Benign Rectal, Anal, and Perineal

Problems
Anatomy
Dentate line divides
the rectal mucosa,
which is generally
insensitive and is lined
with columnar mucosa,
from the anoderm,
which is highly
sensitive (because of
somatic innervation)
and lined with modified
squamous mucosa.
Benign Rectal, Anal, and
Perineal Problems
Anatomy (continue)
The anal canal is surrounded by two muscles
- Internal sphincter innervated by autonomic
nervous system, maintaining resting anal
tone and under involuntary control
- External sphincter innervated by somatic
nerve fibers, generates the voluntary anal
squeeze and plays the key role in
maintaining anal continence
Benign Rectal, Anal, and Perineal
Problems
Anatomy (continue)
The areas
surrounding the
anorectum is
divided into four
spaces
- Peri-anal
- Ischioanal
- Supralevator
- Intersphincteric
(intermuscular)
Hemorrhoids

Fibro-muscular cushions that line the

anal canal
Classically found in three locations
- Right anterior
- Right posterior
- Left lateral
- Small secondary cushions may be
found lying between the main
cushions
Hemorrhoids

They are part of normal anal

anatomy
Play role in normal mechanism of
fecal continence, they get engorged
during straining or performance of
Valsalva maneuver, which completes
the occlusion of the anal canal and
prevents stool loss with none
defecatory straining
Hemorrhoids

Broadly classified as
- Internal proximal
to dentate
- External distal to
dentate, redundant
folds of peri-anal
skin, usually
asymptomatic
unless thromboses
Hemorrhoids
Hemorrhoids

Internal Hemorrhoids Disease

Manifested by two main symptoms
- Painless Bleeding
- Protrusion
(Pain is rare as they originate above
dentate line)
Most popular etiologic theory states that
Hemorrhoids result from chronic
straining at defecation
Continued straining causes
engorgement and bleeding, as well as
hemorrhoidal prolapse
Hemorrhoids

Internal Hemorrhoids Disease

(continue)
Grades
- Grade 1 Bleeding without prolapse
- Grade 2 prolapse that spontaneously
reduce
- Grade 3 prolapse necessitating
manual reduction
- Grade 4 irreducible prolapse
Hemorrhoids

Internal Hemorrhoids Disease

History
- Bleeding
- Protrusion
- Chronic Constipation (extensive bathroom
readers)
Physical examination
- Visual inspection may reveal prolapsing
hemorrhoidal tissue appearing as rosette of three
distinct pink-purple hemorrhoidal groups
- If no prolapse, anoscopy reveals redundant
anorectal mucosa proximal to dentate line in the
classic locations
Hemorrhoids

Internal Hemorrhoids Disease

Management
Ranges from (depending on hemorrhoid
grade)
Reassurance
to
operative hemorrhoidal
excision
Hemorrhoids

Internal Hemorrhoids Disease /

Management
Therapies classified into three
categories
Diet and lifestyle modification
None operative and office procedures
Operative hemorroidectomies
Hemorrhoids

Internal Hemorrhoids Disease / Management

(1)Diet and life style modification
All patients grade 1 or 2 and most patients with
grade 3
Correct constipation
High fiber diet
Liberal water intake
Fiber supplement
Sitz bath (soothing effect ability to relax anal
sphincter)
Topical creams
Hemorrhoids

Internal Hemorrhoids Disease / Management

(2)None operative and office procedures
If diet and life style modification are not effective

Rubber band ligation

Ligation of hemorrhoid with elastic bands
Successful in 2/3 to 3/4 in patients with grade 1 or 2
- Complications
- Bleeding
- Pain
- Thromboses
- Perianal sepsis (pain, fever, difficult urination)
Hemorrhoids
Hemorrhoids
Internal Hemorrhoids
Disease / Management
(2)None operative and
office procedures
Infrared coagulation
applied to apex of each
hemorrhoid at top of anal
canal
Infrared radiation coagulates
tissue protein and evaporates
water from cell
Extent of tissue destruction
depends on intensity and
duration of the application
Not effective in treating large
amount of prolapsing tissue,
most useful for grade 1 and
small grade 2 hemorrhoids
hemorrhoids

Internal Hemorrhoids Disease /

Management
(2)None operative and office procedures
Sclerotherapy
Less popular nowadays
Injection of sclerosant into anorectal
submucosa to decrease vascularity and
increase fibrosis (injection at apex of
hemorrhoids at anorectal ring)
Agents used (phenol in oil, sodium morrhuate,
and quinine urea)
Hemorrhoids

Internal Hemorrhoids Disease /

Management
(3) Operative Hemorrhoidectomies
Reduction of blood flow to anorectal ring
Removal of redundant hemorrhoidal tissue
Fixation of redundant mucosa

Procedures
Hemorrhoidectomy
Stapled Hemorrhoidectomy
Hemorrhoids

External Hemorrhoids
Asymptomatic except when secondary thrombosed
Thrombosis may result from defecatory straining or
extreme physical activity or may be random event
Patient presents with constant anal pain of acute onset
Physical examination identifies external thrombosis as
purple mass at anal verge
Management
- Depends on patients symptoms
- In the first 24 72 hours after onset, pain increase
and excision is warranted
- After 72 hours, pain generally diminishes
Hemorrhoids

External Hemorrhoids
If operative treatment is
chosen, entire thrombosed
hemorrhoid has to be
excised
Incision and drainage of
clot shouldnt be done as
this can lead to re-
thrombosis and
exacerbation of symptoms