Chapter 6: Treatment of Ano-Rectal Problems

This painful condition usually develops with straining to pass stool. Surgical intervention is recommended, especially in the presence of severe discomfort. The treatment depends on the time of presentation after appearance of the haematoma.

Stage 1 treatment: Within 24 hours of onset

While the haematoma is still fluid, the treatment is by simple aspiration of the blood (Fig. 6.1). No local anaesthetic is necessary. If this is unsuccessful, surgical drainage is recommended.

Equipment

You will need a:

• 2 mL or 5 mL syringe

• 19-gauge needle

Stage 2 treatment: Within 24 hours to 5 days of onset

By now the blood has clotted, and a simple incision over the haematoma to remove the thrombosis followed by deroofing is the most appropriate treatment.

Equipment

You will need:

• 1% lidocaine with adrenaline (1–2 mL)

• a 25-gauge needle and 2 mL syringe

• a no. 15 scalpel blade

• 1 plain-toothed dissecting forceps (not essential).

Method

1. Swab the perianal area with povidone iodine, then inject 1–2 mL of LA into the pedicle of the skin around the base of the haematoma (Fig. 6.2a). An alternative is to apply a liberal amount of local anaesthetic ointment and wait 20 to 30 minutes.

2. Make a stab incision with the scalpel blade into the skin over the haematoma.

3. Extend the incision along the main axis of the haematoma (Fig. 6.2b).

4. Evacuate the thrombus with gentle, lateral pressure (Fig. 6.2c) or lift out with forceps.

5. An alternative and perhaps better method is to deroof the haematoma with scissors (like taking the top off a boiled egg). Squeeze out the clot.

6. Apply pressure to the incised area with a plain gauze swab to achieve haemostasis.

7. When bleeding has stopped, apply a small dressing of gauze, then a combine (5 cm × 5 cm) folded in half.

8. Retain the dressing with well-fitting underpants (not adhesive), apply an ice pack and rest in bed. Remove the next day.

9. No stitch is required unless haemostasis is a problem.

Stage 3 treatment: Day 6 onwards

The haematoma is best left alone unless it is very painful or (rarely) infected. Resolution is evidenced by the appearance of wrinkles in the previously stretched skin. The haematoma will ultimately become a skin tag.

Note: A gangrenous haematoma or a very large thrombosed pile should be surgically excised. The patient should have analgesics and Sitz baths.

Follow-up

The patient should be reviewed in 4 weeks for rectal examination and proctoscopy, to examine for any underlying internal haemorrhoid that may predispose to further recurrence. Prevention includes an increased intake of dietary fibre and avoidance of straining at stool.

The skin tag is usually the legacy of an untreated perianal haematoma. It may require excision for aesthetic reasons, for hygiene, or because it is a source of pruritus ani or irritation.

Method

1. Make a simple elliptical excision at the base of the skin under LA (Fig. 6.3). Suturing of the defect is usually not necessary.

2. Apply a light gauze dressing for about 24 hours. The patient is advised to have twice-daily salt baths until healing is complete.

Before the procedure

• Two glycerine suppositories (to empty rectum)

• Paracetamol and codeine oral analgesics

Rubber band ligation of haemorrhoids (best for stages 2 and 3) is a simple technique performed through a lubricated proctoscope which can be held by the patient after insertion (Fig. 6.4a). One or two rubber bands are stretched over the loading cone onto the metal drum of the banding instrument. It is now usually performed at routine colonoscopy. Associated carcinoma has to be considered.

Method

1. Thread the long grasping forceps through the drum of the banding instrument and grasp the haemorrhoid about 1 cm above the dentate line (Fig. 6.4b). (It is important to keep above the dentate line.)

2. Apply gentle traction to the haemorrhoid to indent its base.

3. Snap the band or bands onto the haemorrhoid by pushing the trigger mechanism (Fig. 6.4c).

Post-procedure

• If possible, avoid a bowel action on day 1.

• Take simple analgesics as necessary.

• Don’t drive home (prone to get vasovagal attacks).

Aims

• To exclude associated tumours (? colonoscopy)

• To produce fibrosis in the submucous layer

• To avoid injection into haemorrhoidal vessels

The procedure is best for small haemorrhoids that bleed frequently. Otherwise it is not favoured practice because of adverse fibrosis.

Equipment

You will need:

• a proctoscope with illumination and lubricant

• a haemorrhoid (Gabriel) injection syringe and needle, or a 10 mL disposable syringe with a 21-gauge needle

• a 5 mL ampoule of 5% phenol in almond oil

• a 19-gauge drawing-up needle

• forceps and cotton wool to wipe away faeces.

Method

1. The patient lies in the left lateral position.

2. Insert the lubricated proctoscope to visualise the haemorrhoids.

3. Draw up 5 mL of oily phenol.

4. Aim the injection at the upper end (base) of the haemorrhoid, which should be above the anorectal ring (injections given below this are very painful). Pierce the mucosa with a quick stab.

5. Inject up to 3 mL into the submucous plane. The bevel of the needle should be directed towards the mucosa rather than towards the lumen of the rectum. The injection should be painless (Fig. 6.5). Inject the phenol slowly until an opalescent swelling (blanching) is seen, displaying the vessels in the mucosa more superficially (the ‘striate’ sign).

6. The amount of phenol injected varies from 1 mL to 5 mL (usually 3 mL).

The acute fissure

Treatment is with warm saline sitz baths, analgesics and 15 g bran or psyllium fibre orally each day for 3 months.

Milder cases

In a milder case of anal fissure the discomfort is slight, anal spasm is a minor feature and the onset is acute.

Conservative management

• Xyloproct^® suppositories or ointment

• High-residue diet (consider the addition of unprocessed bran)

• Avoidance of constipation with hard stools (aim for soft bulky stools)

• Glyceryl trinitrate ointment (Nitro-bid^® 2%) diluted 1 part with 9 parts white soft paraffin applied to the lower anal canal 2 to 3 times daily. A commercial preparation is Rectogesic^® ointment—apply 3 times daily for 6 weeks or until healed. Warn the patient about headache and lightheadedness

• Some clinics favour the topical application of 2% diltiazem cream¹

More severe chronic fissures

The feature here is a hyperactive anal sphincter, and a practical procedure is necessary to solve this painful problem. Methods include:

Method 1: Digital anal dilatation

Under general anaesthesia (or even adequate local anaesthesia), undertake four-finger (maximum) anal dilatation for 4 minutes. This is effective, but is usually followed by a brief period of incontinence.

Anal dilatation under general anaesthesia is a most appropriate treatment for children with anal fissures.

Method 2: Inject botulinum toxin into the sphincter

Several studies indicate excellent results when botulinum toxin is injected into the surrounding internal sphincter. Its availability and considerable cost are limiting factors.

Method 3: Lateral sphincterotomy

The anal sphincter mechanism comprises internal and external sphincters. The spasm of the internal sphincter that occurs because of an anal fissure is relieved by the procedure of lateral sphincterotomy, allowing the fissure to heal in about 2 weeks. The procedure gives dramatic relief; however, the complication of permanent faecal incontinence has to be considered and surgical intervention with excision of the fissure is usually preferred practice.¹

Main features

• Fleeting rectal pain in adults

• Varies from mild discomfort to severe spasm

• Lasts 3 to 30 minutes

• Often wakes patient at night

• Can occur at any time of day

• A functional bowel disorder

Management

• Explanation and reassurance

• Salbutamol inhaler (2 puffs statim) worth a trial

Alternatives include glyceryl trinitrate spray for the symptom or prophylactic quinine bisulphate at night.

Clinical features

• Severe, constant throbbing pain

• Fever and toxicity

• Hot, red, tender swelling adjacent to anal margin

• Non-fluctuant swelling

Careful examination is necessary to make the diagnosis. Look for evidence of a fistula-in-ano and an ischio-rectal abscess.

Treatment

Drainage via a cruciate incision over the point of maximal induration (Fig. 6.6a).

Method

1. Infiltrate 10 mL of 1% lidocaine with adrenaline in and around the skin overlying the abscess (in some people a general anaesthetic may be preferable).

2. Make a cruciate incision.

3. Insert artery forceps to open the abscess cavity and evacuate the pus.

4. Excise the corners of the cruciate incision to produce a circular skin defect (about 2 cm in diameter) (Fig. 6.6b).

5. Dress the wound with gauze soaked in a mild antiseptic.

Post-procedure

• Change gauze dressings twice daily.

• Have warm saline Sitz baths prior to new dressing.

• If undue bleeding occurs, pack the cavity for 24 hours and add covering dressings.

Antibiotics

If a perianal or perirectal abscess is recalcitrant or spreading with cellulitis, use metronidazole 400 mg (o) 12 hourly for 5–7 days plus cephalexin 500 mg (o) 6 hourly for 5–7 days.

It is important to distinguish the common viral warts from the condylomata lata of secondary syphilis. Counselling and support are necessary. Not all warts are sexually transmitted.

Treatment

The warts may be removed by chemical or physical means. The simplest and most effective treatment for readily accessible warts is:

• podophyllotoxin 5% paint (a more stable preparation)

  • Apply bd with plastic applicator for 3 days.

  • Repeat in 4 days if necessary (may need four treatments).

          or

• podophyllin 25% solution in tinct benz co

  • Apply with a cotton wool swab to each wart.

  • Wash off in 4 hours, then dust with talcum powder.

  • Repeat once weekly until warts disappear.

          or

• imiquimod (Aldara™) cream

  • Apply 3 times weekly until resolved.

These polyps are usually overgrown anal papillae which present as an irritating prolapse. They are removed by infiltrating the base with local anaesthetic, crushing it with artery forceps and applying a ligature. They are benign but the removed lesion should undergo histological examination if there is any doubt.

In addition to the usual measures, consider cleaning the anus (after defaecation) with cotton wool dampened in warm water. Cotton wool is less abrasive than paper, and soap also irritates the problem.

General measures

• Stop scratching.

• Bathe carefully: avoid hot water, excessive scrubbing and soaps.

• Use bland aqueous cream, Cetaphil^® lotion or Neutrogena^® soap.

• Keep the area dry and cool.

• Keep bowels regular and wipe with cotton wool soaked in water.

• Wear loose-fitting clothing and underwear.

• Avoid local anaesthetics and antiseptics.

If still problematic and a dermatosis is probably involved, use:

• hydrocortisone 1% cream, or

• hydrocortisone 1% cream with clioquinol 5% to 3% (most effective).

If an isolated area and resistant, infiltrate 0.5 mL of triamcinolone intradermally.

If desperate, use fractionated X-ray therapy.

In the emergency situation it may be possible to reduce the swelling and thence the prolapse by covering the prolapse with a liberal sprinkling of fine crystalline sugar (common table sugar).

• Every patient who presents with ano-rectal problems should undergo a digital rectal examination for ano-rectal cancers.

• Practitioners need to be properly trained in techniques such as sclerosant injections and rubber band ligation in order to reduce the likelihood of complications.

• Be aware of the association of haemorrhoids and colorectal carcinoma.