Common Anorectal Disease
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- Calvin Short
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1 Common Anorectal Disease Anorectal pain Rectal bleeding Anal mass Pruritus ani ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก 1 ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก 35 ก ก 1 ก ก 2 rectum ก sigmoid colon ก sacral promontory levator ani muscle กก anal canal rectum ก rectum longitudinal muscle taenia rectum mesentery, sacculations appendicae epiploicae rectum 3 lateral curves convex ก convex rectal mucosa ก valves of Houston 3 rectum ก 3 upper, middle lower part ( 1) 1
2 1 ก ก 3 rectum ก ก sacrum, coccyx, levator ani m., coccygeal m., medial sacral vessels sacral n. plexus rectum ก urinary bladder, ureter, vas deferens, seminal vesicles prostate ก uterus, fallopian tubes, ovaries posterior vaginal wall ก anal canal ก anal verge anorectal ring 4 anorectal ring puborectalis muscle กก ก anorectal ring ก dentate line anal verge anoderm ก perianal skin anoderm squamous epithelium ก secondary skin appendage ก hair follicle, sebaceous gland sweat gland dentate line pectinate line true mucocutaneous junction anal verge 6-12 dentate line transitional zone squamous epithelium anoderm cuboidal columnar epithelium anal canal ก internal external sphincter internal sphincter ก ก circular smooth muscle rectum involuntary muscle external sphincter ก voluntary striated muscle 3 subcutaneous, superficial deep group internal external sphincter ก intersphincteric plane fibrous tissue ก longitudinal smooth muscle rectum ก ก conjoined longitudinal muscle 2
3 columns of Morgagni ก mucosa 8-14 dentate line column of Morgagni anal crypt anal crypt ก anal gland ก submucosa intersphincteric plane ( 2) anal gland ก ก anorectal abscess fistula in ano 2 ก ก 2 Anorectal pain ก ก ก ก ก ก ก ก ก ก ก ก กก ก ก ก ก ก ก ก 4 ( 3) ก ก dentate line ก ก ก ก ก 6 ก ก dentate line ก ก ก ก ก ก ก ก ก 3
4 3 anorectal pain 5 ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก 4 - ก ก ก ก ก ก ก ก ก (tenesmus) ก ก ก ก 7 - ก ก ก ก ก ก ก ก ก ก ก ก ก ก 6 - ก ก ก ก ก ก กก ก - ก ก 6 ก ก ก ก ก ก ก ก ก ก ก ก ก - ก ก ก ก ก ก ก ก - HIV ก ก ก ก ก ก ก ก ก ก 4
5 ก ก ก ก ก ก acute anorectal pain ก กก ก ก ก ก กก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก 4 ก ก ก ก (patulous anal orifice) ก ก ก ก ก ก ก ก ก ก ก degenerative neuromuscular process กก ก ก (digital rectal examination) ก ก ก ก ก ก กก ก ก ก ก ก ก ก ก ก ก bimanual palpation 2 ก ก ก ก ก 7 ก ก ก ก ก กก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก กก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก acute anal fissure, anorectal abscess กก ก ก ก thrombosed external hemorrhoid prolapsed strangulated internal hemorrhoid ก ก ก ก ก ก ก ก ก ก ก ก functional ก ก ก proctalgia fugax levator syndrome ก ก anoscopy proctoscopy ก ก ก ก ก ก ก กก anoscopy ก ก ก ก ก ก ก ก ก ก ก 5
6 ก ก ก ก ก 4 ก ก ก ก levator ani ก spasticity levator syndrome 4 ก ก ก ก ก ก ก ก ก ก กก ก ก ก ก ก ก 4 ก ก ก anoscopy ก ก ก ก ก extrinsic disease processes ก ก 4 กก anoscopy ก ก ก ก flexible sigmoidoscopy descending colon splenic flexor colon ก (colonoscopy) ก ก ก ก 6-10 ก ก solitary rectal ulcer flexible sigmoidoscopy ก ก ก ก ก ก incomplete rectal prolapsed ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก sacrum ก chronic intramuscular abscess กก ก ก ก ก ก ก ก ก ก ก ก กก cauda equina peripheral pelvic pain pathways ก ก 4 ก ก ก ก Organic causes Inflammatory conditions Anorectal abscesses Anal fistula Proctitis 6
7 Crohn's Ulcerative Idiopathic Radiation Infectious Pararectal inflammation Prostatitis Tubular ovarian abscess Endometritis Diverticular abscess Pelvic appendicitis Mechanical causes Anal fissure External hemorrhoidal thrombosis Acute hemorrhoidal prolapse Incomplete rectal prolapse (retroanal intussusception) Descending perineum syndrome Pelvic surgery Pudendal neuropathy Neoplastic causes Benign tumors Peripheral nerve Muscle: anal sphincter or pelvis Peripheral nerve muscle: anal sphincter or pelvis Bone endometriosis: sacrum or pelvis Malignant tumor: primary and metastatic Rectum Anus Prostate Cervix Uterus Ovary Nerve: peripheral cauda equina Bone Pelvic muscle 7
8 Krukenberg tumor Neurogenic causes Multiple sclerosis Peripheral neuropathy Degenerative lumbosacral disk disease Orthopedic causes Coccygeal trauma Sacropelvic fractures Osteogenic tumors Functional/idiopathic causes Levator syndrome Proctalgia fugax Depression Chronic idiopathic rectal pain ก ก ก ก ก ก ก anorectal abscess ก perianal abscess ก ก ก ก intersphincteric ischiorectal abscess ก ก ก ก ก ก ก 8 ก ก ก กก ก ก ก ก ก ก postanal space abscess ก ก ก ก ก intersphincteric abscess 9 ก ก ก ก ก ก ก ก ก ก ก ก anal fissure anal abrasion 1 ก ก ก ก ก ก thrombosed external hemorrhoid ก ก 1-2 ก ก 1 ก ก ก ก ก inflammatory neoplastic condition anorectum ก ก ก ก ก ก ก levator muscle spasm proctalgia fugax ก ก ก ก ก ก ก ก rectum ก กก ก กก ก ก ก ก ก ก กก ก (coccygeal pain) ก ก ก ก ligament periosteum coccyx ก กก ก ก presacral cyst coccyx ก 9 8
9 ก ก ก ก anorectal abscess ก ก HIV ก steroid ก ก ก ก ก ก ก 7 acute anal fissure ก ก ก ก ก ก ก ก ก ก ก 40 ก ก 4 ก ก chronic anal fissure ก ก lateral internal sphincterotomy ก ก ก ก 3 ก ก 1.3 ก ก 10 ก chronic anal fissure ก nitric oxide, botulinum toxin, calcium agonist, cholinergic agonist, alpha-adrenoceptor antagonist beta-adrenoceptor agonist ก ก ก ก 11, 12 ก ก ก ก ก lateral internal sphincterotomy ก thrombosed external hemorrhoid hemorrhoidectomy ก ก ก ก กก ก กก elective case ก ก ก evacuate clot ก 13 ก ก ก ก ก ก ก ก ก chronic idiopathic perineal pain ก proctalgia fugax (levator syndrome), coccydynia, descending perineum syndrome chronic idiopathic anal pain ก ก ก ก ก ก ก 14 ก ก ก ก ก ก ก steroid 6 direct nerve muscle blocks 4, biofeedback ก ก ก ก ก ก ก ก ก ก ก กก ก ก 14 Rectal bleeding ก ก ก ก ก ก ก ก ก ก ก 2 ก ก ก ก ก ก ก ก ก ก 9
10 ก ก ก ก hematochezia ก ก กก ก ก ก ก ก ก 15 outlet bleeding - ก ก - ก ก ก - ก - ก ก colorectal cancer ก ก ก ก suspicious bleeding - ก ก - ก ก ก ก ก ก ก - ก ก colorectal cancer ก ก กก ก ก ก ก ก ก ก resuscitate ก ก ก ก chronic rectal bleeding ก 2. ก 3. ก ก ก ก ก ก 6. ก 7. ก ก 8. ก 9. ก ก 10. ก ก 11. ก ก ก ก ก 12. ก ก ก ก 13. ก ก ก 17. ก ก 10
11 18. polyp ก ก 19. polyp ก 20. ก 20 ก ก ก ก outlet suspicious ก ( 4) 4 rectal bleeding 5 ก ก ก ก ก ก ก ก ก ก ก ก anoscopy ก ก outlet bleeding flexible sigmoidoscopy suspicious bleeding colonoscopy 15 ก ก ก 1 ก ก ก ก ก ก ก ก ก ก ก ก ก ก hypertrophied anal papilla ก ก ก ก ก ก ก ก ก ก ก ก anal fissure anal abrasion ก ก ก ก ก tenesmus ก ก ก ก ก ก ก ก ก ก ก 11
12 ก ก ก ก prolapsed internal hemorrhoid external hemorrhoid ก ก hemorrhoidectomy ก ก ก internal hemorrhoid ก ก ก ก ก ก ก ก ก sclerosing agent rubber band ligation ก ก ก hypertrophied anal papilla ก ก ก ก excision ก ก ก ก ก acute anal fissure ก ก ก lateral internal sphincterotomy ก chronic anal fissure ก ก ก ก ก ก ก ก ก กก ก ก ก ก กก ก ก ก ก ELP.co Anal mass ก ก ก ก ก ก ก ก ก ก 16 - ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก - ก ก ก ก ก - ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก - HIV ก ก ก ก ก ก ก ก ก ก ก ก ก กก 16 - ก ก ก ก ก anal verge ก erythema ก ก ก ก perineal body gluteal cleft 12
13 - ก ก ก ก ก ก ก กก ก ก ก - ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก anoscopy ก ก ก ก ก anal crypts ก ก ก ก ก ก ก ก ก ก ก ก ก squamous cell carcinoma, lymphoma, melanoma, adenocarcinoma basal cell carcinoma ก ก colonoscopy adenocarcinoma ก ก ก ก ก ก ก 16 ก ก ก กก ก กก ก ก ก กก ก ก ก ก ก ก ก anal crypt anoscopy ก ก ก perianal ischiorectal space 16 ก ก ก ก ก skin tag ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก กก anoscopy ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก 3 4 ก thrombosed external hemorrhoid perianal hematoma 17 anoderm dentate line ก ก ก กก ก ก ก ก ก ก 16 13
14 ก ก ก ก ก ก ก ก ก ก ก ก ก sentinel pie ก ก ก hypertrophied anal papilla ก กก anal papillae dentate line 16 ก ก ก ก ก ก กก ก ก ก ก ก ก ก ก ก ก ก ก HIV ก condylomata acuminata 16, 18 ก ก ก ก ก ก ก squamous cell carcinoma, lymphoma, melanoma, adenocarcinoma basal cell carcinoma ก ก melanoma ก ก ก ก adenocarcinoma ก ก anal gland ก ก ก ก ก ก ก ก ก ก ก (tract) ก ก ก external opening probe ก ก false tract 16 ก ก ก ก ก ก ก ก กก ก ก ก ก ก ก ก ก ก ก ก ก ก กก ก ก (concentric fold) rectal procidentia ก prolapsed internal hemorrhoid (radiated fold) 19 ( ) 14
15 anal mass 5 ก ก 16 ก anal abscess ก ก perianal superficial ischiorectal space ก ก ก 2 3 ก ก ก ก hemorrhoidectomy ก acutely thrombosed external hemorrhoid ก hemorrhoidectomy ก กก ก ก thrombosed external hemorrhoid ก ก 1 ก ก ก ก ก ก ก ก ก ก 13 15
16 ก excision hypertrophic anal papilla ก ก ก ก ก ก ก hypertrophic anal papilla ก ก ก ก ก ก ก ก ก ก ก condylomata acuminata ก excision fulguration ก ก ก podophyllin bichloroacetic acid ก ก ก ก ก ก ก imiquimod ก ก 20 ก ก ก excision ก ก ก ก ก ก ก ก ก ก ultrasonography ก ก ก ก ก Lay-open fistulotomy ก ก ก ก ก ก ก fistulotomy seton procedure cutting drain ก ก ก ก seton procedure ก ก ก ก ก endorectal advancement flap ก ก ก fistula ก ก internal opening flap ก ก ก ก ก ก rectal procidentia ก กก ก ก ก ก ก ก sacrum ก ก ก ก ก ก ก ก ก ก ก ก ก 19 Pruritus ani ก ก ก ก 8 pruritus ani ก ก ก ก , ก ก ก ก ก ก ก ก ก ก ก 1-5 ก กก 4 21 ก ก กก ก ก ก ก ก ก ก (vicious cycle) ก ก ก ก 22 ก 8 16
17 ANAL IRRITATION CAUSE OBVIOUS NO CAUSE FOUND Fistula in ano Hemorrhoid Treadworm PRURITUS ANI ก ก ก ก 21, 22 ก ก ก ก - ก ก ก ก ก ก - ก ก ก ก ก ก - ก ก ก tetracycline, quinidine colchicine, mineral oil 8 ก - ก ก ก ก ก ก ก ก 8 ก - ก ก - ก ก กก ก ก 23 ก ก - systemic disease ก multiple sclerosis ก ก - ก ก 24 - ก ก ก ก ก ก ก - ก ก ก ก ก ก ก ก ก ก ก prone jackknife 22 17
18 ก ก ก กก ก 8 ก ก ก ก ก ก 24 ก ก ก ก ก occult blood ก ก ก ก ก ก ก ก 22 ก 24 ก ก ก ก ก ก ก ก ก ก กก ก Washington Hospital Center ก 1 ก 2 white lichenified skin 3 lichenified skin coarse ridger skin ulcer กก ก ก anoscopy ก ก กก ก ก - ก - ก ก sigmoidoscopy proctitis, infection inflammatory bowel disease ก ก - manometry compliance ก rectal balloon ก ก ก ก ก ก ก ก 21 ก Caplan ก patch test 27 ก ก ก กก manometry ก ก ก ก ก resting pressure 21 - ก ก ก saline infusion test ก ก ก ก ก ก ก ก ก ก 600 ml. early leakage soiling ก ก ก 1300 ml ก ก Wood lamp ก - serology syphilis 22 - กก scotch tape test 22 18
19 ก ก 22 pruritus ani ก Personal hygiene Diet Anatomic compromise Systemic disease Gynecologic conditions Neoplasms Diarrheal states Radiation Psychogenic drugs Poor cleansing habits resulting in chronic exposure to residual irritating feces; conversely, overmeticulous cleansing with excessive rubbing and soap use Consumption of large volumes of liquids: coffee (caffeinated and decaffeinated, coffee-containing products), chocolate, citrus, spicy foods, tea, beer, and foods high in milk content; vitamin A and D deficiencies Obesity, deep anal clefts, excessive hair, tight-fitting clothing (tight clothing or clothing that impairs adequate ventilation), fistula, fissure, skin tags, prolapsing papilla, or mucosal prolapse Jaundice, diabetes mellitus, chronic renal failure, iron deficiency, thyrotoxicosis, myxedema, Hodgkin's lymphoma, polycythemia vera Pruritus vulvae, vaginal discharge (endocervicitis, vaginitis) Bowen's disease, extramammary Paget's disease, squamous cell carcinoma, cloacogenic carcinoma, rectal or polypoid lesions Irritable bowel syndrome, Crohn's disease, chronic ulcerative colitis Postirradiation changes Anxiety, neuroses, psychoses Quinidine; colchicine; antibiotics (tetracycline); IV hydrocortisone phosphate; ointments or creams that contain "caine" drugs; and nonprescription medications for personal hygiene such as perfumed soaps and ointments that may contain 19
20 alcohol, witch hazel, or other astringents Dermatologic conditions Psoriasis, seborrheic dermatitis, atropic dermatitis. lichen simplex, and lichen sclerosis; Infections viruses herpes simplex, cytomegalovirus, papilfomavirus; bacteria Staphyto coccus aureus, erythrasma, mixed infections; fungi derma tophytosis, candidiasis; parasites pinworms, scabies, pediculosis; spirochetes syphilis Idiopathic 8Ds ก pruritus ani 8 Diseases of the anorectum Diabetes and dyscrasias Diseases of gynecologic origin Diarrheal states Drugs Diet and deficiency of vitamins Dermatoses Disposition of patient ก ก ก ก ก ก 25 8 ก ก ก ก ก ก skin tag ก ก excision ก กก ก Jensen ก ก excision skin tag ก 67 ก ก ก 55 ก 25 ก mebendazole 100 ก ก ก ก ก 21 ก (idiopathic pruritus ani) ก ก ก ก ก ก ก ก ก ก ก ก ก ก 22 20
21 ก ก ก ก ก 2 ก ก ก ก ก ก ก ก ก ก ก ก ก ก ก antihistamine diphenhydramine hydrochloride (Benedryl) 25 mg. 4-6 / chlorpheniramine maleated 4 mg. ก 24 silver nitrate ก ก ก 24 ก ก ก ก ก methylene blue ก ก ก ก ก ก ก 26 ก ก ก ก ก ก ก pruritus ani ก ก ก ก ก 2. ก ก ก ก ก ก ก 27 ก ก 3. ก ก ก ก ก ก ก ก ก ก ก ก ก ก 120 ก 4. ก ก anal crease ก ก ก ก 5. ก 20 ก ก ก 6. ก ก ก mechanical chemical trauma - ก ก ก - ก ก ก ก ก 8-10 ก - ก ก ก ก ก ก 7. ก ก 8. ก ก 9. ก ก ก ก ก ก 21
22 10. ก ก ก ก ก hydrocortisone cream ก ก ก ก ก ก ก ก 2 / ก ก ก 3-4 steroid cream กก ก skin atrophy secondary pruritis burn 21 22
23 Evaluation of the Normal IBD, anal canal/ pelvic tumors, deep perianal abscess,functional/ idiopathic causes, levator syndrome complaint of Inspection anorectal pain Abnormal Anal margin tumors, descending perineum syndrome, thrombosed external hemorrhoid, acute hemorrhagic prolapse, perianal abscess, anal fissure, anal fistula Anal ultrasound Normal Perianal abscess, degenerative neurologic disease, functional/ idiopathic causes, levator syndrome Treatment Anoscopy Abnormal Fissures, tumors anal canal, inflammatory processes of the anorectum, prolapsing internal hemorrhoids Directed Anorectol Endoscopy history examination Normal Hemorrhoids, fissure, fistula, extraintestinal pelvic tumors or abscesses, functional idiopathic cause, degenerative Proctoscopy neurologic diseases Abnormal Inflammatory conditions of the rectum, incomplete rectal prolapse, tumor distal rectum Normal Anal canal tumors, IBD, functional/ idiopathic causes, degenerative neurologic disease External Abnormal Ischiorectal abscess, fissure, anal margin tumors, thrombosed external hemorrhoid Palpation Depression Normal Internal Abnormal Pelvic abscess, prostatitis, pelvic inflammatory disease, intersphincter abscess, deep posterior anal abscess, tumors anal canal/ distal rectum, tumors (extracolonic) pelvis, IBD, degenerative neurologic disease, levator syndrome, incomplete rectal prolapse IBD= inflammatory bowel disease ก anorectal pain 4 23
24 Chronic rectal bleeding Lateral internal Outlet bleeding Suspicious bleeding sphincterotomy Anal fissure Anoscopy flexible sigmoidoscopy Anoscopy Ulcerated external Cause found Cause not found Rigid proctoscopy hemorrhoid Colonoscopy Internal Treat hemorrhoid Prolapse Bleeding stops Bleeding continues Proctitis Follow up Neoplasm Inflammatory Diverticular Neoplasia Rectal Benign bowel disease disease prolapse anorectal disease Crohn s colitis Ulcerative colitis Benign Malignant ก chronic rectal bleeding 15 Treat appropriately 24
25 Anal mass Diagnosis Evaluation Treatmant Abscess Incision and drainage Pain Exam under Thrombosed Excision anesthesia external hemorrhoid Conservative History Inspection Palpation Condyloma Excision Fulgeration No pain Neoplasm Biopsy Anoscopy Hypertrophied Excision anal papilla Conservative Fistula Fistulotomy Seton Advancement flap ก ก anal mass 16 25
26 Pruritus ani History, physical exam Diagnostic evaluations Systemic diseases Diabetes Renal failure Jaundice Lymphoma Myeloproliferative disorders Culture/ O&P exam Anoscopy Sigmoidoscopy Diagnosis- Biopsy specific test Serology Scrapings/ exam by magnification Scotch-tape test Wood s lamp exam Anorectal/ vaginal infecction Diarrheal states Diet and drugs Anatomic predisposition Dermatoses Anorectal neoplasm Anorectal diseases Other: radiation or psychogenic Idiopathic IBD Coffee Deep gluteal cleft Bowens Treatment Obesity Paget s Hirsutism Topical and Chemical exposure Cloacogenic oral medications Irritant soaps Squamous Fistula Mechanical cleansing Fissure Viral Bacterial Parasitic Fungal Psoriasis Hemorrhoids Seborrheic dermatitis Sphincter incompetence IBD= inflammatory bowel disease O&P= Ova & parasites ก pruritus ani 22 26
27 References 1. Roberts P. Patient evaluation. In: Beck DE, Wexner SD, editors. Fundamentals of Anorectal Surgery. 2 nd ed. Bath: W B Saunders Company Ltd., 1998; Nivatvongs S, Gordon PH. Surgical anatomy. In: Gordon PH, Nivatvongs S, editors. Principle and Practice of Surgery for the Colon, Rectum and Anus. 2 nd ed. Missouri: Quality medical publishing, Inc. 1999; Kodner IJ, Fry RD, Fleshman JW, Birnbaum EH, Read TE. Colon, rectum, and anus. In: Schwartz SI, editor. Principles of Surgery. 7 th ed. USA: McGraw-Hill companies, 1999; Oliver GC. Anorectal pain. In: Wexner SD, Vernava AM, editors. Clinical Decision Making in Colorectal Surgery. New York: Igaku-Shoin Ltd., 1995; Hughes Sir E, Cuthbertson AM, Killingback MK, editors. The symptom of large bowel disease. Colorectal Surgery.Singapore: Churchill Livingstone, 1983; Hughes Sir E, Cuthbertson AM, Killingback MK, editors. Anorectal pain of uncertain origin. Colorectal Surgery.Singapore: Churchill Livingstone, 1983; Hughes Sir E, Cuthbertson AM, Killingback MK, editors. Anorectal suppuration I: abscess. Colorectal Surgery.Singapore: Churchill Livingstone, 1983; Hicks TC, Stamos MJ. Pruritus ani: diagnosis and treatment. In: Beck DE, Wexner SD, editors. Fundamentals of Anorectal Surgery. 2 nd ed. Bath: W B Saunders Company Ltd., 1998; Nivatvongs S. Diagnosis. In: Gordon PH, Nivatvongs S, editors. Principle and Practice of Surgery for the Colon, Rectum and Anus. 2 nd ed. Missouri: Quality medical publishing, Inc., 1999; Hughes Sir E, Cuthbertson AM, Killingback MK, editors. Anal fissure. Colorectal Surgery.Singapore: Churchill Livingstone, 1983; Metcalf AM. Anal fissure. In: Beart RW, editor. Surg Clin North Am 2002; 82(6): Boulos PB, Pitt James. Can anal fissure be treated without surgery? In: Boulos PB, Wexner SD, editors. Current Challenges in Colorecal Surgery. China: W B Saunders Company Ltd., 2000; Metcalf A. Anorectal disorders. Postgrad Med 1995; 98(5): Keighley MRB, Williams NS, editors. Chronic idiopathic perineal pain. In: Surgery of the Anus, Rectum and Colon. 2 nd ed. China: W B Saunders Company Ltd., 1997; Church JM. Chronic rectal bleeding. In: Wexner SD, Vernava AM, editors. Clinical Decision Making in Colorectal Surgery. New York: IGAKU-SHOIN Ltd., 1995; Nogueras JJ. Anal mass. In: Wexner SD, Vernava AM, editors. Clinical Decision Making in Colorectal Surgery. New York: IGAKU-SHOIN Ltd., 1995; Hughes Sir E, Cuthbertson AM, Killingback MK, editors. Hemorrhoids. Colorectal Surgery.Singapore: Churchill Livingstone, 1983;
28 18. Gordon PH. Condyloma acuminatum. In: Gordon PH, Nivatvongs S, editors. Principle and Practice of Surgery for the Colon, Rectum and Anus. 2 nd ed. Missouri: Quality medical publishing, Inc., 1999; Gordon PH. Rectal procidentia. In: Gordon PH, Nivatvongs S, editors. Principle and Practice of Surgery for the Colon, Rectum and Anus. 2 nd ed. Missouri: Quality medical publishing, Inc., 1999; Vukasin P. Anal condyloma and HIV-associated anal disease. In: Beart RW, editor. Surg Clin North Am 2002; 82(6): Smith LE. Perianal dermatologic disease. In: Gordon PH, Nivatvongs S, editors. Principle and Practice of Surgery for the Colon, Rectum and Anus. 2 nd ed. Missouri: Quality medical publishing, Inc., 1999; Hicks TC, Opelka FG. Pruritus ani. In: Wexner SD, Vernava AM, editors. Clinical Decision Making in Colorectal Surgery. New York: IGAKU-SHOIN Ltd., 1995; Dasan S, Neil SM, Donaldson DR, Scott HJ. Treatment of persistent pruritus ani in a combined colorectal and dermatological clinic. Br J Surg 1999; 86: Keighley MRB, Williams NS, editors. Pruritus ani. In: Surgery of the Anus, Rectum and Colon. 2 nd ed. China: W B Saunders Company Ltd., 1997; Jensen SL. A randomised trial of simple excision of non-specific hypertrophied anal papillae versus expectant management in patients with chronic pruritus ani. Ann R Coll Surg Engl 1988; 70: Farouk R, Lee PWR. Intradermal methylene blue injection for the treatment of intractable idiopathic pruritus ani. Br J Surg 1997; 84: Shocket E. Anal cleansing vs. irritation. Dis Colon Rectum 2000; 43(8):
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