Anorectal Disorders

ANORECTAL PAIN

The patient may complain that defecation is painful or almost impossible because of anorectal pain.

Anal fissure

Anal fissures cause pain on defecation and usually develop after a period of constipation (may be brief period) and tenesmus.

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

An acute fissure will usually heal spontaneously or within a few weeks of a high-fibre diet, warm sitz baths after bowel movements and laxatives.

Conservative management (if persistent)

• Xyloproct, Proctosedyl or Scheriproct suppositories or ointment or

• Glyceryl trinitrate ointment (Nitro-bid 2%) diluted 1 part with 9 parts white soft paraffin applied to the lower anal canal (e.g. Rectogesic 2% ointment gently inserted with a gloved finger tds for 4 wks). An alternative is 2% diltiazem cream twice daily for 6–8 weeks.

Prevention

• High-residue diet (consider the addition of bran or wheat preparations) to give soft faeces

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

More severe chronic fissures The feature here is a hyperactive anal sphincter, and a practical procedure such as injection of botulinum toxin into the sphincter is necessary to solve this painful problem. Otherwise more radical surgery is necessary—lateral internal sphincterotomy is the gold standard.

Proctalgia fugax

Main features:

• fleeting rectal pain

• varies from mild discomfort to severe spasm

• lasts 3–30 mins

• often wakes patient at night

• a functional bowel disorder

• affects adults, usu. professional males

Management

• Explanation and reassurance

• Options (mainly anecdotal): salbutamol inhaler (2 puffs statim) or glyceryl trinitrate SL spray statim or calcium-channel blockers

Perianal haematoma

Within 24 h of onset: simple aspiration of blood or surgical drainage under LA

Within 24 h to 5 d of onset: express thrombus through small incision under LA (deroof skin)

Day 6 onwards: leave alone unless very painful or infected

Strangulated haemorrhoids

A marked oedematous circumferential swelling will appear if all the haemorrhoids are involved. If only one haemorrhoid is strangulated, proctoscopy will help to distinguish it from a perianal haematoma. Initial treatment is with rest and ice packs prior to haemorrhoidectomy at the earliest possible time. Relatively urgent referral is recommended.

Perianal abscess

Careful examination is essential to make the diagnosis. Look for evidence of a fistula, Crohn disease and anorectal cancer.

Treatment Drainage via a deep cruciate incision over the point of maximal induration. If abscess is recalcitrant or spreading with cellulitis use metronidazole 400 mg (o) 12 hrly for 5–7 d ...