30 - anorectal and pelvic floor disorders

what are haemorrhoids

enlarges anal cushions

- no clear cause

- common in pregnancy, obesity and increased age

bleeding, painless, straining

management/treatment of haemorrhoids

treat underlying causes e.g. constipation

topical treatment - anusol, lidocaine cream, ointments

haemorrhoidal artery ligation, rubber band ligation

haemorrhoidectomy

stapled haemorrhoidectomy

what are anal fissures

small tear in lining of anus

symptoms of anal fissures

sharp pain on defaecation (due to passing hard faeces)

bleeding

treatment of anal fissures

treat underlying cause

GTN ointment/dlitiazem + lignocaine

surgical - botox, sphincterectomy

what is a perianal abscess

type of anorectal abscess that occurs in perianal space

symptoms of perianal abscess

excruciating pain

signs of sepsis

risk factors for perianal abscess

diabetes

BMI high

immunosuppression

trauma

treatment of perianal abscess

antibiotics if septic

incision and drainage

do not go looking for fistulas - causes pain

symptoms of anorectal fistula

pus discharge

faecal soiling

treatment of anorectal fistula

surgery is really only option but only success in 50%

what is pelvic floor disturbance

collection of wide spectrum of symptoms related to defaecation

aetiology of pelvic floor disturbance

childbirth

surgery

abuse

perianal sepsis

what is chronic constipation

difficult or reduced frequency of defaecation

types of chronic constipation

organic

drug related

dietary

functional

- slow transit

- evacuation related - blockage?

what drugs cause constipation

iron - most common side effect

anti-muscarinics

TCA's

anti-epileptics such as carbamazepine, gabapentin, pregabalin

anti-psychotics

antispasmodics

diuretics

opioids

verapamil

assessment of chronic constipation

exclude sinister cause

- colonoscopy

- CT colon

- exclude anaemia

- qFIT

- IgG for coeliac

- faecal calprotectin

detailed history to establish type

colonic transit studies

treatment of chronic constipations

1. baseline laxatives - ensure compliance

2. proculopride (women only) if failed with 2 or more regular laxatives from different classes at highest dose for 6 moths and invasive measures considered

- lubiprostone (all adults) same reason

- linaclotide - IBS-C

surgical options for chronic constipation

sigmoid colectomy

subtotal colectomy with end ileostomy

subtotal colectomy with ileorectal anastomosis

trial w/ ileostomy prior to major operative intervention

types of faecal incontinence

passive - internal sphincter defect

urge - rectal pathology, functional

mixed - prolapse

overflow - constipation

how to assess faecal incontinence

detailed history- determine type

obstetric/surgical history

trauma/abuse?

clinical examination

anorectal physiology

endo-anal ultrasound

defector proctogram

PR exam

what does anal manometry measure

anal sphincter function - resting pressure, squeeze increment, duration

estimation of functional length of anal canal

anorectal pressure response during abrupt increase in intra-abdominal pressure

changes in anal pressure during defaecation

recto-anal inhibitory reflex - internal sphincter

what is the best modality for assessing anatomy and dynamic function in anorectal dysfunction

defaecation proctogram

what does a defaecating proctogram provide info on

pelvic floor mobility

pathological function of musculature

changes to form and axis of organs

compensated/decompensated function

internal hernias

management of faecal incontinence

low fibre diet

loperamide

pelvic floor exercises

EMG if required

irrigation

anal plug

surgical intervention of faecal incontinence

sphincter repair

correct anatomical defect

sacral nerve stimulator

anal bulking agent for passive faecal incontinence

name 2 mixed anorectal disorders

rectocoel

internal rectal prolapse

what is rectocoel

passive loss of stool from being trapped due to incomplete evacuation

what is internal rectal prolapse

symptoms of obstructive defaecation and faecal incontinence

management of mixed anorectal disorders

improve rectal evacuation with various techniques

biofeedback

enemas

loperamide

surgical intervention

different types of fistula

submucosal fistula - fistula track passes superficially beneath the submucosa and does not involve any sphincter muscle 

inter-sphincteric fistula - track passes through the internal sphincter and continues in the inter-sphincteric plane to the perianal skin, not including the external anal sphincter 

trans-sphincteric fistula - track crosses through the internal and external anal sphincter on its exit towards the perianal area 

suprasphincteric fistula - fistulous tract passes through the internal sphincter but traverses the external sphincter below the puborectalis muscle 

extrasphincteric fistula - fistulous track may pass outside the sphincter complex through the ischiorectal fossa to the perianal skin, very high up, hard to treat 

Chronic pelvic pain

found in complex patients with multiple behavioural psychological issues

manage with EUA, pudendal nerve block, regular enemas/suppositories

In any anorectal disorder should you mesh?

NO

if have to biological mesh 

rectal prolapse

rectum stretched and sticks out anus

prehabilitation with biofeedback

if fit/active rectopexy

Which colorectal imagine characterises pathologies in rect and anal canal, rules out fistulas, sepsis and mainly used for anal/rectal staging cancer?

MRI rectum

Out of CT colonoscopy and colonoscopy which is better and why?

colonoscopy better because can take biopsy at same time whereas CT colonoscopy can’t

which special functional colorectal imaging is useful in obstetric anal sphincter injuries and in fistula disease

Endoanal USS 

anorectal anatomy & physiology

anorectum -control of defeacation -maintenance of continence

anorectum split into -upper -middle -lower rectum folds

function requires -pelvic floor -rectal compliance -intact pelvic neurology

in lower rectum transition zone from columnar mucosa proximally and squamous mucus distally

rectal cushions present in the zone

difference in male and female anorectal anatomy

female sphincter bulkier than male

anorectal angle not as acute in males as in female

anorectal canal: 4.4cm in men - 4cm