2. Anal Fissures
• Most common cause of rectal pain
- “My hemorrhoids are killing me”
• A fissure is a painful linear ulcer situated in
the anal canal and extending from just below
the dentate line to the margin of the anus.
• Typical symptoms of an anal fissure are
extreme pain, out of proportion to the size of
the lesion and rectal bleeding.
• Patients often avoid having a bowel
movement due to the pain.
7. Anal Fissure - Treatment
• Stool softeners or antidiarrheals (immodium or
lomotil)
• Sitz baths
• Hydrocortisone cream or suppositories
• Canasa (mesalamine) suppositories
• Nitroglycerine ointment
• Dilatation
• Cauterization
• Surgery
8. Pruritis Ani
• Pruritis Ani is an unpleasant cutaneous sensation
characterized by varying degrees of itching and burning
• There are many causes:
- excessive moisture (sweating or moist sticky
stools)
- Loose or irritating stools
- Fecal incontinence
- Certain foods or beverages
- Chewing gum with sorbitol
- Skin conditions
- Other anorectal conditions
9. Pruritis Ani
• Physical findings include only minimal erythema and excoriations in
the early stages to raw, red, and oozing or pale and lichenified skin
with exaggeration of the radiating folds of anal skin in the later
stages.
• The treatment is directed at regaining a clean, dry, and intact
perianal skin.
- Reassurance - Inform the patient there is no significant underlying
pathology, treatment is mainly symptomatic and directed toward
decreasing moisture in the perianal area.
- Education – Patients are instructed to cleanse the area several times
daily especially after a bowel movement, no medicated soaps, Sitz
baths, hairdryer, the use of gauze pads or cotton balls
- Dietary – No coffee, tea, colas, chocolate, beer, alcohol, or dairy
products. Keep a dietary diary.
- Local therapy – A barrier cream such as calamine or balneol
- Dilute steroid lotion such as synalar, or hytone
- More potent topical steroids for refractory cases or
perianal psoriasis
-Miscellaneous therapy – Shaving, antihistamines (atarax), oral
steroids, gloves
15. Thrombosed External Hemorrhoids
• A thrombosed external hemorrhoid is the
result of a rupturing blood vessel around the
anal opening.
• The blood leaks out and forms a clot
• With or without edema
• The cause is sometimes unknown but usually
secondary to anything that increases the intra-
abdominal pressure very quickly, such as
lifting, straining, coughing, or pregnancy.
16. Thrombosed External Hemorrhoids
• Will appear as a bluish or purple knot around
the anal opening, usually left lateral or right
lateral. If edema is present, the clot may not
be as visible.
• Treatment : Excision
20. Perianal Abscess
• A perianal abscess is an infected cavity filled
with purulent material found near the anus or
rectum.
• An abscess results from acute infection of a
small gland just inside the anus when bacteria
or foreign matter enters the tissue through
the gland.
• Symptoms will include pain, swelling, fever,
malaise, and drainage.
21. Perianal Abscess
• Treatment consists of draining the puss from the
infected cavity by making an opening in the skin
near the anus to relieve the pressure. This is
usually done in the office setting but a large or
deep abscess may require hospitalization
• Antibiotics are not an alternative to incision and
drainage.
• I and D will not affect fistula formation.
• 50% of perianal abscesses will develop a fistula.
24. Condyloma Acuminatum
• Condyloma is caused by the HPV virus
• Most commonly HPV 6, 11
• HPV 16, 18 behave more aggressively and are
more frequently associated with dysplasia and
malignant transformation.
• Are sexually transmitted
• Virus may lay dormant for six to nine months
25. Condyloma Accuminatum
• Almost all patients note visible perianal warts
• 2/3 of patients will experience pruritis ani
secondary to irritation of the warts or inability
to cleanse the area properly or with the use of
hydrocortisone cream
• Treatment – topical / surgery
29. Perianal Crohn’s Disease
• Often confused as “painful hemorrhoids”
• May be presenting symptom for colonic Crohn’s
disease
• Presents ususally as edematous, erythematous
perianal tag with ulceration or as perianal abscess
• Treatment – Treat underlying colonic Crohn’s
- Local treatment such as
suppositories, creams and ointments
- Ciprofloxacin/Flagyl
- Remicade
33. Rectal Procidentia
(Rectal Mucosal Prolapse)
• Rectal procidentia is the protrusion of the entire thickness
of the rectal wall through the anal sphincter.
• Usually seen in elderly females with decreased pelvic
muscle tone.
• Usually presents with anal incontinence, discomfort, the
sensation of incomplete evacuation and tenesmus
• In later stages a permanently extruded rectum is noted
• Usually diagnosed by a physical examination which will
reveal a protruding large red mass with concentric folds.
• A mild case of mucosal prolapse may present with no
obvious prolapse but a very patulous anal opening.
• Treatment is colorectal surgery referal
36. Squamous Cell Carcinoma
• Squamous Cell Carcinomas of the anal margin
resemble those occurring in skin elsewhere in the
body.
• They typically have rolled everted edges with central
ulceration
• Any chronic unhealed ulcer should be considered a
potential squamous cell carcinoma until proven
otherwise by biopsy.
• Treatment usually consists of local excision for lesions
less than 2 cm, larger lesions and lesions involving
more of the anal canal may require radiation therapy
or APR
38. Perianal Comedones
(Giant Comedones)
• Can occur around the perianal area
• Usually present as large, yellowish, indurated
nodules with hair extruding from them
• Can sometimes become infected and
therefore painful
• Treatment – Expression of sebum like material
- Excise lesion
41. Perianal Edema
• Perianal Edema is the swelling of the tissue
around the anal opening without thrombosis
• May appear skin colored or slightly
erythematous but no purplish color due to no
thrombosis
• Treatment – ice packs, sitz baths, topical
ointments and excision
• Commonly seen during and after pregnancy
44. Grade 4 Internal Hemorrhoids
• Typically internal hems are not painful
• Grade 4 hems are prolapsed internal hems
that cannot be manually reduced.
• Appear erythematous and edematous and will
have radial grooves versus concentric rings
• May become gangrenous
Treatment : Immediate Surgical Removal
