinus, before radiography has little to recommend if. The radiographs thus obtained are seldom illuminating, and the procedure is likely to cause a recrudescence of inflammation. Endoluminal ultrasonography and magnetic resonance imaging are being developed as techniques for mapping complex fistulas. Radiography of the thorax should be undertaken and the possibility of pulmonary tuberculosis considered, despite the fact that today it will be found in only a small proportion of patients with fistula in ano usually of Asian origin (see below). Special clinical types of fistulas in mo Fistula connected witI~ an anal fissure. Unlike the usual fistula in ano. pain (due to

the fissure) is a leading symptom. The flstula is very near the anal orifice, usually posterior, and the external opening is often hidden by the sentinel pile. Fistula with an internal opening above the anorectal ring is due, almost invariably, to penetration by a foreign body or probing and interference with a high abscess. A supralevator fistula arising spontaneously will be seen only once or at most twice in a surgical career. Granulomatous infections and Crohns disease, If induration around a fistula is lacking, if the opening is ragged and flush with the surface, if the surrounding skin is discoloured and the discharge is watery, or if the external openings are multiple, tuberculosis or Crohns disease should be considered. In more than 30 per cent of patients suffering from pulmonary tuberculosis, virulent tubercle bacilli are present in the rectum. About 23 per cent of flstulas in the UK are due to Crohns disease or tuberculosis. In Asian communities, the incidence of tuberculosis is higher. Crohns disease should also be suspected if there are other stigmata, and a small bowel meal may be necessary. If tuberculosis is suspected, a chesf radiograph and sputum cultures are mandatory. However, the diagnosis can usually only be made on histological examination of biopsy material from the track. If due to tuberculosis, the flstula will usually respond to antituberculous drugs alone. Fistulas with many external openings may arise from tuberculous proctitis, ulcerative proctocolitis, Crohns disease of colon or ileum, bilharziasis, and lvmphogranuloma inguinale with a fibrous rectal stricture. Colloid carcinoma may complicate fistulas in ann. Crohns disco, is the most frequent cause seen in this country from this group. Carcinoma arising within ptrianal fistulas. Colloid carcinoma of the rectum is notoriously liable to be complicated by perianal flstulas. In some instances, the flstulous condition, with its discharge of rabid material, overshadows the primary carcinoma, and not a few unfortunate patients have had their condition diagnosed for a tame as an inflammatory flstula in ano. If a primary tumour is present in the rectum, usually it can be detected and its nature established by biopsy. Dukes established conclusively that colloid carcinomatous flstulat can develop without a primary neoplasm in the rectum. He regarded such cases as examples of coboid carcinoma developing in a reduplicated portion of the intestinal tract. Both adenocarcinoma and squamous-cell carcinoma are known to arise within chronic flstulous tracks. The former can develop from the anal granular tissue: the latter is an example of true malignant change of squamous epithelium lining the wall of the track. Hidradenitis suppturativa. This is a chronic infection of apocrine glands around the anal margin giving rise to numerous sinuses. The mons pubis and groin also can be affected. After excision of the area, granulation and healing is accelerated by using Sslastac foam dressing (Hughes).

Treatment. That the fistulous track must be laid open from its termination to its source was a rule promulgated by John of Arderne more than 600 years ago. The operation can best be described in stages: Step 1. Preoperative cleansing enemas are necessary. When the patient has been anaestbetised, he or she is placed in the lithotomy position or in the prone jackknife position, according to the preference of the operator. Using bidigital palpation under anaesthesia, it is often possible to obtain more information concerning a fistula than can be learned from probin& it is surprisingly easy to push a probe through the wall of the track. Unfortunately, many inexperienced operators find it more reassuring to create a false passage than to risk criticism for not being able to demonstrate the internal opening. Careful bidigital palpation of the perianal tissue will often reveal a cord-like induration, representing the track, which will lead the intra-anal finger towards the proxt.mal opening. Rather than insert a probe through the distal orifice at this stage, it is better to endeavour to find the internal opening via a proctoscope. If the internal opening still cannot be seen, the insertion of a probe retrogradely into an anal crypt, especially one with a nearby hypertrophied papilla, oftet~ reveals the internal portion of the track (Fig. 54.37). The injection of diluted methylene blue or other dye into the external mouth of the fistula to establish the site of the internal opening is occasionally necessary, but is not recommended as a routine. Step 2. A probe-pointed director (Fig. 54.38) is inserted into the distal orifice, and it is advanced delicately until it reaches a point where it does not pass readily. The track is opened along the director, and bleeding is controlled. Step 3. If it is not at once evident in which direction the track passes, granulations are wiped away with gauze (it is seldom necessary to use a cu.rette). Often this will leave a granulation-filled spot at one site only. Gentle probing at this spot frequently will give the clue to the continuation of the fistula. The director is reinserted, and again followed with the knife for a short distance. This procedure is repeated until the entire track, and any side channels, are laid open. As far as possible. all muscle is divided at right angles to its fibres. in the rare event of the track passing above the anorectal ring, cutting should cease at the level of the dentate line, and from thenceforth the operation is conducted as suggested below, in most instances, probing and laying open the track can be repeated until the entire track is laid open. Pursuing this course, if there is no internal opening the track will become bereft of granulations on wiping it. As a rule, the internal opening can be demonstrated either by direct inspection through a proctoscope, or by a bent probe inserted into an anal crypt. In the latter circumstance, the internal portion of the track is excised in continuity. Step 4. The edges of the track are trimmed, 13mm of tissue being

removed a step that makes postoperative packing unnecessary after the first 24 to 36 hours. Hughes advocates primary split skin grafting of the wound resulting from fistulotomy. The grafts are taken from the inner aspect of the thigh and applied to the anal wound, being stitched to the skin edges and to each other in the depths of the wound. Tulle gras is then superimposed. and a firm pack of cottonwool applied. The first dressing is done on the 5th postoperative day. When skin grafting is not employed, digital dilatation of the anus, or the passage of a St Marks Hospital dilator every other day, prevents pocketing or bridging of the granulating wound. Biopsy. Always send a piece of track for biopsy. Fig. 54.38 A director with a probe-pointed malleable extremity is a useful Instrument. High-level fistulas The treatment of the-se cases is difficult. If the track is laid open as for low-level fistulas, incontinence will follow. There are four types (Parks): Supralevator fistula secondary to local disease (Fig. 54.34(3)). It occurs as a result of Crohns disease, ulcerative colitis, carcinoma, a foreign body perforating the rectal ampulla from above, or trauma. This flstula is quite unrelated to the ordinary type and the treatment is that of the cause. A traumatic fistula usually needs a colostomy. None of these fistulas requires to be laid open, which would in any case cause incontinence. Transsphincteric fistula (Fig. 54.34(2)) with perforating secondary track. The condition starts as an lntersphincferic track (Fig. 54.34(1)), often with a high secondary track in the ischiorectal fossa up to the levator ani. Here lies the danger. Although the anal opening may be low, during exploration of the high secondary track, unless great care is taken, the probe can be pushed through the levator ani into the rectal ampulla, thus converting a low fistula into a high-level type. Treatment should first of all be directed to the low transsphincteric fistula and healing of the upper track may follow. If it fails to do so, or if the opening into the rectum is of any size or near the anorectal bundle, a colostomy must sometimes be done before sound healing will take place. High tracks often require staged operations. A seton a time-honoured device (i.e. a ligature of silk or linen) is helpful when the internal opening is near the anorectal ring. Insertion of a seton and subsequent re-examination of the patient without anaesthesia will establish whether the internal opening is situated so near to the anorectal ring that incontinence would result if the track were laid open. Under these conditions, a staged operation and a coveting colostomy would be the

proper treatment. While the seton remains in situ it acts as a wick/drain and allows the acute inflammatory reaction around the track to subside: this can greatly simplify subsequent surgery. In expert hands, primary repair of divided sphincter muscle can preserve continence when a high-level track is laid open. Intersphincteric fistula. The track starts as a primary anal gland abscess (Fig. 54.29(A)), and it runs between the internal and external sphincter along the plane of the longitudinal muscle fibres. It may have an opening into the rectum above the anorectal ring and below at the site of a perianal abscess (Fig. 54.29(B)). Providing it is recognised it is easy to treat. The internal sphincter is divided and the whole track is laid open without fear of incontinence. Suprasphincteric fistula. Occasionally the intersphincteric track passes over the top of the sphincter before passing down again in the ischiorectal fossa. Treatment of this type is very difficult and is sometimes best done by an indwelling seton.

NONMALIGNANT STRICTURES
Congenital: a stricture at the level of the anal valves, due to incomplete obliteration of the proctodeal membrane, sometimes does not give rise to symptoms until early childhood; patients who have had an operation for imperforate anus in infancy may require periodic anorectal dilatation. Spasmodic: an anal fissure causes spasm of the internal sphincter; rarely, a spasmodic stricture accompanies secondary megacolon (Chapter 50), possibly due to chronic use of laxatives. Organic: postoperative stricture sometimes follows haemorrhoidectomy performed incorrectly. Low coloanal anastomoses, especially if a stapling gun is used, can narrow down postoperatively; irradiation stricture is an aftermath of irradiation; senile anal stenosis a condition of chronic internal sphincter contraction is sometimes seen in the aged. Increasing constipation is present with pronounced

straining at stool. Faecal impaction is liable to occur. The muscle is rigid and feels like a tight umbrella-ring. There is no evidence of a fissure in ano. The treatment is internal sphincterotomy or dilatation at intervals. Lymphogranuloma inguinale (Chapter 60). This is by far the most frequent cause of a tubular inflammatory stricture of the rectum, and 80 per cent of the sufferers are women. Freis reaction is usually positive. This variety of rectal stricture is particularly common in black races, and may be accompanied by elephantiasis of the labia majora. In the early stages, antibiotic treatment may lead to cure. In advanced cases excision of the rectum is required. Inflammatory bowel disease. Stricture of the anorectum also complicates ulcerative proctocolitis and large-bowel Crohns disease; in this instance the stricture is annular, and often more than one are present. A carcinoma should be suspected if a stricture is found, until a biopsy is obtained. Endometriosis of the rectovaginal septum may present as a stricture. There is usually a history of frequent menstrual periods with the appearance of severe pain during the first 2 days of the menstrual flow. Neoplastic. When free bleeding occurs after dilatation of a supposed inflammatory stricture, carcinoma should be suspected (Grey Turner), and a portion of the stricture should be removed for biopsy. Sometimes in these cases repeated biopsies show inflammatory tissue only. If, however, the symptoms show a marked progression, malignancy should be strongly suspected. Clinical features Increasing difficulty in defaecation is the leading symptom. The patient finds that increasingly large doses of aperients are required, and if the stools are formed, they are pipe-stem in shape. In cases of inflammatory stricture, tenesmus, bleeding, and the passage of mucopus are superadded. Sometimes the patient comes under observation only when subacute or acute intestinal obstruction has supervened. Rectal examination. The finger encounters a sharply defined shelf-like interruption of the lumen. If the calibre is large enough to admit the finger, it should be noted whether the stricture is annular or tubular. Sometimes this point can be determined only after dilatation. A biopsy of the stricture must be taken. Treatment Prophylactic. The passage of an anal dilator during convalescence after haemorrhoidectomy greatly reduces the incidence of postoperative stricture. Efficient treatment of lymphogranuloma inguinale in its early stages should lessen the frequency of stricture from that

cause. Dilatation by bougies. For anal and many rectal strictures dilatation by bougies at regular intervals is all that is required. Incision and primary free skin graft. For post-operative and senile strictures this operation gives by far the best results. The stricture is exposed and divided posteriorly so as to remove about 1 am of the flbrosed ring. A back cut is made and a triangular piece of skin removed with its apex above in such a way as to ensure complete and adequate enlargement of the strictured reg?on. A split skin graft is then taken from the inner side of the thigh, laid firmly into the defect, and sutured into position with fine catgut sutures. Dressings are applied to keep it firmly in position and renewed on about the 4th day when the bowels are allowed to act. The percentage take is high and the results surprisingly good. Colostomy must be undertaken when a stricture is causing intestinal obstruction, and in advanced cases of stricture complicated by fistulas in ano. In selected cases, this can be followed by restorative resection of the stricture-beating area. If this step is anticipated, the colostomy is placed in the transverse colon. Rectal excision and coloanal anastomosis. When the strictures are at or just above the anorectal junction, and are associated with a normal anal canal, but irreversible changes necessitate removal of the area, excision can be followed by a coloanal anastomosis with good functional results. A similar procedure can be done for an otherwise incurable supralevator fistula, especially postirradiation.

MALIGNANT TUMOURS
Carcinoma of the anus differs from carcinoma of the rectum in histological structure, behaviour, and types of treatment. This is mainly because of its accessibility, its sensitivity and its abundant lymph drainage, both superficial and deep. Seventy per cent of anal tumours arise in the anal canal: 30 per cent are squamous-cell carcinomas of the anal verge. Squamous-cell carcinoma. Because of its superficial situation, the presence of this lesion is frequently recognised by the patient, who often presents early. However, there are exceptions: Radiation carcinoma sometimes develops in the anal and perianal skin of a patient unwisely treated with lightly filtered radiographs for pruritus am. The chronic radiation dermatitis becomes so familiar to the patient that too often he

does not perceive the superimposition of carcinoma. Simple papilomas (anal warts) sometimes take on a carcinomatous change (Fig. 54.39). Occasionally, a squamous-cell carcinoma develops in the track of a longstanding fistula in any. The following malignant tumours of the anal canal are also found, but they are rare. Basaloid carcinoma. This is also known as cloacogenic carcinoma and is a form of nonkeratinising squamous carcinoma, It can metastasise to lymph nodes, and can be highly malignant. It is not VOT\ Sensitive to jrradiaticn. Mucoepidernioid carcinoma. This tumour arises near the squamocolumnar cell junction and is of average malignancy. It is not well kcratinised and is radiosensitive. Basal-cell carcinoma Like the true squamous-cell carcinomas of the anal verge and lower anal canal these are skin tumours and behave accordingly. Melanoma. Melanoma of the anus presents as a bluish-black soft mass that is apt to be confused with a thrombotic pile, and therefore unfortunately incised. Such trauma, followed by the trauma of defaecatiori, incites the tumour to rapid metastasis. Left undisturbed, it ulcerates, and the colour of the tumour changes from blue to black. The inguinal lymph nodes are soon involved. Unless a melanoma is excised a* an early stage, it disseminates by the bloodstream. The tumour is radioresistant and has ~ very poor prognosis (Fig. 54.40). Clinical features Anal cancer can occur at almost any age, but is usually found in the 6th and 7th decades. It is a rare condition, accounting for approximately 2 per cent of all cobrectal cancers. Symptoms include rectal bleeding, mucus discharge, tenesmus, the sensation of a lump in the anus and a change in bowel habit. Occasionally, a patient may present with a mass in the inguinal region due to metastatic lymph nodes. Rectal examination may reveal an ulcerating, hard, tender, bleeding mass in the anal canal or at the anal verge. The lesion may fungate through the anal canal and appear on the perianal skirt, or present through a chronic draining anal fistula. Predisposing conditions

There appears to be a relationship between anal condybomata caused by the human papilloma virus and anal cancer. Similarly, the disease is more prevalent in patients infected with the human immunodeficiency virus. Several reports suggest a significantly higher incidence of anal cancer in patients with Crohns disease. Treatment of squamous carcinoma of the anus and anal canal Tumours of the anal verge. For small squamous-cell lesions of the anal verge, wide local excision leaving a margin of at least 2.5 cm of tissue all round is sufficient to effect a cure. Lymphatic dissemination will be to the inguinal nodes, which should be watched carefully. If they become involved, block dissection removal of the glands of one or both groins will be necessary and carries a fair prognosis for cure. Fig. 54.39 Neglected papillomas of the anus which have become malignant. Fig. 54.40 Malignant melanoma of the anal canal. Tumours of the anal canal. The traditional treatment for carcinoma of the anal canal has been abdominoperineal excision, removing the growth and perianal area widely. If and when the inguinal lymph nodes became involved, a radical dissection of the groins was carried Out. Although this operation is based on sound pathological principles, the need for a permanent colostomy and the morbidity associated with it have encouraged surgeons to Srst try a more conservative approach. Radiotherapy alone has been used for selected small tUmoUrs for a long time. This has been applied by external beam, interstitial and intracavitary techniques (Pack). Approximately 50 per cent of turnouts treated in this way are said to be eradicated, making subsequent abdominoperineal excision unnecessary (Quan). In patients who present with inguinal lymph node metastases, block dissection of the groin is indicated in addition to the radiotherapy. A combination of chemotherapy and radiotherapy, so-called chemoradiation, has recently been described by Nigro, and is rapidly becoming the preferred initial therapy for all anal canal tumours. The patient is given a combination of 5fluorouracil andmitomycin for approximately I week. Some authors have used a combination of bleomycin, cisplatinum and adriamycin. The chemotherapy is followed by radiotherapy given over 37 weeks. The patient is then examined 4 6 weeks after cessation of treatment. If there is obvious tumour remaining, an abdominopermeal excision is performed. If there has been a good response to therapy, the scar is excised; and if no microscopic carcinoma is present, the patient is followed up carefully. The therapy does have unpleasant side effects: most patients suffer proctitis and perineal dermatitis from the radiotherapy, and leucopenia and thrombocytopenia are frequent with the chemotherapy; all patients

must be warned about the possibility of alopecia. Nevertheless, approximately twothirds of patients respond to chemoradiation, and avoid a major surgical procedure, and 90 per cent of patients are alive and well 2 years after treatment. This therapy is applicable for all tumours, but those with a diameter of 5 cm or more have a higher failure rate. Although many of these are likely to result in eventual abdominoperineal excision, it is probably best to treat them initially by chemoradiation, as this may make subsequent surgery easier. In the frail patient with an advanced lesion, a defunctioning colostomy may be the only therapy available to relieve the patient of distressing symptoms such as incontinence.