Abscesses. Why do patients present? Perianal Abscess. Anorectal Abscess. Anorectal Abscess. Treatment. Pain Bleeding Drainage Mass

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1 Anorectal Disease for the Primary Care Physician Introductions Division of Colorectal Surgery Kirk A. Ludwig MD Timothy J. Ridolfi MD Timothy J. Ridolfi MD, Assistant Professor, Division of Colorectal Surgery Medical College of Wisconsin, Milwaukee WI Mary Otterson MD Carrie Y. Peterson MD 2 What do Colorectal Surgeons Do? Benign Anorectal Conditions Abscesses, Hemorrhoids, Fistulas, Fissures, Fecal Incontinence, Prolapse Inflammatory Bowel Disease Colon Cancer Rectal Caner Diverticulitis Tools of the Trade 3 4 Common Benign Anorectal Conditions Abscesses Fistulas Hemorrhoids Fissures Fecal Incontinence Prolapse Anal Condyloma Anatomy of the Anal Canal 5 6 1

2 Why do patients present? Pain Bleeding Drainage Mass Abscesses Pain/Swelling No Bleeding Sometimes drainage A Hemorrhoid can be anything 7 8 Perianal Abscess Anorectal Abscess Types (4 types) Perianal Ischioanal Supralevator Intersphinteric 9 10 Anorectal Abscess Etiology 90% cryptoglandular infected anal gland 10% other Symptoms Pain Swelling Urinary Symptoms Treatment Perianal / Ischioanal abscess Drainage Bedside or in OR As close to anal verge as possible Wick or Place drain (Pezzar drain) Abx for immunosupression, cellulitis Deeper abscesses will require surgical drainage 12 2

3 Anal Fistula Sometimes Pain No bleeding Drainage Anal Fistula Most fistulas are thought to arise due to cryptoglandular infection Anal Fistula Four types Intersphinteric Transphinteric Suprasphinteric Extrasphinteric Intersphinteric Trans-sphinteric Suprasphinteric 3

4 Extraspinteric Anal Fistula Treatment Principles Eliminate fistula Prevent recurrence Preserve sphincter function Most commonly approached with Fistulotomy Seton Placement Fistulotomy Fistulotomy with Cutting Seton Rectal advancement Flap LIFT (Ligation of Intersphinteric Fistula Tract) 4

5 Fistula Plug Anal Fissure Pain especially with bowel movements Bleeding Minimal drainage Anal Fissure Anal Fissure Associated with Constipation and straining Frequent bowel movements Causes anal canal to crack Chronic Fissure accompanied by skin tag and/or hypertrophied anal papilla 27 Anal Fissure Usually posterior Treatment Fiber and sitz baths Topical Nitrogylcerin Topical Calcium channel blocker Botulinum Toxin Surgical Treatment 5

6 Lateral Internal Sphincterotomy Hemorrhoids No Pain Bleeding No Drainage Caused by venous congestion Most commonly secondary to straining and constipation Pregnancy Hemorrhoids Hemorrhoids Anatomic Location External Internal 33 Internal Hemorrhoid Classification Treatment Medical Fiber Decreased Straining 6

7 Hemorrhoid Treatment - Banding Hemorrhoidectomy Stapled hemorrhoidectomy Doppler Guided Arterial Ligation Thrombosed External Hemorrhoid Thrombosed External Hemorrhoid 7

8 Condyloma Condyloma Itching most common symptom HPV-mediated Calmoseptene ointment & Sitz baths for itching Colorectal referral Need biopsy to determine dysplasia and excision Rectal Prolapse Rectal Prolapse Circumferencial folds Best examined with pt straining on toilet Associated with long-standing constipation & bowel dysfunction Disordered defecation Straining Incontinence? Fiber can help by making stools softer and easier to pass Rectal Prolapse Several surgical options but none are perfect Perineal resection Mesh rectopexy Fecal Incontinence A number of etiologies Obstetric injury, sphincter muscle damage from trauma or anorectal procedures, proctitis, prolapse, tumors Medical treatments Fiber & bulking agents Constipating agents

9 Fecal Incontinence Depending on the etiology, we can offer a number of other treatments Biofeedback referral Solesta Sacral nerve stimulation Sphincteroplasty Questions Contact Information: Timothy J. Ridolfi MD Assistant Professor Division of Colorectal Surgery Department of Surgery Medical College of Wisconsin tridolfi@mcw.edu