Chapter 6: Treatment of Ano-Rectal Problems

PERIANAL HAEMATOMA

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 ...