Anal pain and Anal pain and DischargeDischarge

Anatomy of the anal canalAnatomy of the anal canal

The anatomical canal is about 3 cm The anatomical canal is about 3 cm long and it extends from the anal long and it extends from the anal verge to the dentate lineverge to the dentate line

The surgical anal canal is about 4 cm The surgical anal canal is about 4 cm long and it extends from the anal long and it extends from the anal verge to the anorectal junction verge to the anorectal junction

Anatomy of the anal canalAnatomy of the anal canal

►Pecten (anoderm) is a hairless part of the Pecten (anoderm) is a hairless part of the external anal canal that exposed by external anal canal that exposed by traction on the rim of the anus ( lined by traction on the rim of the anus ( lined by keratinized stratified squamous keratinized stratified squamous epithelium )epithelium )

►The junction between the Pecten and the The junction between the Pecten and the large mucosa is known as dentate line .large mucosa is known as dentate line .

Anatomy of the anal canalAnatomy of the anal canal

The rectum is lined by columnar epitheliumThe rectum is lined by columnar epithelium

The transitional zone is lined with cuboidal The transitional zone is lined with cuboidal epithelium that lines the anal canal from epithelium that lines the anal canal from the columns of morgagni to the dentate the columns of morgagni to the dentate line.line.

Below the dentate line the anal canal is Below the dentate line the anal canal is lined by squamous epithelium . lined by squamous epithelium .

Muscle layers of the anal Muscle layers of the anal canalcanal

Internal sphincter (involuntary ) : Internal sphincter (involuntary ) : is a continuaion of circular smooth of is a continuaion of circular smooth of

the rectum under control of the the rectum under control of the autonomic nervous systemautonomic nervous system

External sphincter (voluntary ) : External sphincter (voluntary ) :

downward extension of the downward extension of the puborectalis, witch is striated muscle puborectalis, witch is striated muscle with somatic innervation ( branch of with somatic innervation ( branch of the internal pudendal nerve S2-S4. the internal pudendal nerve S2-S4.

Differences between the upper and the Differences between the upper and the lower hlaves of the anal canal according lower hlaves of the anal canal according

to the dentate lineto the dentate line

Above the dentate lineAbove the dentate lineBelow the dentate lineBelow the dentate lineEndodermal in originEndodermal in originEctodermal in originEctodermal in origin

Lined by columnar epitheliumLined by columnar epitheliumLined by squamous epitheliumLined by squamous epithelium

Under control of the autonomic Under control of the autonomic nervous sys. (sensitive to nervous sys. (sensitive to stretch )stretch )

Under control of the somatic Under control of the somatic innervation (sensitive to pain, innervation (sensitive to pain, touch , temperature) touch , temperature)

Drains its venous blood via the Drains its venous blood via the sup.sup.

rectal vein to the portal venous rectal vein to the portal venous

Drains its venous blood via Drains its venous blood via inferoir rectal vein into the inferoir rectal vein into the systemic venous systemic venous

drains its lymph to the internal drains its lymph to the internal iliac lymph nodes.iliac lymph nodes.

Drains its lymph to the inguinal Drains its lymph to the inguinal lymph nodes.lymph nodes.

HemorrhoidsHemorrhoids

Definition :Definition : they are engorgement of they are engorgement of venous plexi venous plexi ““cushionscushions”” that sit in the that sit in the anorectal junction.anorectal junction.

Could beCould be : :

External: below the dentate lineExternal: below the dentate line

Internal: above the dentate lineInternal: above the dentate line

Commonly situated atCommonly situated at : :

3 o3 o’’clock clock ““left lateralleft lateral””

7 o7 o’’clock clock ““right posteriorright posterior””

11 o11 o’’clock clock ““right anteriorright anterior””

Classification of internal Classification of internal hemorroidshemorroids

First degree: painless bleeding usually First degree: painless bleeding usually associated with defecationassociated with defecation

Second degree: protrude during Second degree: protrude during defecation but spontaneously reducedefecation but spontaneously reduce

Third degree: protrude during Third degree: protrude during defecation and must be manually defecation and must be manually reducedreduced

Forth degree: permanently prolapsedForth degree: permanently prolapsed

Possible causesPossible causes

ConstipationConstipation

StrainingStraining

Anorectal carcinomaAnorectal carcinoma

Portal HTNPortal HTN

Pregnancy Pregnancy

Signs and symptomsSigns and symptomsPainless bright red rectal bleedingPainless bright red rectal bleedingProlapsing lumpProlapsing lumpItchingItchingMucus dischargeMucus dischargeN.B.N.B.

sever pain is not typically associated with sever pain is not typically associated with internal hemorrhoids but is commonly seen internal hemorrhoids but is commonly seen with thrombosed external hemorrhoids with thrombosed external hemorrhoids

but if pain is present with absence of but if pain is present with absence of strangulation look out for other conditions strangulation look out for other conditions ““fissure , hematoma, abcessfissure , hematoma, abcess””

Clinical assessmentClinical assessment

History:History:

Age, type of bleeding, bowel habitAge, type of bleeding, bowel habit

Examination:Examination:

Digital rectal examinationDigital rectal examination

Investigation:Investigation:

Protoscopy , rigid sigmoidoscopy, Protoscopy , rigid sigmoidoscopy, colonscopy,colonscopy,

Barium enema. Barium enema.

complicationscomplications

Profuse hemorhageProfuse hemorhage

UlcerationsUlcerations

FibrosisFibrosis

StrangulationStrangulation

GangreneGangrene

thrombosisthrombosis

TreatmentTreatment

Advice the patient to :Advice the patient to :

receive a high fiber dietreceive a high fiber diet

use laxativesuse laxatives

avoid straining avoid straining

sitz bathsitz bath

keep a good hygiene keep a good hygiene

Cont. treatmentCont. treatment

The definite treatment varies according The definite treatment varies according to to

the degree of hemorroids:the degree of hemorroids:

11stst degree degree : sclrotherapy : sclrotherapy

infrared photocoagulationinfrared photocoagulation

cryothrapycryothrapy

22ndnd degree degree : rubber band ligation : rubber band ligation

33rdrd and 4 and 4thth degree degree : hemorrhoidectomy : hemorrhoidectomy

Cont. treatmentCont. treatment

Thrombosed external hemorrhoids Thrombosed external hemorrhoids should be excised if seen within 48 hr, should be excised if seen within 48 hr, beyond this time, conservative beyond this time, conservative therapy with analgesics and sitz baths therapy with analgesics and sitz baths is appropriate.is appropriate.

ContCont……

Anal FissureAnal Fissure

DefinitionDefinition It is painful liner tears in the It is painful liner tears in the lining of the anal canal below the lining of the anal canal below the dentate dentate

line i.e. ( tear in squamous epithelium ).line i.e. ( tear in squamous epithelium ).

It is the commonest cause of sever anal It is the commonest cause of sever anal painpain

EpidemiologyEpidemiology

Acute or chronic tear in the anal canal Acute or chronic tear in the anal canal usually in posterior midline ( M=F in usually in posterior midline ( M=F in young adult)young adult)

Anterior fissure is common in Females.Anterior fissure is common in Females.

Lateral or multiple fissures should raise Lateral or multiple fissures should raise suspicion of trauma, inflammatory suspicion of trauma, inflammatory bowel disease ( Chronbowel disease ( Chron’’s disease), s disease), lymphoma, neoplasm or infection. lymphoma, neoplasm or infection.

CausesCauses

ConstipationConstipation

Inflammatory bowel diseaseInflammatory bowel disease

Sexual transmitted diseaseSexual transmitted disease

Post anal surgeryPost anal surgery

Signs and symptomsSigns and symptoms

burning pain is associated with burning pain is associated with defecation. defecation.

Bleeding : the blood is usually bright red Bleeding : the blood is usually bright red and associated with acute fissures. and associated with acute fissures.

Physical exam Physical exam

Acute fissureAcute fissure showing just tear in the showing just tear in the anal mucosa. anal mucosa.

Chronic fissureChronic fissure may reveal a sentinel tag may reveal a sentinel tag or hypertrophied papilla. or hypertrophied papilla.

TreatmentTreatment

Conservative ( acute fissure )Conservative ( acute fissure )

- fiber supplement- fiber supplement

- bulk laxatives- bulk laxatives

- stool softner- stool softner

- sitz baths- sitz baths

- topical nitroglycerine ointment- topical nitroglycerine ointment

- Botox - Botox

Cont. TreatmentCont. Treatment

Surgical ( with chronic fissure to Surgical ( with chronic fissure to reduce the internal sphincter spasm ) reduce the internal sphincter spasm )

- sphincter dilation- sphincter dilation

- Lateral internal sphincterotomy- Lateral internal sphincterotomy