Anorectal Pain. Andy Ramwell Consultant General and Colorectal Surgeon St George s Hospital and Parkside

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1 Anorectal Pain Andy Ramwell Consultant General and Colorectal Surgeon St George s Hospital and Parkside

2 Anatomy

3 Cause Anal fissure Infection Skin fungal, bacterial, STI Perianal abscess/fistula Skin problem dermatitis, psoriasis Malignancy Anal ulcer Haemorrhoids Pain syndromes

4 Anal fissure Commonest cause of pain Sharp pain during defeacation Dull ache afterwards Can last for hours May be able to localise Bleeding May have abnormal bowel habit

5 Anal Fissure Chronic fissure 6/52 + Sentinel pile/tag Intra-anal fibroepithelial polyp Multiple fissure Consider other causes IBD, TB, HIV Post partum

6

7 Anal fissure - Treatment Conservative Soften bowels Topical lignocaine Oral analgesia GTN 0.4% (Rectogesic) Diltiazem 2% (Anoheal) Botulinum toxin Surgery Lateral sphincterotomy Fissurectomy Advancement flaps Low pressure fissures

8 Infection - Skin Fungal Bacterial Viral/STI Often with pruritus Treat with steroid cream +/- antibiotic/antifungal Skin swab? GU clinic?

9 Dermatology Dermatitis Psoriasis Lichen sclerosis Very itchy Dermatology review

10 Infection - abscess Severe, constant pain Cannot sit Usually obvious signs of inflammation Intersphinteric abscess

11 Anal fistula

12 Abscess - treatment Antibiotics Early stages If induration Incision and drainage Treat fistula Lay open Seton Glue/plug LIFT procedure

13 Malignancy Can present with pain Usually constant Progressive Lump

14 Anal Cancer

15 Anal Cancer - Introduction 4% of large bowel malignancies new cases per year in Eng/Wales Increasing incidence 80% are squamous Anal receptive intercourse relative risk by 33 times More common x30 in HIV+ve Anal warts relative risk by x27 and x22

16 Anal cancer - treatment Local excision Chemoradiotherapy Nodal treatment Salvage surgery Extralevator abdominoperineal excision and reconstruction

17 Anal Ulcers Crohn s Nicorandil Malignant

18 Haemorrhoids Not usually painful Uncomfortable Irritate/itch Bleed Prolapse

19 Painful haemorrhoids

20 Thrombosed haemorrhoids Perianal haematoma Can be incised and squeezed under LA True thrombosed haemorrhoids Conservative Rx May not need other intervention Investigate other symptoms eg bleeding

21 Haemorrhoids - treatment Conservative Diet Stool softener Topical treatments Outpatients Injection sclerotherapy Banding

22 Haemorrhoids treatment Operative Haemorrhoidectomy Stapled haemorrhoidopexy Ligasure Haemorrhoidal ligation procedures THD HALO

23 Transanal Haemorrhoidal Dearterialisation

24 Pain syndromes Proctalgia fugax Chronic idiopathic anal pain (levator ani syndrome) Coccydynia

25 Proctalgia Fugax Sudden, short lived, severe, self limiting bursts of anorectal pain Only lasts longer than 5 mins in 10% Max 30 mins Variable pattern, M=F, 30% at night <5 times per year in 51% Lifetime prevalence 8-18% 90% anal pain PR is normal

26 Chronic Idiopathic anal pain Bearing down pain Worse sitting Prevalence 6-7% Declines after 45yrs F>M Major psychological overlay Frequently have puborectalis tenderness on PR

27 Coccydynia Severe rectal, perineal and sacrococcygeal pain Continuous, burning pain Radiates buttocks/thighs Mainly female Worse sitting down Pain can be reproduced by manipulation of the coccyx Very difficult treatment

28 History When? During defeacation usually a fissure With wiping skin issue Constant thrombosed pile, abscess, malignancy Timescale Acute, sudden thrombosed pile, fissure Over a few days abscess Over months malignancy, skin problem

29 History Is there rectal bleeding? Alarm symptoms Weight loss Bowel habit

30 Examination Is there anything to see? A fissure may be hidden Is the skin warm and/or swollen? Is there a lump? What colour is it? Is the anus moist or dry? Is a PR possible? Don t attempt if there is a fissure

31 Summary Anal fissure is the commonest cause of anal pain No obvious cause needs EUA Often conservative measures will work