ANAL PAIN

JAMES FRANCOMBEJAMES FRANCOMBE

CONSULTANT COLORECTAL CONSULTANT COLORECTAL SURGEONSURGEON

WARWICK HOSPITALWARWICK HOSPITAL

ANAL PAINANAL PAIN

•RELATIVELY COMMONRELATIVELY COMMON

•SEE OFTEN IN CLINICSSEE OFTEN IN CLINICS

•SEE OFTEN AS EMERGENCYSEE OFTEN AS EMERGENCY

•TREATMENT PERCEIVED EASYTREATMENT PERCEIVED EASY

•TREATMENT CAN BE DIFFICULTTREATMENT CAN BE DIFFICULT

•OUTCOME VARIABLEOUTCOME VARIABLE

ANAL PAINAETIOLOGY

• FISSURE IN ANOFISSURE IN ANO•ABSCESS/SEPSIS/FISTULAABSCESS/SEPSIS/FISTULA•TRAUMATICTRAUMATIC•NEOPLASTICNEOPLASTIC•THROMBOSED HAEMORRHOIDSTHROMBOSED HAEMORRHOIDS•THROMBOSED PERIANAL THROMBOSED PERIANAL HAEMATOMAHAEMATOMA•RECTO-ANAL INTUSSUSCEPTIONRECTO-ANAL INTUSSUSCEPTION

HAEMORRHOIDSHAEMORRHOIDS

DO NOT CAUSE PAIN ....... UNLESS THROMBOSED

THEY ITCH, FEEL SWOLLEN, UNCOMFORTABLE, ANGRY, FLARE UP BUT THEY DO NOT CAUSE PAIN UNLESS THROMBOSED

THROMBOSED HAEMORRHOIDS

PAIN RELIEFPAIN RELIEFLAXATIVESLAXATIVESSPHINCTER RELAXATION SPHINCTER RELAXATION ( ANOHEAL/GTN)( ANOHEAL/GTN)‘‘THE FROZEN FINGERTHE FROZEN FINGER’

IF ALL ELSE FAILS

SURGICAL EXCISION

THROMBOSED

PERIANAL

HAEMATOMA

THROMBOSED PERIANAL HAEMATOMA PAINFULPAINFUL ACUTE ONSETACUTE ONSET MAY HAVE BEEN MAY HAVE BEEN

STRAINING/COUGHING STRAINING/COUGHING PROLONGED SITTINGPROLONGED SITTING

SPONTANEOUSSPONTANEOUS

THROMBOSED PERIANAL HAEMATOMATREATMENT ANALGESIA

ANOHEAL LAXATIVES ICE-PACK

USUALLY RESOLVE SPONTANEOUSLY

THROMBOSED PERIANAL HAEMATOMATREATMENT

SURGICAL IF MEDICAL FAILS

INCISE AND DRAIN LA (SKIN TAGS)

EXCISE ?GA (NO TAGS)

FISSURE IN ANOFISSURE IN ANO

•COMMON

•PAINFUL DEFECATION ‘PASSING GLASS’

•BLOOD SPOTS AND DRIPS

•INTERMITTENT

•PAIN AFTER 1-2 HOURS

•OFTEN CONSTIPATED ‘HARD MOTION’

FISSURE IN ANOFISSURE IN ANOISCHAEMIC ULCER -USUALLY POSTERIORISCHAEMIC ULCER -USUALLY POSTERIOR

SPHINCTER SPASM - POOR BLOOD SUPPLYSPHINCTER SPASM - POOR BLOOD SUPPLY

NATURALLY SLOW TO HEAL DUE TO ABOVENATURALLY SLOW TO HEAL DUE TO ABOVE

FISSURE IN ANO

TREATMENTTREATMENT

DECREASE PAINDECREASE PAIN -LIGNOCAINE GEL-LIGNOCAINE GEL

REGULATE BOWELSREGULATE BOWELS -LAXATIVE-LAXATIVE

SPHINCTEROTOMYSPHINCTEROTOMY -CHEMICAL-CHEMICAL

-SURGICAL-SURGICAL

FISSURE IN ANOFISSURE IN ANOSPHINCTEROTOMYSPHINCTEROTOMY -CHEMICAL-CHEMICAL•DILTIAZEM 2% TOPICAL BD 6 WEEKSDILTIAZEM 2% TOPICAL BD 6 WEEKS

•RCT BETTER THAN GTN (LESS SIDE EFFECTS)RCT BETTER THAN GTN (LESS SIDE EFFECTS)

•BOTOX INJECTIONSBOTOX INJECTIONS

•HEALS 75% AT 6 WEEKSHEALS 75% AT 6 WEEKS

•RELAPSE MAY BE HIGHRELAPSE MAY BE HIGH

FISSURE IN ANOFISSURE IN ANOSPHINCTEROTOMYSPHINCTEROTOMY -SURGICAL-SURGICAL

BEWARE OF WOMEN POST CHILD BIRTHBEWARE OF WOMEN POST CHILD BIRTH

FAILED MEDICAL /BOTOX TREATMENTFAILED MEDICAL /BOTOX TREATMENT

TAILORED SPHINCTEROTOMY TAILORED SPHINCTEROTOMY

OPEN IF POSSIBLEOPEN IF POSSIBLE

UPTO 10% GAS INCONTINENCE-USUALLY UPTO 10% GAS INCONTINENCE-USUALLY TEMPORARY.TEMPORARY.

FISSURE IN ANOFISSURE IN ANO

POOR MEDICAL RESPONSE TO POOR MEDICAL RESPONSE TO TREATMENTTREATMENT

SENTINEL TAGSENTINEL TAG

LONG HISTORY >6 MONTHSLONG HISTORY >6 MONTHS

FIBRES OF IAS EXPOSEDFIBRES OF IAS EXPOSED

ABSCESSABSCESS•COMMONCOMMON

•EMERGENCYEMERGENCY

•CRYPTOGLANDULAR THEORY OF ORIGINCRYPTOGLANDULAR THEORY OF ORIGIN

•PERCEIVED ‘JUST AN ABSCESS’PERCEIVED ‘JUST AN ABSCESS’

•USUALLY LEFT TO JUNIOR SURGEONUSUALLY LEFT TO JUNIOR SURGEON

•POOR OPERATIONPOOR OPERATION

ABSCESSABSCESS•ACUTE SITUATIONACUTE SITUATION

•INCISE AND DRAININCISE AND DRAIN

•BIOPSY SKIN (?CROHNS)BIOPSY SKIN (?CROHNS)

•RIGID SIG AND PROCTOSCOPY(?CA ?FISTULA)RIGID SIG AND PROCTOSCOPY(?CA ?FISTULA)

•PACK GENTLY (IF AT ALL –NEW EVIDENCE)PACK GENTLY (IF AT ALL –NEW EVIDENCE)

FISTULAFISTULA•ABNORMAL CONNECTION BETWEEN 2 ABNORMAL CONNECTION BETWEEN 2 EPITHELIASED SURFACES. EPITHELIASED SURFACES. A TUNNELA TUNNEL

•DEVELOP FROM ABSCESS (25% FORM DEVELOP FROM ABSCESS (25% FORM FISTULA)FISTULA)

•DISCHARGE INTERMITTENTLY PRECEDED BY DISCHARGE INTERMITTENTLY PRECEDED BY PAINPAIN

FISTULA CLASSIFICATIONFISTULA CLASSIFICATION

INTERSPHINTERICINTERSPHINTERIC

TRANS-SPHINCTERICTRANS-SPHINCTERIC

SUPRALEVATORSUPRALEVATOR

EXTRASPHINCTERICEXTRASPHINCTERIC

+/- SECONDARY TRACTS/HORSESHOE+/- SECONDARY TRACTS/HORSESHOE

FISTULA TREATMENTFISTULA TREATMENT

INTER-SPHINTERIC INTER-SPHINTERIC

LAY OPEN LAY OPEN

TRANS-SPHINCTERICTRANS-SPHINCTERIC

LOWLOW -LAY OPEN-LAY OPEN

HIGHHIGH -SETON/FLAP/PLUG-SETON/FLAP/PLUG

FISTULA TREATMENTFISTULA TREATMENT

TO CURE MEANS TO CUT OPENTO CUT OPEN MEANS TO CUT SPHINCTERCUT SPHINCTER CUTS CONTINENCEMORE YOU CUT THE MORE THEY LOOSECONTINENCE DECREASES WITH AGE

FUNCTIONAL LENGTH OF FEMALE ANAL SPHINCTER APPROX 2 CM. CUT 6MM THEN 30% OF SPHINCTER CUT ----CHANCE INCONTINENCE APPROX 30%

ANAL ANATOMY

NEOPLASTICUSUALLY SQUAMOUS CELL CA

HOWEVER VARIETY

MELANOMA, LOW RECTAL CA

CLEAR CELL CA

RARIETIES

TRAUMATIC SELF INDUCED-SEXUAL GAMES

INFLICTED- TRUE TRAUMA EITHER RTA, CHILDBIRTH, IMPALEMENT STUPIDITY-USUALLY WHILST UNDER THE INFLUENCE!!!!!!!

RECTOANAL INTUSSUSCEPTION VERY EARLY PROLAPSE RECTUM TELESCOPES INTO ANAL

CANAL MAY SEE ON SIGMOIDOSCOPY SEEN ON DEF. PROCTOGRAM MAY LEAD TO COMPLETE

PROLAPSE CAN CAUSE PAIN,OFTEN MULTIPLE

INVESTIGATIONS-ALL NORMAL

RECTOANAL INTUSSUSCEPTIONTREATMENT

BIOFEEDBACK DEFECATORY DYNAMIC

RETRAINING LAPAROSCOPIC ANTERIOR

RECTOPEXY