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Anorectal Surgery

Made Easy

Anorectal Surgery

Made Easy

Ajit Naniksingh Kukreja MS FICS(USA) FIAGES LLB


Ratandeep Surgical Hospital and Endoscopy Clinic Nakshatra, IInd Floor Maninagar, Ahmedabad Gujarat, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD


New Delhi Panama City London Dhaka Kathmandu

Jaypee Brothers Medical Publishers (P) Ltd.


Headquarters Jaypee Brothers Medical Publishers (P) Ltd. 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P. Medical Ltd. 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com Jaypee Brothers Medical Publishers (P) Ltd. 17/1-B, Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com 2013, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the author contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the author specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the author. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Anorectal Surgery Made Easy First Edition: 2013 ISBN 978-93-5025-719-7 Printed at Jaypee-Highlights Medical Publishers Inc. City of Knowledge, Bld. 237, Clayton Panama City, Panama Phone: + 507-301-0496 Fax: + 507- 301-0499 Email: cservice@jphmedical.com Jaypee Brothers Medical Publishers (P) Ltd. Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: jaypee.nepal@gmail.com

Dedicated to

Late Smt. Parvati Kukreja Late Ramkishan Kukreja Late Shri Pursusingh Kukreja

Naniksingh Pursusingh Kukreja Parivar, INDIA

Preface
Considering the prevalence of anorectal diseases and developments in anorectal disorders, there are surprisingly few books on Anorectal Surgery. The goal of every good medical textbook is to teach excellence in medicine. This is the main purpose of this book Anorectal Surgery Made EasyWith DVD. This book specically attempts to draw together all up-to-date strands of relevant information. Everything a trainee, practicing surgeon or proctologist needs to know. The book is written at a level appropriate for both medical students (Undergraduate and Postgraduate), Surgeons and Proctologists. The book is clearly set out in twenty-one chapters starting with History of Surgery and covers the whole spectrum of new frontiers in management of anorectal disorders. Sections describe the clinical manifestations, diagnosis, and treatment of each condition. Useful tables, pictures, tips, notes and caution warnings are included. The chapters themselves are comprehensive yet free of unnecessary detail. Only key references are included so that readability is not inhibited by overly dense text. This book will answer a lot of common questions and some odd ones that bring an interesting approach to managing patients with anorectal problems. Once you get started reading the book, you will learn to think in nontraditional ways, ways that will help you manage problems that might previously have been very hard for you to manage. Discretion dictates, that I cannot credit individually those who have had an inuence on my writing. In any case, great as

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Anorectal Surgery

that inuence has been, my rst word of thanks goes to my entire family. I am indebted to my family who has, as always, given me the seless support and far more encouragement than I deserve. Primary acknowledgment must go to the many dedicated scientists who have discovered the principles of surgery. The scientic literature acknowledges individual contributions, but textbooks cannot adequately pay such tribute. I am indebted to all these unnamed investigators. I would like to take this opportunity to thank all those who have contributed so generously their experience, and time, in order to produce this work. Not to forget my philosophers, teachers and guides, relatives, friends, staff, well wishers and last but not least my patients. I am condent that this textbook will enjoy wide recognition, and hope that it will become a reference work for proctologists around the globe. No matter, how you choose to use this book, I wish you a lot of joy, and hope to get some feedback from you at my email address: info@ratandeep.com

Ajit Naniksingh Kukreja

Acknowledgments
I am grateful to Smt HariDevi and Shri Naniksingh Pursusingh Kukreja and Family, Smt Devi and Shri Lekhraj Pursusingh Kukreja for guiding me to conceptualize, develop and complete this title. Indeed, without the help and will of the family, nothing would have been accomplished. Rev Dadaji JP Vaswani, Bhai Chamnjeet Singh Lal, Swami Purshottampriyadas Ji for showering their blessings. The effort of Dr Jyotsna Ajit Kukreja, Dr Preeti Ratansingh Kukreja, Dr (In Making) Renuka Ajit Kukreja, Anamika Ajit Kukreja and Late Ms Rekha Christian in coordinating the process is acknowledged. This book is a fruit of cooperation and relentless dedication of many individuals and institutions. They include my patients who provided the opportunity and encouragement to explore these ideas. Further thanks goes to my teachers Dr SM Patel, Dr KL Sheth and Dr RL Vadi for their blessings. The entire team of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who gave the most careful reading of the book, and advice based on years of experience. As have many others, I feel compelled to mention Smt Jyoti and Shri Prakash Kandhari, Smt Sulochana and Shri Ratansingh Kukreja, Smt Varsha and Shri Jitendra Kukreja, Smt Sheela and Shri Dilip Kukreja, Smt Sunita and Shri Dharmendra Kukreja, Smt Geeta and (Late) Shri Ramkishansingh Kukreja, Smt Pooja (Anjali) and Shri Hemant Lakhani, Smt Dhara and Shri Hero Bhojwani, Smt Urvashi and Shri Jenish Puri, Smt Unnati and Shri Girish Kandhari, Kirti Kukreja, Trilochan Kukreja, Kush Kukreja, Karuna Kukreja and Pradeep Kukreja and all Kukreja family kids

Anorectal Surgery

and kins for creating an enjoyable environment for writing the book. And nally my coordinates, friends and staff at Ratandeep Surgical Hospital and Endoscopy Clinic for their emotional support.

Contents
1. History of Surgery 1
The Atharva Veda Lists the Eight Divisions of Ayurveda 1

2. Embryology 10
Objectives of Studying Embryology 10 Clinical Correlation 11

3. Anatomy 16
Rectum16 Clinical Signicance of Third Sacral Vertebra 18 Endoscopic and Surgical Signicance of Rectum 18 Vascular Supply of Rectum and Anal Canal 23 The Venous Drainage of the Rectum 25 The Lymphatics 27 The Nerve Supply to the Anorectal R egion 27 The Sphincters 30 The Corrugator Cutis Ani Muscle 32 The Internal Sphincter 33 The Longitudinal Muscle 34 Milligans Septum 34 The Anorectal Muscle Ring 35 The Anococcygeal Ligament or Body 36 The Levator Ani Muscle 36 The Pelvic Triangles 39 The Perineopelvic Spaces 39

4. Physiology
Function of Internal Anal Sphincter 48 Function of External Anal Sphincter 49 Neurophysiology (Defecation Reex) 50

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5. Evaluation of Patient with Anorectal Disorders 52


History Taking in Patients with Anorectal Disorders 52

6. Clinical Examination
Evaluation of a Patient with Anorectal Disease 63 Digital Rectal Examination 70 Digital Rectal Examination Work-up in Fistula in Ano 74 Examination Under Anesthesia 74

63

7. Investigations
Fecal Occult Blood Test 75 Pathology and Clinical Use 82 Radiology in Patients with Anorectal Disorders 84 Normal Findings 86 Pathology and Clinical Use 87 CT Colonography 89 Relative Contraindications to CT Colonography 90 Preparation of the Colon for CTC 91 Role of Spasmolytics 94 Scanning94 Interventional CT 97 Dynamic MRI Defecography 97 MRI Normal Findings 98 Pathology and Clinical Use 98 Anal Manometry 100 Purpose of Performing Anal Tonometry 105 Electromyography117 Endoscopy119 Complications127 Rigid Sigmoidoscopy 127 Flexible Sigmoidoscopy 137 Preparation139

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Contents

xiii

Colonoscopy141 Technique146 Bleeding149 Postpolypectomy Coagulation Syndrome 149 Colonoscopic Tattooing 151

8. Preoperative Work-up
For Ambulatory Anorectal Surgery 153 Patient Evaluation 155

153

9. Constipation
Risk Factors for Chronic Constipation 160 Epidemiology162 Pathophysiology163 Pelvic Floor Dysfunction 165 Constipation in Elderly 168 Constipation in Children 168 Normal-Transit Constipation 170 Slow-Transit Constipation 171 Pelvic Floor Dyssynergia or Dysfunction or Defecatory Disorders 174 Constipation in Pregnancy 177 Evaluation of an Individual with Constipation 178 Physical Examination 181 Laxatives190

159

10. Obstructed Defecation Syndrome


Rectocele211 Symptoms213 Laparoscopic Rectocele Repair Technique 221 Rectal Intussusception 222 Enterocele225 Classication226 Total Pelvic Organ Prolapse 228 Physical Examination 229

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11. Biofeedback
A Standard Biofeedback Training Protocol 232 Efcacy of Biofeedback Therapy 239

232

12. Functional Anorectal Disorders


Levator Ani Syndrome 243 Proctalgia Fugax 246 Perineal Descent Syndrome 253 Pruritus Ani 255 Perianal Infection 258 Colorectal and Anal Disease 260 Systemic Disease and Psychological Factors 262 General Control Measures 267 Solitary Rectal Ulcer Syndrome 270

241

13. Anorectal Malformations


Imperforate Anus 276 Prevalance276 Manifestation and Diagnosis 277 Associated Anomalies 283 Laparoscopic Assisted Pull-Through 287

275

14. Fissure in Ano


Pathogenesis291 Perpetuating Factors 291 Internal Anal Sphincter Physiology 292 Acute Fissure in Ano 293 Treatment295 Medical Therapy 296 Surgical Management 300

289

15. Hemorrhoids (Piles)


Epidemiology307 Clinical Features and Presentation 313 Differential Diagnosis 314 Treatment318

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Contents

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Dietary and Lifestyle Modications 318 Oral Medication 319 Topical Treatment 320 Sclerotherapy322 Cryotherapy328 Radiofrequency Coagulation and Excision 333 Doppler Guided Hemorrhoidal Artery Ligation 335 Stapled Hemorrhoidectomy 348 Surgical Hemorrhoidectomy 354 Milligan-Morgan (Open) Hemorrhoidectomy 357 The Harmonic Scalpel and Ligasure 361 Atomizer Wand 362 Thrombosed Internal Hemorrhoids 364 Thrombosed External Hemorrhoids 364 Hemorrhoids in Special Situations 366

16. Anorectal Abscess


Clinical Anatomy 368 Pathogenesis371 Physical Examination 373 Treatment376 Horseshoe Abscess 377 Postoperative Care 380 Special Consideration 381

368

17. Hidradenitis Suppurativa


Prevalence384 Etiology384 Pathogenesis385 Treatment386 Nonsurgical Treatment 387 Hormonal Therapy 387

383

18. Fistula in Ano


History of Fistula in Ano 391 Pathogenesis393

391

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Clinical Presentation 393 Physical Examination 395 Differential Diagnosis 396 Classication397 Patient Work-up 400 Other Tests 403 Management405 Treatment406 Medical Therapy 406 Mucosal Advancement Flap 413 Preoperative Preperation 416 Future and Controversies 419 Special Situations and Considerations 420 Anal Fistula Plug 424 Ligation of Intersphincteric Fistula Tract (LIFT) 426 Video-Assisted Anal Fistula Treatment (VAAFT) 427

19. Pilonidal Sinus


Denition428 Epidemiology and Demographics 430 Etiology431 Physical Findings and Clinical Presentation 432 Diagnosis432 Differential Diagnosis 434 Work-up434 Laboratory Tests 435 Treatment435 Role of Antibiotics 436 Operative Treatment 438 Chronic Treatment 440 Karydakis Flap 444 Limberg Flap 445 Bascom Flap 445 The Z-Plasty 447

428

Contents

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Management Options in Special Situations 450 Recurrent Pilonidal Disease 450

20. Rectal Prolapse


Etiology453 Diagnosis457 Rectal Prolapse Treatment 460 Surgical Therapy 460 Wells Posterior Ivalon Rectopexy 464 Postoperative Care 469

453

21. Fecal Incontinence


Factors Maintaining Fecal Continence 475 Causes of Anal Incontinence 475 Treatment493 Nonsurgical Options 494 Operative Procedure 497 Sacral Nerve Stimulation 502

474

Index 513

chapter

History of Surgery

India is a country that will mesmerize anyone with its intriguing history and fascinating past. The roots of modern medicine are found in Vedas which are at least 6000 BC old. There were originally four main books of spirituality, which included among other topics, health, astrology, spiritual business, government, army, poetry and spiritual living and behavior. These books are known as the four Vedas; Rik, Sama, Yajur and Atharva.

The Atharva Veda Lists the Eight Divisions of Ayurveda


Internal Medicine, Surgery of Head and Neck, Ophthalmology and Otorhinolaryngology, Surgery, Toxicology, Psychiatry, Pediatrics, Gerontology or Science of Rejuvenation, and the Science of Fertility. The Vedic Sages took the passages from the Vedic Scriptures relating to Ayurveda and compiled separate books dealing only with Ayurveda. One of these books, called the Atreya Samhita is the oldest medical book in the world! Quoting Herodotus: The practice of medicine is very specialized among Indians. Each physician treats just one disease. The country is full of physicians, some treat the eye, some the teeth, some of what belongs to the abdomen, and others internal diseases. The art of surgery in Indian medicine is known as Salyatantra. Originating from foreign bodies of all origins denoted as Salya, especially the arrows which was the most common and most dangerous foreign body causing wounds and requiring surgical treatment (Salyabroken parts of an arrow and such other sharp weapons; tantramaneuver). Sushruta was a great surgeon of ancient India, though there is considerable controversy about his age. Sushruta is stated to be the son of Vishvamitra in the Sushruta Samhita. Sushruta was sent

Anorectal Surgery

Fig. 1.1: Sushruta

to study Ayurveda with special emphasis on Salya (Surgery) under Divodasa Kashi Raja Dhanvantari of the Upanishadic age. Surgery was widely used in Indian medicine. In the ancient World, Indian surgeons performed the most elaborate operations. Over 121 different steel instruments (Fig. 1.2) were used to sew-up wounds, drain fluid, remove kidney stones and to perform plastic surgery. An official punishment for adultery was to cut-off your nose, so surgeons had plenty of opportunities to reconstruct and refine noses. Indian surgery has great potentialities for research. The Indian technique of rhinoplasty has earned many laurels outside the country. Similarly, plastic surgery as a whole, management of injuries, and some simple measures as substitutes of surgical manipulations have of late been brought to light. Sushruta the father of Indian Surgery (Fig. 1.1) is the author of the Sushruta Samhita, the work known after his name, and one of the most authentic reference in Indian medical literature. There are references to accidental loss of leg of Vispala who was

History of Surgery

Fig. 1.2: Ancient Indian surgical instruments; 1. Simhamukha swastika; 2. Kanka mukha svastika; 3. Dvitala yantra; 4. Arsa yantra; 5. Bhagandara yantra; 6. Vadisa sala; 7. Darbhakrti khala mukha sala; 8. Karna sodnana; 9. Garbha sanku; 10. Ardha-chandra-mukha sala; 11. Mallaka samputa; 12. Alabu yantra; 13. Ghati yantra; 14. Yoni vraneksana; 15. Vrana vasti; 16. Vasti yantra; 17. Suvasti yanta; 18. Uttara vasti; 19. Mandalagara sastra; 20. Karapatra; 21. Vrddhipatra; 22. Utpala patra; 23. Kusapatra; 24. Sararimukha sastra; 25. Antar-mukha sastra; 29. Vadisa; 30. Danta sanku; 31. Esani; 32. Yantra sataka for phlebotomy; 33. Dhumanadi; 34. Yantra sataka for lithotomy; and 35. Fracture immobilization bed

Anorectal Surgery

immediately provided an iron leg-prosthesis to walk with. The origin of the surgery can be traced back to the earliest times (Table 1.1), probably back to the Indus Civilization. The Rigveda mentions many a surgical feat of the celestial twin medical experts, The Ashvins. Amongst the eight divisions of medical knowledge (Ayurveda), surgery was considered the first and the most important branch. As early as 1200 BC, Agnivesha took the Herculean task of gathering, pruning, emphasizing and compiling the Kalpas, small monographs into textbooks of medicine. As most of the references on ancient medicine and surgery were in form of Kalpas. The ancient Indian medical practitioners were categorized into either: the Salya-cikitsakas (surgeons) or the Kaya-cikitsakas (physicians). Surgery had not yet been incorporated into the encyclopedic tradition as represented by the Agniveshatantra. Sushruta had put in lot of efforts to get surgery achieve a leading position in general medical training. Sushruta Samhita, the composition of Sushruta, known after his name, is the transalation of what he learnt at the feet of his preceptor Divodasa Dhanvantari. There are references that along with Sushruta, Aupadhenava, Vaitarana and others too had their instruction from Divodasa Dhanvantari and they also had with their own limitations prepared a treatise on Salyatantra. Amongst these compositions, only the Sushruta Samhita has remained the only treatise for two of the eight branches of Ayurveda, namely Salya and Salakya. The progress of internal medicine saw a steep rise, where as surgery declined and was ultimately practiced by some traditional families, and the knowledge was limited to theory only. The reason being: Abandonment of dead body dissection Relegation of the manual work to inferior artisans gradually deprived those who studied the work of Sushruta of practical knowledge. The Sushruta Samhita is in two parts: The Purvatantra in five sections and the Uttaratantra. These two parts together cover Salya and Salakya, the main essence of the Samhita.

History of Surgery
Table 1.1: Landmarks in history of anorectal surgery Hippocrates 400 BC Treated hemorrhoids with white-hot iron or by burning them off and treated fistulas by use of seton (The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BC by Hippocrates. In these writings, symptomatic hemorrhoids were described as the result of infection of the veins within the rectum with stool, causing the temperature within the vein to rise and the vein to swell. Successful treatment could be obtained by cauterizing the hemorrhoids with a red-hot iron) Clysters described the procedure for fistulotomy and use of seton 14th Century John Arderne, described Herbert Mayo described pilonidal sinus as a disease that involved a hair-filled cyst at the base of the coccyx Described surgery for imperforate anus Coccygodynia described Performed sigmoid resection and exteriorization of the proximal bowel as permanent colostomy Performed sigmoid resection and exteriorization of the proximal bowel as permanent colostomy Hodge coined the name pilonidal, from the Latin pilus that means hair and nidus that means nest Thiersch described the Thiersch perineal procedure for management of rectal prolapse Became one of founders of American Proctologic Society And was popularly known as the Father of proctology Delorme described the sleeve re section for management of prolapse rectum Contd...

Clysters John Arderne Herbert Mayo

1379 14th Century 1833

Amussat Billroth Fistulotomy Hodge Thiersch J W Matthews

1835 1859 1879 1879 1880 1891 1899

Delorme

1900

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Contd... Table 1.1: Landmarks in history of anorectal surgery Wolff Noble 1900 1902 1935 Milligan and Morgan Eisenhammer Ferguson Barron Park et al. Madigan and Morson Parks Stephens and Smith 1937 1951 1952 1963 1966 1969 1976 1984 1992 1995 K Morinaga 1995 Wolff reported carcinoma in pilonidal sinus Noble described endorectal advancement flaps for management of rectovaginal fistula Proctalgia Fugax described Milligan and Morgan in United Kingdom descibed open hemorrhoidectomy Internal sphincterotomy was first described Ferguson described closed hemor rhoidectomy for management of hemorrhoids Barron described rubber band ligation for management of hemorrhoids Parks et al. described perineal descent syndrome Distinctive characteristics of solitary rectal ulcer described Parks refined the classification system for fistula in ano that is still in widespread use Classified anorectal anomalies intermediate, low cloacal, and rare Rome Criteria I for constipation defined Sacral nerve stimulation first described for management of fecal incontinence Conceived of a novel approach in form of Doppler Guided hemorrhoidal artery ligation for management of hemorrhoids. Longo described stappled hemor rhoidectomy for management of hemorrhoids Rome Criteria II for constipation defined as high,

1995 1999

History of Surgery

Along with other specialties like medicine, pediatrics, geriatrics, diseases of the ear, nose, throat and eye, toxicology, aphrodisiacs and psychiatry. Though the Sushruta Samhita is compilation of the science of surgery, it also incorporates the relevant aspects of other disciplines too. Because Sushruta himself was of the opinion that if you want to master your faculty you should have sound knowledge of allied branches. The Samhita consists of five books in an encyclopedia: 1. Sutra-sthana 2. Nidana-sthana 3. Sarira-sthana 4. Kalpa-sthana and 5. Cikitsa-sthana making a total of one hundred and twenty chapters. Of special mention are: The Nidana-sthana that provides knowledge of etiology, signs and symptoms of important surgical diseases and those ailments, related to surgery. The Sarira-sthana which provides knowledge of the rudiments of embryology and anatomy of human body along with instructions for venesection (cutting of veins), the positioning of the patient for each vein, and protection of vital structures (marma) along with the essentials of obstetrics. The Cikitsa-sthana deals with the principles of management of surgical conditions including obstetrical emergencies along with a few chapters on geriatrics and aphrodisiacs. Needing special mention is Uttaratantra also named Aupadravika briefly dealing with a lot of complications of surgical procedures like fever, dysentery, cough, hiccough, kurmi-roga, pandu, kamala, etc. Sushruta was always of the opinion that anyone who wants to master surgery should study anatomy by practical observation of the various structures composing the body. This is dealt with in detail in the Sarira-sthana of the Sushruta Samhita. He practiced a phasewise approach to study embryology before anatomy and in those prehistoric days he recommended human body dissection.

Anorectal Surgery

Sushruta in his book, has described over 120 blunt and sharp surgical instruments, (Fig. 1.2) 300 surgical procedures and classifies human surgery into eight categories. He was of the feeling that a surgeon, by his own experience and intelligence, may invent and add new instruments to make surgical procedures simpler. There is also a mention of 14 types of bandaging capable of covering almost all the regions of the body are described for the practice of the student on dummies. Procedures of surgical importance in modern surgery like cauterization by Ksharas (alkaline substances) or Agni and application of leeches were used abundantly. Thermal cauterization for therapeutic purposes has been advocated by heating various substances and applying them at the desired sites. Sushruta has described surgery under eight heads: (Fig. 1.3) 1. Chedya (excision) 2. Bhaidya (incision) 3. Lekhya (scarification)

Fig. 1.3: Sushruta performing surgery

History of Surgery

4. 5. 6. 7. 8.

Vedhya (puncturing) Esya (exploration) Ahrya (extraction) Vsraya (evacuation) Sivya (Suturing)

There is also mention of certain surgical conditions of ano-rectal region, in Sushruta Samhita. There is description of different methods of management of both hemorrhoids and fistulae. Different types of incision to remove the fistulous tract like langalaka, ardhalangalaka, sarvabhadra, candraadha (curved) and kharjurapatraka (serrated) are described for management of different type of fistula.

chapter

Embryology
Objectives of Studying Embryology 

1. General understanding of the early events of human development. 2. Understand the key divisions, events and time course of human development. 3. Understand the concept of mixed embryonic origins of different tissues and organs. 4. General understanding of the term critical periods of development. 5. Understand the critical period in development. The hindgut gives rise the rectum, and the upper part of the anal canal apart from the distal third of the transverse colon, the descending colon, the sigmoid. The cloacal membrane ruptures at the end of the seventh week, creating the anal opening for the hindgut and a ventral (Fig. 2.1) opening for the urogenital sinus. The tip of the urorectal septum forms the perineal body between the two, proliferation of ectoderm closes the caudalmost region of the anal canal at this time, and this region recanalizes during the ninth week. The caudal part of the anal canal is supplied by the inferior rectal arteries, branches of the internal pudendal arteries as it originates in the ectoderm. The cranial part of the anal canal is supplied by the superior rectal artery, a continuation of the inferior mesenteric artery, the artery of the hindgut as it originates in the endoderm. Just below the anal columns, the junction between the endodermal and ectodermal regions of the anal canal is delineated by the pectinate line.

Embryology

11

Fig. 2.1: Embryo at 5th week showing development of gastrointestinal tract

At this line, the epithelium changes from columnar to stratified squamous epithelium.

Clinical Correlation 
Malformations
Rectoanal atresias, and fistulas occur in 1 out of 5000 live births (Fig. 2.2). Abnormal partitioning of the cloaca by the urorectal septum into the rectum and anal canal posteriorly and the urinary bladder and urethra anteriorly results in anorectal malformations.

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Fig. 2.2: Rectovestibular fistula in female

Malformations are caused by abnormalities in formation of the cloaca, due to ectopic positioning of the anal opening and not to defects in the urorectal septum. Approximately 50% of children with rectoanal atresias have other birth defects.

High (Supralevator) Anomalies (40%)


Also known as anorectal agenesis There is absence of anal canal and rectum ends above levator ani muscle This causes severe obstruction Is associated with anomalies in vertebrae and urinary tract There may coexist defective innervation of pelvic muscles, fistulas from rectum to bladder, urethra or vagina Complicated surgery is needed for reconstruction

Embryology

13

B
Figs 2.3A and B: Imperforate anus before and after surgery

Low (Translevator) Anomalies (40%)


Includes ectopic (perineal, vestibular or vulvar) anus (Fig. 2.2) Anal stenosis and covered (imperforate) anus (failure of cloacal diaphragm to rupture) (Figs 2.3A and B) No severe obstruction No/rare associated anomalies Normal pelvic innervation Simple surgery is curative

Intermediate Anomalies (15%)


Includes anal agenesis (may be associated with Larsens syndrome) Anorectal stenoses Anorectal membrane Need complicated surgery

Others (5%)
Perineal groove Persistent anal membrane

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Anorectal Surgery

Also persistence of cloaca (bladder, genital tract and bowel empty into single narrow channel that opens onto perineum with small orifice) Exstrophy of cloacal membrane

Imperforate Anus (Figs 2.3 and 2.4)


There is no anal opening. Defect occurs because of a lack of recanalization of the lower portion of the anal canal.

Congenital Megacolon
Occurs due to an absence of parasympathetic ganglia in the bowel wall (aganglionic megacolon or Hirschsprung disease) (Fig. 2.5). These ganglia are derived from neural crest cells that migrate from the neural folds to the wall of the bowel. Congenital megacolon occurs due to mutations in the RET gene, a tyrosine kinase receptor involved in crest cell migration.

Fig. 2.4: High imperforate anus on radiography

Embryology

15

Fig. 2.5: Congenital megacolon

In most cases the rectum is involved, and in 80% the defect extends to the midpoint of the sigmoid. In only 10 to 20% are the transverse and right-side colonic segments involved, and in 3% the entire colon is affected.

chapter

Anatomy
Rectum

The rectum extends from the level of the third sacral vertebral body to the anorectal line. It differs from the sigmoid colon for its specialized role in defecation and continence in combination with the anal canal. As compared to the sigmoid colon The rectum has no sacculations, No appendices epiploicae, and No mesentery. The rectum is about 10 to 15 cm and is connected proximally with the sigmoid colon and with the anal canal distally by passing through the pelvic diaphragm. The circumference varies from 15 cm at the rectosigmoid junction, to 35 cm or more at ampullary portion, its widest portion. The anorectal junction lies opposite the apex of the prostate in males and is 2 to 3 cm in front of and slightly below the tip of the coccyx. The posterior bend is called the perineal flexure of the rectum. The angle rectum forms with the upper anal canal is called the anorectal angle. Though both the ends of rectum lie in the median plane, The rectum itself deviates in three lateral curves (Fig. 3.1): 1. The upper to the right is convex 2. The middle bulges to the left and is the most prominent, and 3. The lower again to the right is convex. Keep in mind the anteroposterior flexure of the rectum, where it follows the curvature of the sacrum and coccyx, and the lateral flexures during sigmoidoscope to avoid causing the patient unnecessary discomfort.

Anatomy

17

There are three-folds of mucosa and circular muscle in rectum, called the valves of Houston, one on right and two on left. The crescentic transverse mucosal folds of the rectum serve to support the weight of the feces and to prevent excessive distention of the rectal ampulla so care should be taken while performing a sigmoidoscopy. Peritoneal covering: 1. Upper one third: Front and sides 2. Middle one third: Sides only 3. Lower one third: Beneath peritoneum of pelvic floor.

The muscular coat of the rectum as in entire colon is arranged in outer longitudinal and inner circular layers of smooth muscle. Though the three teniae coli of the sigmoid colon, come together so that the longitudinal fibers form a broad band on the anterior and posterior surfaces of the rectum which converts to fibrous layer in the sphincters. The complete circular muscles thickens below to form the internal anal sphincter.

Fig. 3.1: The curves of the rectum

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Anorectal Surgery

Parasympathetic innervation: Relaxes smooth muscle Contracts bowel Gives feeling of fullness. Sympathetic innervation: Contracts smooth muscle Relaxes bowel Gives feeling of pain. Upper two-thirds distends into abdominal cavity as against lower one-third which distends into ischioanal fossa.

 linical Significance of Third C Sacral Vertebra


Termination of a definite mesentery Change in the blood supply Tinea of the sigmoid spread out to reinforce the longitudinal muscle coat The site of the rectal narrowing to join the sigmoid It marks the change in color, capillary pattern Change in the rugosity of the rectal mucosa.

 ndoscopic and Surgical Significance E of Rectum


It is divided into two portions, the sphincteric and ampullary portions. The sphincteric portion, surrounded by the levator ani and the fascial collar from the supra-anal fascia, corresponds to the annulus haermorrhoidalis. The ampullary portion extends from the third sacral to the pelvic diaphragm at the insertion of the levator ani.

Anatomy

19

Relations
The relations of rectum have a diagnostic significance while performing a per rectum examination (Figs 3.2 and 3.3). They are important in ascertaining the spread of rectal growths. They also provide important landmarks in operative removal of the rectum.

Fig. 3.2: Relations of rectum

Fig. 3.3: Relations of rectum: female and male

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Anorectal Surgery

Anterior
In Females (Fig. 3.3)
1. 2. 3. 4. 5. 1. 2. 3. 4. 5. 6. Rectouterine pouch of Douglas Small bowel Bladder Uterus Vagina [Posterior fornix]. Rectovesical pouch Small bowel Dennonvillers fascia Bladder Vas, seminal vesicle Prostate.

In Males (Fig. 3.3)

Dennonvillers fascia seperates the rectum from anterior structures and forms an important surgical plane of dissection to be considered in excision of rectum.

Posterior (Fig. 3.2)


Fascia Median sacral and rectal vessels Sympathetic trunk Pelvic splanchnic nerves Piriformis Sacral and coccygeal roots

These roots if involved in rectal growth spreading posteriorly can cause severve sciatic pain. Sacrum Coccyx Anococcygeal body

Anatomy

21

Lateral
Peritoneum Fat Nodes Obturator internus and its fascia Alcocks canal with contents Levator ani Coccygeus Ischioanal fossa Lateral ligaments of rectum.

Anal Canal
The anal canal has a complex physiology and is anatomically peculiar, this accounts for its crucial role in continence and, along with, its susceptibility to a variety of diseases. The edge of the anal orifice, the anal verge or margin (anocutaneous line of Hilton) (Fig. 3.4), marks the lowermost edge of the anal canal and is sometimes the level of reference for measurements taken during sigmoidoscopy. Most schools prefer the dentate line as a landmark because it is more precise. The difference between the anal verge and the dentate line is usually 1 to 2 cm. The epithelium distal to the anal verge acquires hair follicles, glands, including apocrine glands, and other features of normal skin, and is the source of perianal hidradenitis suppurativa, inflammation of the apocrine glands. The anal canal is 4 cm long formed of two distinct parts (Table 3.1) demarcated by the dentate [Pectinate] line (Fig. 3.4). It begins at the anorectal junction and ends at the anal verge [from pelvic floor-puborectalis to anal orifice]. The mid anal canal represents the junction between the endoderm and the ectoderm. There are three mucosal cushions with arteriovenous plexuses (Fig. 3.4).

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Anorectal Surgery
Table 3.1: Difference between the two halves of anal canal Upper half Origin: Endoderm Mucosa: Columnar Appearance: Columns, valves and cushions Innervation: Autonomic Arterial supply: Superior rectal artery Venous drainage: Portal Lower half Origin: Ectoderm Mucosa: Squamous Appearance: Skin Innervation: Somatic Arterial supply: Inferior rectal artery Venous drainage: Systemic

Lymphatic drainage: Para-aortic lymph nodes Lymphatic drainage: Superficial inguinal lymph nodes Common site for hemorrhoids Malignancy: Adenocarcinoma No hemorrhoids here Malignancy: Squamous cell carcinoma

Fig. 3.4: Anal canalgeneral description

Anatomy

23

They help in continence and mucous productions. Situated at constant places of 3, 7, and 11 clock position When enlarged forms hemorrhoids. Pain in the anus is usually felt with a high degree of acuity and is well localized to the perineum and anal canal itself.

Vascular Supply of Rectum and Anal Canal


The vascular anatomy of the rectum is significant in the origin and pathogenesis of internal hemorrhoids. Internal hemorrhoids are usually found in the right anterior, right posterior and left lateral areas, as the plexus in which they are formed, are fairly constant in relation to the terminations of the larger arterial bundles. The inferior mesenteric artery, continues to the rectum as the superior hemorrhoidal, below its last sigmoid branches. The superior hemorrhoidal artery along with superior hemorrhoidal vein runs in the subserous fascia of the mesorectum (Fig. 3.5). At the level of the second sacral vertebra and on reaching the rectal wall, it divides into right and left main branches, before piercing the rectal wall to reach the submucosa they extend to the fascia propria of the rectum. The right and left branches give off several secondary lateral branches, after the primary division. These secondary branches ramify around the upper rectum, and reach the submucosa after piercing its musculature, here it anastomoses between their terminal capillaries and those of the corresponding veins (Fig. 3.5). Around two inches above the anorectal line, the main branch of the right side continues downward and penetrates the rectal musculature, on reaching the submucosa, it divides into an anterior and a posterior branch (Fig. 3.5). 1. Without dividing the anterior continues to the annulus hemorrhoidalis.

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Anorectal Surgery

Fig. 3.5: Vascular supply of rectum and anal canal

2. The posterior branch divides into smaller secondary branches, after reaching the annulus hemorrhoidalis of the posterior quadrant, of these, one branch reaches the mid-lateral aspect and the other, the posterior midline of the annulus hemorrhoidalis. Accompanied by its veins, the left main branch pierces the rectal wall, and divides into two fairly large terminals on reaching the

Anatomy

25

submucosa, in its left anterior quadrant, an anterior branch which reaches the annulus hemorrhoidalis, and in the left posterior quadrant, a posterior branch which again reaches the annulus hemorrhoidalis. The following also contribute to the arterial supply of rectum (Fig. 3.6): Middle rectal artery from internal iliac Inferior rectal artery from internal pudendal Median sacral artery. All arteries supply all layers The posterior and the lateral aspects of the anal musculature get their supply from the inferior hemorrhoidal artery The adjacent integument by superficial and deep branches Where as the anterior aspect is supplied by a separate transverse perineal branch, which arises arising independently from the pudendal. The musculature at different levels is supplied by the terminal branches of the above vessels.

The Venous Drainage of the Rectum


The veins usually follow the same course and give off branches corresponding to the arteries, yet they require special description (Figs 3.5 and 3.6). As they play an important role in the formation of hemorrhoids and external or perianal hematomata. The inferior hemorrhoidal veins are prominent at the anal verge and they form what is commonly known as the external hemorrhoidal plexus. In the pecten of the anal canal, the terminal branches from this plexus, anastomose with the radicals of the venous plexuses of the superior hemorrhoidals. Clinically, this anastomosis is not significant.

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Anorectal Surgery

B
Figs 3.6A and B: (A) Arterial supply of rectum and anal canal; (B) Venous drainage of rectum and anal canal

Anatomy

27

The Lymphatics (Fig. 3.7)


Anorectal Lymphatics
They are divided into three groups as follows: 1. Perianal group 2. Anorectal group (Anal and rectal portions) 3. Extrarectal group.

Perineal Group
This group drains the superficial and deep layers of the perineal skin terminate in the inferolateral group of inguinal nodes.

Anorectal Group
The anal portion: Three plexuses in form of the mucosal, submucosal and intermuscular are demonstrable. The rectal portion: These plexuses communicate with the extrarectal group of lymphatics.

Extrarectal Group
Spreading along the ramifications of the inferior hemorrhoidal vessels, they reach the obturator fascia and the hypogastric nodes. Majority of the lymphatics from the rectal lymph sinus either pass through or drain into nodes contained in upward zone, which includes the lymphatics and tissues in the retrorectal space with the important nodes of Gerota is therefore, most important clinically for consideration of metastasis of cancer.

The Nerve Supply to the Anorectal Region (Fig. 3.8)


Parasympathetic fibers supply the smooth muscle, including the internal sphincter. Sympathetic fibers are mainly vasomotor. Somatic motor fibers supply the external sphincter. Sensory fibers are concerned with the reflex control of the sphincters and with pain.

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Anorectal Surgery

Fig. 3.7: Lymphatics of rectum and anal canal

The fibers in the pelvic splanchnic nerves reach the intestine by way of plexuses. During rectal dissection all pelvic nerves are in danger of injury, as they lie in the plane between the peritoneum and the endopelvic fascia.

Anatomy

29

Fig. 3.8: Nerve supply of rectum and anal canal. Motor fibersRed; Sensory fibersBlue; Parasympathetic fibersInterrupted lines

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Anorectal Surgery

To reduce the possibility of nerve injury, the dissections performed for benign conditions are undertaken closer to the bowel wall. The anal canal is very sensitive below the pectinate line, so that external hemorrhoids may be very painful.

Pudendal Nerve Motor Latency Test (Fig. 3.8)


Pudendal nerve terminal motor latency testing is useful as a diagnostic tool in fecal incontinence. It has also been used as a predictive factor in sphincteroplasty repairs. Pudendal nerve latency is the measurement of the time from stimulation of the pudendal nerve at the ischial spine to the response of the external anal sphincter Normal pudendal nerve terminal motor latency is < 2.2 ms. Apart from the ischial spine other points can be used for the test, which will cause a different response time. The most common has a normal latency of 4.0 ms or less. Anything over the normal latency time means the nerve is not operating normally and is therefore probably damaged. The use of nerve blocks and the PNLT in diagnosis is tricky, so due care should be taken for the same.

The Sphincters
The External Sphincter (Fig. 3.9)
The external sphincter is formed by three striated muscles: 1. Subcutaneous 2. Superficialis 3. Profundus.

The Subcutaneous Muscle (Fig. 3.9)


Situated immediately below the transitional anal skin (transiderm). The bulk of the muscle of this portion of the external sphincter usually annular and arranged somewhat to or on the same longitudinal plane with the internal sphincter.

Anatomy

31

Fig. 3.9: Coronal section showing anorectal muscles

Forming the lower wall of the anal canal, it occasionally presents small posterior extensions, continuous with the strong converging legs of the superficialis muscle. In males anteriorly, it may decussate with the bulbocavernosis and the retractor scroti, And in the female it is continuous with the sphincter vaginae. The prominent insertions of the fibroelastic extensions of the conjoined longitudinal muscle which forms the intersphincteric line, separate the upper and inner margin is separated from the lower edges of the internal sphincter.

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Anorectal Surgery

The terminal extensions of the subcutaneous muscle into the skin form the corrugator cutis ani.

The Superficialis Muscle (Fig. 3.9)


Embracing the anal canal at the level of the internal sphincter the elliptical band of muscle fibers, constitutue the superficialis muscle. Considered the largest, longest and strongest portion. It arises from the sides of the coccyx and forms an important muscular component of the anococcygeal body. The mid-portion of the anal canal is surrounded by its diverging halves. They converge and insert into the central tendinous raphe in the male anteriorly, where as they diverge and fuse with the sphincter vaginae in the female. Anteriorly the crossing fibers extend laterally into the fascial shelf and attach to the ischial tuberosity and nearby fascia. The anterior and posterior communicating spaces in both sexes extend directly above the superficialis fibers, and below the profundus muscle.

The Profundus Muscle (Figs 3.9 and 3.10)


The portion of the external sphincter immediately above the superficialis muscle with annular fibers is the profundus muscle. Sometimes, the uncrossed fibers extend posteriorly to reach the anococcygeal ligament. Anteriorly the profundus, and posteriorly the puborectalis muscle form the upper margin of the anorectal muscle ring. The profundus lies in close relation to the legs of the levator. A common crossed arrangement of the entire muscle, extends to the opposite ischial tuberosity on either side.

The Corrugator Cutis Ani Muscle (Fig. 3.11)


The terminal insertions of the fibro-elastic extensions of the longitudinal muscle into the anal canal and perianal skin form the corrugator cutis ani muscle.

Anatomy

33

Fig. 3.10: Diagrammatic representation ofposterior pull of superficialis muscle and anterior pull of puborectalis muscle during voluntary control of the outlet

The extensions penetrate the substance of the subcutaneous muscle as well as pass on either side of this muscle.

The Internal Sphincter (Fig. 3.11)


The thickened terminal portion of the circular muscle coat of the rectum forms a component of the internal sphincter. The internal sphincter is surrounded by the superficialis portion of the external sphincter. It forms the entire inner muscular layer of the wall of the anal canal. The internal sphincter is separated from the upper border of the subcutaneous by the prominent insertions of the longitudinal muscle, Immediately below its lower margin, and forms the intermuscular septum of the intersphincteric line. The pecten overlies the internal sphincter and is, covered by squamous epithelium with subjacent areolar tissue containing lymphatics, crypts, preformed anal glands, capillaries and nerves.

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Anorectal Surgery

The anal canal measures from 1.5 to 2.5 cm anteriorly in length, 2 to 3 cm in length laterally, and 3 to 4 cm in length posteriorly.

The Longitudinal Muscle (Fig. 3.11)


The longitudinal muscle coat of the rectum is formed by an attenuation of the anterior and posterior longitudinal bands and tinea of the sigmoid. It spreads out to surround the inner circular muscle coat. The longitudinal coat becomes fibroelastic in character, fuses with the levator and fascial extensions at the anorectal junction and becomes the longitudinal muscle. This fascial arrangement fixes and protects the anal canal and acts as a tendon sheath for the divisions of the anal musculature.

Milligans Septum (Fig. 3.11)


Milligans septum is a septum of fascia, which extends from the lower border of the internal sphincter muscle to be inserted into the ischial tuberosity and the skin. Before that, it turns outward below the superficialis and above the subcutaneous muscles. Posteriorly, the septum is incomplete. The intermuscular sulcus (Fig. 3.11) lies in the space between the subcutaneous and internal sphincter muscles. It is readily palpated in the anal canal and is located at the level of Milligans septum. The pull of the insertions of the conjoined longitudinal muscle cause the retraction of the skin of the canal and a depression is formed called intermuscular sulcus. It encircles the canal and serves as a landmark in diagnosis and treatment.

Anatomy

35

Fig. 3.11: The intermuscular sulcus

The Anorectal Muscle Ring


A combined musculo-fascial ring is formed by the levator ani muscle, in conjunction with the profundus portion of the external sphincter. This ring completely surrounds the anorectal junction. The posterior and upper margin of the anorectal ring is formed by the puborectalis division of the levator ani which posteriorly reinforces the anal canal. Anteriorly, it thins out until there remains only a thin sheath of reflector levator fibers called the junction of Luschka. In the anterior quadrant, only the profundus portion of the external sphincter forms the anorectal muscle ring.

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Anorectal Surgery

The Anococcygeal Ligament or Body


It is a firm composite musculo-fascial structure Which extends from the posterior aspect of the anal canal to the tip and sides of the coccyx or the lower sacrum. At different levels the following fuses into it: 1. The strong insertions of the glutei muscles. 2. The ischiococcygeus. 3. The pubococcygeus, and the puborectalis muscles. 4. The superficialis fibers. 5. The terminal posterior extensions of the combined longi tudinal muscle and superficial fascia. Superiorly, it fascial stratum is the supraanal fascia, which supports the rectal ampulla, and inferiorly it is bounded by the skin.

The Levator Ani Muscle (Fig. 3.12)


The levator ani is comprised of many muscular fused parts. The following are four principal paired muscles forming the levator: 1. Pubococcygeus 2. Puborectalis 3. Iliococcygeus 4. Ischiococcygeus.

The Pubococcygeus Muscle (Figs 3.12 and 3.13)


Origin: 1. A common origin with the puborectalis 2. The posterior surface of the pubic arch 3. The arcus tendineus. The main portion of the pubococcygeus continues posteriorly along with the puborectalis and is interlaced to a point of being inseparable, until the pubococcygeus passes around the rectum and is inserted as follows:

Anatomy

37

Fig. 3.12: Superficialis and subcutaneous muscles pulled laterally to demonstrate profundus above and levator plate below

Insertion: 1. The anococcygeal body 2. The coccyx 3. The lower sacrum. The corrugator cutis ani is formed by fibers of pubococcygeus intermingling with the fibroelastic extensions of the conjoined longitudinal muscle.

The Puborectalis Muscle (Fig. 3.12)


Though on a slightly lower plane, this muscle arises practically in common with the pubococcygeus. As they pass posteriorly, the fibers of the puborectalis and pubococcygeus, intermingle and continue to do so until the puborectalis begins to swing on the posterior side of the rectum, to encircle the rectum and become part of the anorectal muscle ring. More than any other muscle of the anorectal muscle ring, Damage to the puborectalis,may result in fecal incontinence.

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Anorectal Surgery

Fig. 3.13: Relationship of the anterior limit of pubis with anterior superior iliac spine

The Iliococcygeus Muscle (Fig. 3.12)


The iliac portion of the levator arises from the fascial covering of the obturator internus muscle. It is directed posteriorly and medially, converging somewhat with the pubococcygeus where they conjointly insert into the coccyx and lower sacrum. This muscle supports the anorectal shelf in the act of defecation.

The Ischiococcygeus Muscle (Fig. 3.12)


This muscle is covered with the same fascial planes from the pubococcygeus and iliococcygeus. It originates from the ischial spine and adjacent sacroiliac fascia. It attaches to the coccyx, the lower sacrum and the median portion of the sacrotuberous ligament.

Anatomy

39

The combined levators fix the pelvic structures and present a fulcrum against which increased abdominal pressure may be exerted in the acts of lifting, coughing, defecation, urination, coitus, and various other activities.

The Pelvic Triangles


The pelvic outlet is divided by an interischial line into: The anterior and The posterior triangles. The anterior triangles consist of the urogenital and urethral or genital. The posterior triangles consist of the anal, ischiorectal or ischioanal. All the structures of the pelvic floor, situated between the peritoneum and the skin are enclosed by the anal and urethral triangles. The anal triangles contain the following musculature: The external and internal sphincters The levator ani with the ischiococcygeus muscle, making up the pelvic diaphragm, and The pyriformis muscle. The deep muscular strata are closely interrelated with the sphincters. The levators coordinate the activity of the sphincters by supporting and fixing the pelvic diaphragm.

The Perineopelvic Spaces


The clinical importance of the perineopelvic spaces and their contained structures is of significance in the surgical therapy of hemorrhoids, fissure and fistulae. These spaces are merely planes of cleavage between closely opposed fascial ensheathments of adjacent organs, as: The prerectal Posterior prostatic

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Anorectal Surgery

Retrorectal Rectovaginal spaces. Their importance in surgical management lies in the fact that these are all potential routes of infectious extensions.

The Perianal Space


This space surrounds the anus and the lower third of the anal canal. A prominent group of these extensions insert into the anal canal as the intermuscular septum, below the lower margin of the internal sphincter. From this septum, the extensions continue downward below the lining of the anal canal into the perianal skin, where they join the lateral extensions and pass externally to the subcutaneous muscle. A space formed by the inner and outer extensions of the perianal space contains: The subcutaneous muscle The external hemorrhoidal plexus of veins with their supporting areolar network. Continuous laterally with the ischiorectal fossa. Posteriorly, it is designated as the postanal space.

The Submucous Space (Fig. 3.14)


The submucous space extends proximally to the upper part of the columns of Morgagni. The internal hemorrhoidal plexus of veins which lies directly above the anorectal line occupies this space. This space contains: The venous radicals A well-marked muscularis with loose areolar tissue Lymphatics Arterial and venous capillaries. The pecten lies between the submucous and perianal spaces. This space is particularly important in hemorrhoidal formation.

Anatomy

41

The Ischiorectal Fossae (Fig. 3.14) Boundaries


The inner wall and roof of the ischiorectal fossae are formed by levator ani muscle.

Anteriorly
Colles fascia and the extensions of the fascial shelf along the posterior aspect of the superficial perineal pouch and The triangular ligament.

Posteriorly
The gluteus maximus muscle The sacrotuberous ligament. In its posteriomedial angle, the fourth sacral nerve traverses the fossae for a short distance.The perforating branches of the second and third sacral nerves leave the fossa below the gluteus, about midway between the coccyx and the ischium. Posteriorly, the two fossae are separated by a thin layer of fascia. Communication between the two fossae usually passes directly behind the profundus. The deepest portion of the fossae is in the area of the ischial spines. The roof of the fossae, Inferiorly, is formed by the skin, reinforced by Milligans septum. Posteriorly it is either incomplete, or There are anomalous defects which permit entrance of infection into the fossae. The vascular pedicle containing the inferior hemorrhoidal artery, veins and nerves, lies posterolaterally. The fascia of the obturator internus muscle forms the lateral walls of the fossae (Fig. 3.14). Alcocks Canal lies behind the obturator fascia and surrounds the pudendal artery, vein and nerve.

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Anorectal Surgery

In males, the fossae are smaller, narrower and deeper.

Dimensions
6 to 8 cm anteroposteriorly 2 to 4 cm wide 6 to 8 cm deep.

Contents
Inferior hemorrhoidal veins and nerves (crossing transversely) The perineal and perforating branches (cutaneous) of the pudendal plexus (posteriorly) The posterior scrotal or labial vessels and nerves (anteriorly).

The Supralevator Spaces (Pararectal) (Fig. 3.14)


Above the levator and below the peritoneal reflections of the abdominal cavity, on either side of the rectum, lie the supralevator spaces. Formidable fascial barriers protect these spaces from infections. The fascia blends with the rectal fascia, As the levator muscles join with the muscles of the rectal wall. The supralevator and

Fig. 3.14: Ischiorectal fossae and pararectal spaces

Anatomy

43

infralevator fasciae are thus continuous with the fascial coverings of the rectum. Anteriorly in the male, the supralevator spaces extend to the prostate and seminal vesicles and in females to the uterosacral ligaments. Thus, infections in both sexes vary according to the conformation of the spaces.

The Retrorectal Space (Presacral) (Fig. 3.15)


This space lies posterior to the rectum and anterior to the sacrum and coccyx. It is lined anteriorly by rectal fascia, posteriorly by the fascia of the sacrum and pyriformis muscle, and inferiorly by the fascia of the structures of the rectal shelf. The retrorectal space is separated from the supralevator spaces by strong fascial concentrations, the rectal stalks.

Fig. 3.15: Retrorectal space

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Anorectal Surgery

It is a potential space and has the potential of large capacity for infectious processes.

The Rectovaginal Space


Extending from the vesicovaginal peritoneal fossa above, to the perineal body below, It is more or less a septum than an actual space. This space is filled with a thin reflection of superficial fascia which forms a line of cleavage between the rectum and the vagina.

The Anococcygeal Triangle (Figs 3.16A and B)


The anococcygeal triangle lies in the sagittal plane: Posterior to: The anal canal Anterior to: The coccyx Below the: Levator shelf Above the: Skin of the gluteal cleft. The triangle lies in the midline and between: The posterior extensions of the pubococcygeus and the superficialis Some posterior extensions of the puborectalis muscles. The vertical triangle can be traced as follows: A line drawn from the tip of the coccyx anteriorly to the midline point at the posterior margin of the profundus muscle A second line from above mentioned point extends downward in midline to a point immediately posterior to the posterior encircling portion of the subcutaneous muscle The third side of the triangle is on a line joining the latter point with the tip of the coccyx. Anoccocygeal triangle is divided into a superficial and a deep portion. The deep portion is situated above the superficialis, below and behind the puborectalis and profundus, and below the levator plate. It extends posteriorly to the coccyx and it is at point at which the ischiorectal fossae communicate through the posterior communicating space.

Anatomy

45

B
Figs 3.16A and B: Anococcygeal triangle

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Anorectal Surgery

Fig. 3.17: Minors triangle


Minors triangle (Fig. 3.17) is a horizontal triangle of the skin and it should not be confused with the anococcygeal triangle.

chapter

Physiology

The gross morphology of the anorectum is essential before considering anorectal function during defecation. Unlike the colon in which the rectum is in direct continuity, the longitudinal muscle layer is not organized into teniae. Instead it forms a continuous outer longitudinal muscle layer, uniformly encircling the rectum. Distally it insinuates between the internal and external anal sphincters, and extends to the distal end of anal canal. The anorectal junction which is the narrowed distal rectum is formed by the longitudinal muscle coat of rectum. This in turn is joined by The sling fibers of the puborectalis muscle Attachments of the levator ani muscles Proximal margins of the internal and external anal sphincters. The puborectalis and levator ani muscles have important roles in maintaining continence and defecation. These striated muscles form part of the pelvic floor and reduce the anorectal angle by their constant tone that serves to pull the rectum anteriorly and elevate it, thereby generating a mechanical effect which tends to prevent entry of stool into the upper anal canal. The internal anal sphincter is a thickened band of smooth muscle, which is in continuity with the circular smooth muscle of the rectum and has a relatively high spontaneous tone. Whereas the external anal sphincter is a striated muscle located distal to internal sphincter, but partly overlies it. The high resting tone of the external anal sphincter as against the internal sphincter can be influenced by voluntary efforts, thus helps in maintaining continence.

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Anorectal Surgery

The normal colonic motility is typical, it produces a slow transit thus facilitating fluid absorption and a mass movement that helps in defecation. Local segmental contractions work for slowly moving the feces forward, where as the peristaltic contractions produce: Retrograde Slow forward movement Along with it the mass contractions empty long segments of the colon in a forward fashion. It takes around 3 to 6 hours for the intestinal contents to reach the colon, and enter the cecum in a liquid state.The feces reach the rectum and become solid within the next 24 hours. The rectosigmoid colon acts as a reservoir, and holds the fecal material for variable periods of time. When the rectal contents move distally, the sensory ability of the anal canal plays an important role in maintaining continence or allowing gas or stool to escape, it allows the individual to voluntarily relax or contract the voluntary sphincter. The factors on which fecal continence depends are as follows: Muscle structures Sensation Bowel motility. The internal anal sphincter and the muscle complex which extends from the levator to the external sphincter are the principal muscles involved in maintaining continence. Sensory afferents that are located in the anal mucosa are responsible for providing pain, touch, temperature, and pressure sensations.

Function of Internal Anal Sphincter


The internal anal sphincter contributes to around 70 to 85% of the resting sphincter pressure. The percent of this contribution of the internal anal sphincter decreases when the rectum distends.

Physiology

49

It is predominantly a slow-twitch, fatigue-resistant smooth muscle. At rest, the internal anal sphincter contracts with a frequency of 15 to 35 cycles per minute. This intrinsic neural reflex stems from an intrinsic innervation located in the intramural plexuses and the myenteric and submucosal ganglia. Thus, the internal anal sphincter is primarily responsible for maintaining anal continence at rest.

Function of External Anal Sphincter


The muscle complex from levator to the external sphincter form the voluntary muscle complex. After the involuntary peristaltic contraction of the rectosigmoid pushes the fecal mass into the anorectal area, the individual gets a sensation and will voluntarily relax these muscles and allow the contents to migrate into the sensitive anal canal. The anal canal in normal individuals is extremely sensitive and it can provide a lot of information: Regarding stool consistency and amount Differentiating between gas, liquid, and solid. If a socially acceptable time and place is not available, the voluntary muscles can push the rectal contents back to be stored into the rectosigmoid. When desired place and time is available, defecation can be initiated after the individual relaxes the voluntary muscles and allows passage of the stool into the anorectum. The peristaltic contractions that are responsible for the emptying of the rectosigmoid can be augmented with a Valsalva maneuver. In most patients with anorectal malformations this motility is impaired, resulting into development of a megarectum. This results into hypomotility which in turn leads to severe constipation and the development of overflow incontinence.

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Anorectal Surgery

Neurophysiology (Defecation Reflex)


Defecation is best explained physiologically on the basis of a modified somatic autonomic reflex which is normally under cortical control. The desire to defecate should conveniently be distinguished from the act of defecation. The so-called trigger zones are probably in the rectal musculature as well as in the anorectal line, the later is the more important trigger zone. The initial sensory stimuli arise and produce the desire to defecate at these trigger zones. To initiate the active phase of defecation threshold stimuli are needed and they normally arise from the anorectal junctional area and are conveyed by the spinal sensory nerves Through the sympathetic afferent nerves, the distention of the rectal wall also gives rise to some extent, the desire to defecate. Which ultimately results reflexly, in a relaxation of the anal sphincters, particularity the internal, and a contraction of the rectal musculature. The act may be inhibited by the will voluntarily. The actual act of defecation, on the other hand is a combination of voluntary relaxation of the anal sphincters with voluntary contraction of the colon and its complimentary muscles, resulting in the expulsion of the rectal contents. In adult life defecation normally becomes a voluntary act and is no longer a reflex. In the autonomic innervated rectum (sympathetico-parasym pathetic) where there is destruction of its cerebral connections, it becomes a purely reflex act. The sensorimotor response of the entire gastrointestinal tract as well as those of the rectum very logically explains the broad subject of constipation. Trigger zones may be entirely extrarectal and in pathologic conditions, provoke a constant tenesmus leading to rectal prolapse.

Physiology

51

The sensory and motor dispersions, before, after, and during the act of defecation are complex and may be reflected throughout the entire nervous system, e.g. fainting, abdominal cramping, organisms, and neurocirculatory phenomena, are common clinical observations. Central stimulation of the Vagus also produces the defecation reflex resulting in a contraction of the rectum and a relaxation of the anal sphincters. In such instances defecation is entirely a cortical response. The segmental movements of the intestines are considered myogenic in origin, and the intrinsic plexuses of Meissner and Auerbach control that peristalsis. The autonomic system (sympathetic and parasympathetic) subserves a regulatory function. Diarrhea may be entirely an intrinsic myogenic basis.

Evaluation of Patient with Anorectal Disorders


History Taking in Patients with Anorectal Disorders

chapter

As in most clinical situations the skill of history taking aids the surgeon arrive at a probable diagnosis even before examining the patient physically. History taking plays an important role, a standard format of origin, duration and progress is the golden standard in clinical practice. The symptomatology in anorectal disorders is very typical of the pathology, following symptoms need a detailed history taking to arrive at a diagnosis: 1. Bleeding per rectum 2. Pain 3. Mucus and pus discharge 4. Swelling 5. Altered bowel habits 6. Prolapse 7. Perianal itching (pruritus ani) 8. Tenesmus 9. Other symptoms related to underlying pathology.

Bleeding Per Rectum


Origin: Acute or chronic, associated history of passage of hard stool before bleeding started is suggestive of acute fissure in ano. Duration: Period since the bleeding started. Progress: If the bleeding has resolved, stabilized or has worsened.

Specific History Related to Bleeding Per Rectum


Color: Bright red, usually originates from lower rectum and anal canal.

Evaluation of Patient with Anorectal Disorders

53

Dark red or brown, usually originates from upper rectum or colon Black, usually also referred to as malena and originates from lesion in small intestine or higher Pain: Bleeding associated with pain is usually due to anal fissure, and painless bleeding is due to hemmorrhoids. Relation to defecation: Whether bleeding is independent of associated with the act of defecation as in prolapsed piles, rectal polyp, fistula in ano, or chronic fissure. Bleeding occurring with passage of hard stool is usually associated with internal piles. In anal fissure there is complain of streak of blood on the side of stool. If there is complain of bleeding per rectum irrespective of the defecation process it is usually associated with prolapsed piles, rectal polyp or chronic fissure in ano. Nature of bleeding: Drops: Drops of fresh blood are usually associated with internal piles. Jet Like: Internal piles Mild or severve Continous or intermittent History of association with something coming out per rectum: Prolapsed internal hemorrhoids Rectal prolapse Rectal polyp Quality of bleeding: If blood is noticed on surface of feces it is presumed to have originated from anal canal, rectum or lower sigmoid colon Blood that is mixed with feces usually originates from bowel higher than sigmoid colon Bleeding occurring independently at the end of defecation is usually from internal hemorrhoids In case of minor bleeding from fissure in ano, perianal skin or thrombosed external hemorrhoids there is staining of tissue on wiping the area.

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Anorectal Surgery

Pain
As against the common belief hemorrhoids are rarely painful unless they are thrombosed or prolapsed and strangulated or if complicated by infection. Similarly carcinoma of rectum is painless in the initial stages and gets painful after the malignancy has infilterated beyond the rectal walls Perianal cutaneous conditions are painful. All anal lesions below the Hiltons line are always painful and lesion of rectum and anal canal that are confined to the wall of the viscera are painless These same lesions on infilterating the walls become painful. Origin: Sudden or gradual Relation to act of defecation. Duration: Period since origin Progress: If the pain is reducing, has stabilized or has worsened Quality of pain: Sharp cuttingacute fissure in ano Throbbingperianal or ischiorectal abscess Aggravated with defecationanal fissure Intermittentfistula in ano Increases on accumulation of discharge and reduces when the same is released Lower abdominal and colickyobstructive lesion of rectum Radiating pain in the legsspreading carcinoma of rectum.

Mucus and Pus Discharge


Sinus or fistula in ano or burst open perianal abscessfrequent purulent discharge Ulcerative infective carcinoma of rectum: Blood stained purulent discharge Collitis, Crohns disease, colloid carcinoma of rectum: Mucus

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Swelling
Swelling arising from perianal region or ischiorectal fossa is always a primary swelling, i.e. Perianal hematoma Perianal abscess Prolapsed thrombosed piles Prolapse rectum Prolapsed rectal polyp Abscess Condyloma of rectum Origin: Acute or chronic Duration: How long has the swelling been in place? Progress: Is the swelling regressing, has stabilized or is increasing in size? Position: Exact position of the swelling Specific feature: Intermittent increase or decrease in size as in chronic ischiorectal abscess Accompanying symptoms: Pain, fever, discharge, etc.

Altered Bowel Habits


Most symptoms related to characteristics of bowel habits are related to carcinoma of rectum and anal canal Increasing constipation: Annular carcinoma at rectosigmoid junction, sigmoid colon or anal canal Tenesmus: Carcinoma ampulla of rectum Spurious diarrhea in morning: Ulcerative carcinoma of rectum Altered shape: Ribbon or tape like in carcinoma of anal canal Chronic constipation: Hemorrhoids or acute fissure in ano

Prolapse
Prolapse literally means Falling out of place. Rectal prolapsed is a condition where the walls of rectum protrude out of the anal canal and are visible without any instrumentation. Internal hemorrhoids can also prolapse on straining. Prolapse is either

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Prolapse of rectal wall, piles and rectal polyp occurring only during the act of defecation Prolapse of recal wall, thrombosed piles which remain prolapsed irrespective of the act of defecation Prolapse can be either reducible or irreducible, it can again reduce spontaneously or has to be manually replaced.

Pruritus Ani
Pruritus ani (also known as anusitis and itchy/sore arse syndrome) is the irritation of the perianal skin. Usually seen in patients with: Threadworm infestation Poor hygiene Chronic discharge Eczema

Tenesmus
Tenesmus is a feeling of incomplete defecation. It is experienced as an inability or difficulty to empty the bowel at defecation. There is sense of fullness and flatulence also.

Other Symptoms
Unexplained loss of weightmalignant growth Cachexiamalignant growth Fever: Regular history of origin/duration/progressall infections specially perianal and ischiorectal Rash in perianal skin: All inflammatory condition with discharge Indigestion and gas troubleconstipation

Relevent Past/Family History


Perianal abscess: Fistula in ano Diseases predisposing factor for fistula in ano: Tuberculosis Crohns disease Ulcerative collitis Colloid carcinoma of rectum

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Family history of: Piles Fissure Rectal prolapse Polyposis Carcinoma of rectum

General Examination
Appearence Cachexia Vital data Systemic examination of related past history All major systems to be examined

Local Examination
Local examination in anorectal disorders is the key to perfect diagnosis. Perform a local examination with adequate light and exposure of the local area. Positions used for local examination: Left lateral also known as Sims position: The most widely used position for local examination, digital rectal examination, and for proctology and sigmoidoscopy - Here in the patient is placed on his or her left side - Buttocks projecting over the edge of the table - Hips flexed for more than 90 degree - Knees flexed to less than 90 degree Dorsal position with legs drawn up Right lateral position Knee-elbow position Lithotomy position Inspection: The best position as mentioned is left lateral position Use proper light and adequately expose the local area to be examined Inspection is aided by lifting the buttock of the patient with left hand

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What to look for while performing inspection: - External skin tags - Sentineal pile - Papillomata - Condylomata - Warts - Growth - Cyst - Ulcer (extensive and everted margins suggestive of anal carcinoma) - Sinus (specially pilonidal sinus in midline at the tip of coccyx) - Fistula in ano (look for external opening) o Goodsalls Rule: (Figs 5.1 and 5.2)

Fig. 5.1: Goodsalls rule

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Fig. 5.2: Schematic representation of Goodsalls rule

o The Goodsall rule states that: o The external opening of a fistulous tract located anterior to a transverse line drawn across the anal verge is associated with a straight radial tract of the fistula into the anal canal/rectum. o Conversely, an external opening posterior to the transverse line follows a curved, fistulous tract to the posterior midline of the rectal lumen. o This rule is important for planning surgical treatment of the fistula. - Fissure in ano - Prolapsed throbosed piles (prolapse appears divided into three parts)

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- Prolapse rectum (ask patient to cough in squatting position, partial prolapse is protrusion less than 5 cm) To differentiate intussusception from complete rectal prolapse, try to move a finger between the protruding mass and anal margin: o If possible it is rectal prolapse o If not possible it is intussusception - Excoriation of perianal skin - Rash due to perianal discharges - Scars in perianal skin Palpation: To a surgeon hand is what a stethoscope is to a physician. What needs to be looked for while performing palpation of the anorectum: - Palpate any swelling as any other swelling is palpated o Temperature o Tenderness o Fluctuation o Mobility o Consistency o Fixity to deeper structures - Similarly palpate any ulcer the way a regular ulcer is palpated o Tenderness o Bleeding o Edge o Base o Surrounding area - Palpation for a sinus is also as in a regular sinus o Temperature o Tenderness o Discharge o Thickening and induration o Surrounding tissue Digital rectal examination: Discussed in detail on page number: 70 -

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The following structures are palpated: - Anal wall - Perianal region - Rectal wall - Rectal contents - Structures around rectal wall Bimanual examination: Dorsal position is the best suited for this type of examination Patient lies on back with legs drawn up, examiner standing on the right side of the patient Examiners left hand palpates the suprapubic region and the right index finger is in the rectum Aids in confirming the number, shape and size, surface and fixity of any lump in the pelvis Also helps in determining the relation of the lump with other pelvic organs At the end of this examination the finger is withdrawn and examined for gross features of the feces, presence of blood, mucus or pus Wiping the finger on a clean gauze piece aids in the interpretation. Regional lymph nodes: Palpation of regional lymph nodes play an important role in determining the spread of anal and rectal carcinoma Inguinal nodes are palpable usually in inflammation and growths of anal canal and perianal region Pelvic and para-aortic nodes are palpable in rectal growths Anoscopy: Discussed in detail on page: 119 Aids in diagnosis of most lesions in anal canal and distal rectum Investigations: Laboratory: - Blood: o In bleeding per rectumhemoglobin o Total and differential countsinflammation and abscess o Erythrocyte sedimentation ratetuberculosis

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- Urine: o Routine physical and microscopic examination - Stool: o Routine physical and microscopic examination - Mantoux test in tuberculosis - Freis test in lymphogranuloma inguinale - Biopsy for histopathological examination in ulcer and growth Radiology: (Imaging) - Discussed on page: 78 Endoscopic: - Discussed on page: 119

chapter

Clinical Examination
Evaluation of a Patient with Anorectal Disease

After obtaining a history, a complete physical examination should be performed. To be sure we are not missing any associated conditions which may affect the ultimate treatment plan. The examination should be thorough and should not be limited to the area of pathology. Though we are eager to correct our patients problems quickly and efficiently, this should not interfere with thoroughness. Just to cite an example, if the patient with hemorrhoidal disease was noted on physical examination to have abdominal distention secondary to ascites, the treatment plan for this patient with hemorrhoidal disease would be very different. Even though the patients chief complaint only involves an anorectal problem. All major organ systems should be evaluated. Usually patients with all types of anal diseases often present complaining of hemorrhoids. A careful patient history leads to the correct diagnosis in most cases. The differential diagnosis of the most common conditions is based on the following key symptoms: Pain Bleeding Itching Discharge Presence of a lump. Internal hemorrhoids are usually not painful unless complications occur. They do cause bleeding and discomfort.

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More advanced internal hemorrhoids protrude with defecation. When thrombosed, external hemorrhoids become symptomatic, causing sudden onset constant pain but no bleeding and no fever. An anal fissure typically causes severe pain with defecation that may persist for several hours; fissures may also lead to minor, bright red rectal bleeding. A perianal abscess may be accompanied by fever but usually manifests as a painful swelling of the perianal skin. Purulent discharge results from spontaneous drainage of a perianal abscess or from an anal fistula caused by an abscess that has drained, but not healed due to a persistent internal opening in the anal canal. The patient should be questioned about bowel habits, including frequency, stool consistency, evacuation difficulties, and incontinence. It is crucial to exclude, with a reasonable degree of certainty, the presence of a tumor located more proximally. Because rectal bleeding is a common symptom of diseases of the anal canal but also a common presenting symptom of neoplasia. Patients who are younger than 50 years of age and who have no risk factors for colorectal cancer should undergo proctosigmoidoscopy, preferably with a flexible endoscope. Patients with following symptoms and history should have a total colon examination before it is assumed that the origin of bleeding is the hemorrhoids: Adominal symptoms Change in bowel habits Anemia Age older than 50 years or A personal or family history of polyps or Colon cancer.

Clinical Examination

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Symptoms
Bleeding per rectum is the primary symptom that leads to worry and is the usual reason for seeing a doctor. Pain (except for acute fissure in ano and thrombosed piles), itching, and anal dysfunctional effects are less reliable diagnostic criteria. Disruption of the supporting and anchoring tissues of the cushions is the underlying lesion in piles and it means that prolapse is inherent in their nature. Prolapse is, however, the other unequivocal symptom. Pruritus Ani. Constipation is again one of the leading symptoms for which most patients seek medical advise. Swelling.

Bleeding
Because the capillaries of the lamina propria are only protected by a single layer of epithelial cells, only little trauma is required to breach them. It is the lax-textured upper part of the anal cushion which mainly prolapses, and drags the mucosa to the outside, as a result trauma often occurs due to wiping or contact with clothes. Repeated trauma produces a chronic inflammatory response, making the damaged mucosa a brighter red, and granular and so more friable and likely to bleed. A great deal of unnecessary investigation can be avoided by time spent unravelling exactly what is meant by bleeding, as these are costly, inconvenient, uncomfortable, and occasionally even hazardous for the patient. As in most instances patient and courteous attention to detail in taking a history in anorectal disease, is always adequately repaid. Hemorrhoids are very common, and yet bleeding may also indicate a more serious condition.

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First- and second-degree piles, which usually remain intra-anal except while defecating, bleed with the bowel movement. Being capillary blood it is bright red. An anal origin is certain, if on leading history the patient reveals that it occasionally drips, because the anus remains closed by tonic contraction of the sphincter except at the moment of defecation. After passage of the stool, if the blood drips to the pan, it is presumed to be originating either from extruded anal mucosa, or from a fissure in the anoderm. Blood also drips into the pan in the only other, and most uncommon, condition, a rectal polyp on a long stalk. Similarly, bleeding into clothing is almost certainly of anal origin. Blood smeared on the stool in the pan is threatening and unlikely to be coming from piles. Since freshly shed blood ought to disperse into the water. The fact that it remains on the stool suggests either that it has congealed there, or is mixed with mucus, indicating a higher lesion. A careful history, in case of passage of clotted blood may provide a useful clue to rule out a colorectal source. If questioning reveals that the clots were only seen on the paper. Piles may still be the explanation because such clotting can have occurred in freshly shed blood lying at the anal verge. It is very rare for a large pile to bleed back into the rectum and proclaim itself by passage of older clots at stool.

Pain
Pain: Type, duration, relation with defecation. Conditions above Hiltons line are painful only after they get inflamed or infilterate outside the rectal wall, but all conditions below are painful: Pain after defecation: Fissure in Ano Throbbing pain: Perianal abscess Sharp cutting pain: Fissure in Ano Gradually increasing: Fistula in Ano

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Radiating to lower limbs: Advanced carcinoma of rectum Pain relieved on discharge of pus: Perianal abscess and fistula in Ano As far as pile symptomatology is concerned, pain is a contentious issue. There seems to be no good reason why a disrupted anal cushion should actually be painful. Although pain is claimed to be a prominent and attributable problem. Distortion combined with edema and congestion from lymphatic and venous impairment may well cause discomfort. In piles that are trapped outside the closed anus. In many cases pain on defecation is due to an easily overlooked fissure. Nonetheless, some patients do experience relief from what they had thought of as pain from successful treatment of their uncomplicated piles, and the wise clinician allows for some hyperbole, perhaps, in description. Episodes of painful irreducible swelling which last a week or so can be most unpleasant in what is commonly and often called strangulated piles or an attack of the piles. Strangulation is usually due to greater or lesser degrees of infarction which in turn results from obstruction of venous drainage by thrombosis and consecutive clotting in the sacculated venous plexus. Complete obstruction of venous return in strangulated piles is in fact very rare. The usual outcome is spontaneous resolution or resolution with conservative treatment, as the clot in the thrombosed piles shrinks and lyses and venous circulation is restored.

Prolapse
All patients with prolapse are disheartened either they have tried to or have not tried to reposition the prolapsed piles. Many patients who have not tried manual replacement of their piles after defecation, having been afraid to, are put-up with more discomfort than they need.

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Others replace them promptly only to be demoralized and inconvenienced by their messy extrusion on exertion later.

Itching
Piles by themselves rarely cause itching, so when the patients main concern is itching, piles are seldom to blame. A local skin condition should be looked for which is usually responsible. Although treatment of coexisting piles may relieve the patient of itching, it is wise not to encourage a patient greatly bothered by pruritus to believe that the solution of his issue is at hand. However, in some patients mucus discharge from a prolapsed pile causes an alleviable irritation.

Anorectal Dysfunction
Disrupted anal cushions can cause defecatory derangement and result into a sensation of incomplete evacuation, particularly when further engorged by fruitless straining. Tenesmusa feeling of unsatisfied defecation may have a more serious explanation.

Soiling
Dried blood and serum from the exposed inflamed mucosal part of a pile on underclothing and may be thought fecal. Third- and fourth-degree hemorrhoids may cause minor sepage of rectal contents to the surface, only very rarely. Mucus may also exude from the exteriorized mucosa of piles and can be the presenting symptom.

Examination
Examination can be confined to the anorectum. When a meticulous history suggests piles and the findings correlate. The only equipment required for anorectal examination are: Proctoscope (anoscope) Rigid sigmoidoscope (rectoscope) Light source

Clinical Examination

69

Biopsy forceps. Irrespective of the proctoscopic findings, some schools of theory advocate full colonoscopy in patients aged 40 or over who present with rectal bleeding that is bright red, on the basis of the frequency of finding right-sided pathology in those of middle age and older.

Signs
Following are the factors that have a great influence on a piles presentation: The vigorous arterial supply The presence and possibly changing diameter of the arteriovenous shunts The variability of cushion bulk due to the capacity of the venous saccules The effects of cushion displacement and anal sphincter contraction on venous and lymphatic drainage. This leads to change in appearance of piles from time to time in the same patient, and even the same symptom may have different causes. Lump in most people complaining of prolapse is simple displacement of the anal cushion(s) in some patients. Where as a lump felt by others may be due to engorgement of the subanodermal veins. Piles suffer little trauma if they are transiently displaced, but if the mucosal part is exposed frequently, it becomes inflamed. The appearance of the pile is also influenced by thrombosis and clotting in the venous sacs, but in such patients there is complain of associated discomfort or severe pain depending on the extent of clotting and consequent infarction. The rule of thumb is, even the fully infarcted pile despite its appearance, will resolve. A disordered cushion may present in one of several ways as a lump at the anal verge. Since uncomplicated piles are impalpable external inspection provides no clue to their presence, nor is anything abnormal found

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on anal digitation. A nodular induration is felt if clotting has occurred. In most patients, the diagnosis is suggested by the history and confirmed by a proctoscopic examination. Sigmoidoscopic exclusion of rectal disease is an essential part of the establishment of the diagnosis. Because piles are common, finding them does not rule out another condition higher in the rectum causing the symptoms. There is, however, no evidence for the claim still occasionally made that hemorrhoids can result from rectal carcinoma or pelvic masses.

Digital Rectal Examination (Fig. 6.1)


Commonly known as digital rectal examination (DRE), is the simplest physical examination done without any expensive gadgets, using the examiners finger and a glove, yet generates a lot of diagnostic information in urology, gynecology, oncology apart from anorectal disorders. A digital rectal examination yields information on sphincter tone (both passive and on contraction), the prostate (in men), and the rectovaginal septum (in women), as well as the presence and characteristics of any mass and the type of stool, if present in the rectum. The physical examination should be performed in a private location and taking care that the patient is completely draped and relaxed. Physical examination of the anorectum is easiest with the patient in the prone jack knife position but the lateral decubitus position or the lithotomy position can also be used. Inspection of the anal verge requires good lighting and a relaxed patient. Use of two gauze sponges allows better retraction of the buttocks to expose the anal verge. Generally, a caring examiner and calm atmosphere are appreciated.

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To facilitate a thorough examination, in some cases, analgesic or anxiolytic agents may be needed. In some conditions, such as thrombosed or gangrenous hemorrhoids, due to extreme pain, the examination should be postponed until the patient is anesthetized or relieved of the acute condition. Performing a DRE may cause injury to the clinician as well as the patient in cases where a sharp-edged foreign body (e.g. metal blade or broken glass) is suspected. In these cases, defer the DRE in favor of anoscopy or sigmoidoscopy under anesthesia after radiographic evaluation. Place the patient in the lateral decubitus position. Wear protective gloves and lubricate the examining finger. Inspect the perianal area visually for important information regarding patient hygiene, trauma, or sexually transmitted diseases. Place the finger firmly against the anal sphincter and ask the patient to bear down. Note any prolapsing rectal mucosa or hemorrhoids. Insert the gloved finger into the anus and perform a 360 sweep to identify any irregularities. After removing the finger from the anus, examine and test adherent stool for the presence of visible or occult blood. A careful perianal and digital rectal examination is the most revealing part of clinical evaluation. Anorectal inspection can detect skin excoriation, skin tags, anal fissures, or hemorrhoids. By gently stroking the perianal skin with a cotton bud or blunt needle in all four quadrants elicits reflex contraction of the external anal sphincter it is possible to assess perineal sensation and anocutaneous reflex. A neuropathy should be suspected, if this perineal sensation and anocutaneous reflex is absent. Digital rectal examination may reveal a stricture, spasm, tenderness, mass, blood, or stool.

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If stool is present, its consistency should be noted and the patient should be asked if they were aware of its presence. A lack of awareness of stool in the rectum may suggest rectal hyposensitivity. By asking the subject to squeeze digital per rectal examination is useful to assess the resting and squeeze tone of the anal sphincter and puborectalis muscle. More importantly, the subject should be asked to push and bear down as if to defecate. During this maneuver, the examiner should perceive relaxation of the external anal sphincter or the puborectalis muscle, together with perineal descent. The abdominal push effort can be gauged by placing A hand on the abdomen. An absence of these normal findings should raise the index of suspicion for an evacuation disorder, such as dyssynergic defecation. Digital rectal examination has a high sensitivity for identifying dyssynergia. Even though digital rectal examination is a useful clinical tool, there is a lack of knowledge on how to perform a comprehensive evaluation. A concerted effort is needed to improve the training of digital rectal examination. The skin is inspected for signs of swelling, discharge, dermatitis, or any perianal lesions. Because most patients contract the sphincter for fear of an accident when asked to push in other positions A suspected rectal or hemorrhoidal prolapse is best seen with the patient seated on a commode. The following structures (Fig. 6.1) can be palpated by the finger passed per rectum in the normal patient: In both sexesthe anorectal ring, coccyx and sacrum Ischiorectal fossae, ischial spines In maleprostate, rarely the healthy seminal vesicles

Clinical Examination

73

Fig. 6.1: Digital rectal examination

In femaleperineal body, cervix, occasionally the ovaries. Abnormalities which can be detected include: Within the lumenfecal impaction, foreign bodies; Within the wallrectal growths, strictures, granulomata, etc. but not hemorrhoids unless these are thrombosed Outside the rectal wallpelvic bony tumors, abnor malities of the prostate or seminal vesicle, distended bladder, uterine or ovarian enlargement, collections of fluid or neoplastic masses in the pouch of Douglas Do not be deceived by foreign objects placed in the vagina The most common is a tampon or a pessary During parturition, dilatation of the cervical os can be assessed by rectal examination since it can be felt quite easily through the rectal wall.

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Digital Rectal Examination Work-up in Fistula in Ano


1. 2. 3. 4. Assess sphincter tone and voluntary squeeze pressure. Determine the presence of an extraluminal mass. Identify an indurated track. Palpate an internal opening or pit.

Examination Under Anesthesia


Traditionally surgeons have relied on examination of patients who have been administered a general anesthetic, a procedure referred to as examination under anesthesia (EUA), to answer questions which remain unanswered during a clinical examination. Very useful particularly in cases of Fistula-in-anoAt EUA, the surgeon attempts to classify the fistula by palpating it to determine its relationship to the sphincter. However, anesthesia and consequent loss of tone impair precise identification of underlying muscles. A metal probe is gently inserted into the external opening and is directed toward the dentate line to find the internal opening. The internal opening is frequently not obvious, and the surgeon may need to inject hydrogen peroxide into the external opening while inspecting the anal canal. Usually because of these aspects EUA is not as straight forward as it sounds. Due care should be taken while probing a track during EUA because injudicious probing during EUA can create new secondary tracts very easily. For example, forceful probing in the roof of the ischioanal fossa can rupture through the levator plate, causing a supralevator extension or even a rupture into the rectum, which would cause an extrasphincteric fistula. The net result is that it can sometimes be very difficult at EUA to classify the primary tract with confidence. There is ample opportunity to make matters worse.

chapter

Investigations
Fecal Occult Blood Test

Occult bleeding is taken to mean bleeding that is truly unknown to the patient and typically manifests as occult fecal blood or iron deficiency anemia, or both. On the other hand in contrast, bleeding that is apparent to the patient (typically manifesting as hematemesis, melena, or hematochezia) but for which the source cannot be identified by standard gastroscopy and colonoscopy, is called obscure bleeding. It was the Dutch chemist Izaak van Deen who first recognized that when a natural resin from the Guaiacum officinale tree was mixed with blood and another reagent such as hydrogen peroxide, eucalyptus oil, or turpentine, the solution would turn blue. The blood loss in the stool that is not clinically apparent is detected by the fecal occult blood test (FOBT). Patients who report rectal bleeding or those with frank blood by rectal examination do not need a FOBT and should undergo further diagnostic evaluation. The FOBT is not specific for colorectal cancer. Even though it is mainly used to screen for colorectal cancer. There are two type of main fecal occult blood tests that are commercially available: 1. The guaiac-based tests, which detect pseudoperoxidase in the heme portion of hemoglobin, and [Guaiac methods for the detection of occult blood (G-FOBT) are based on a chemical oxidation reaction between heme and alpha guaiaconic acid.] 2. The immunochemical tests which is more expensive and it detects the globin portion of human hemoglobin. The basis of the guaiac test is that after the addition of a hydrogen peroxide developer, the pseudoperoxidase of hemoglobin oxidizes guaiac to form a blue-colored quinone compound.

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The amount of blood present in the stool is the major factor on which a positive guaiac test is direcly related. About 0.5 to 1.5 ml of blood is lost normally on a daily basis into the gastrointestinal tract. To be positive, the FOBT test requires approximately 2 ml/day of blood and to be consistently positive requires more.

Several Factors have an Impact on FOBT Performance Characteristics


Bleeding from proximal gastrointestinal lesions may allow for degradation of the heme, this in turn will then not catalyze the guaiac reaction. Bleeding from the right colon is one such situation. The myoglobin or hemoglobin in red meat can give a falsepositive reaction, although ingesting 8 oz of cooked red meat/day has only a 5% probability of giving a positive test result. If fecal specimens are tested immediately after collection. Peroxidase-rich raw vegetables and fruits (including turnips, horseradish, artichokes, mushrooms, radishes, broccoli, cauliflower, and cantaloupe) may give a false-positive result. The likelihood of a false-positive test results because of plant peroxidases can be reduced if a specimen is developed several days after collection, because the plant peroxidases are unstable with time. Gastric irritants such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and excessive alcohol consumption may also produce positive results. Oral iron supplements and acetaminophen do not affect the guaiac test. Because ascorbic acid is a reducing agent and interferes with the oxidation of guaiac. Ascorbic acid (vitamin C) in excess of 250 mg/day or multivitamins with vitamin C may cause a falsenegative result. Other antioxidants should also be avoided. Antacids may also cause false-negative results. The processes of collecting and processing FOBTs are important in the evaluation of the results.

Investigations

77

Delaying the processing of the slides allows for dehydration of the specimen, which allows degradation of peroxidase activity and will decrease the sensitivity of testing. The delay between preparation and laboratory testing should not exceed six days. The issue of rehydration of dried slides with water is controversial. The false-positive rate is increased in case the slides are rehydrated as rehydration of slides increases sensitivity and decreases specificity. Proper patient instruction and preparation are essential during collection of specimens. In case of menstruating females, the patients should not collect specimens until three days after menses have stopped. Similarly, if obvious rectal bleeding or hematuria is noted the patient should not collect sample for three days after bleeding or hematuria have stopped. For three days before testing, patients should avoid ingesting red meat, vegetables with high amounts of peroxidase (broccoli, turnip, cantaloupe, cauliflower, radishes), aspirin, NSAIDs, and vitamin C. The detection of the blue color of a positive test may be affected by other factors like: 1. Including a thick stool smear 2. Exposure to high ambient temperatures 3. Black stools from iron ingestion. The FOBT has low sensitivity and specificity, as a screening test for colorectal cancer. The sensitivity of the FOBT in patients with colon cancer is approximately 30%. About 2 to 6% of asymptomatic adults have a positive FOBT test; of those, about 10% have cancer and 20 to 30% have adenomas. The rest have upper gastrointestinal sources of bleeding, nonneoplastic lower gastrointestinal sources of bleeding, including hemorrhoids, or no identified source of bleeding. Other gastrointestinal lesions, including hemorrhoids, angiodysplasia, diverticular disease, and upper gastrointestinal lesions, can lead to increased blood in the stool.

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Bleeding from colon cancers can be intermittent or not detectable; and other factors can give false-positive or falsenegative readings. Because only one specimen is obtained during a digital rectal examination, office collection is less sensitive than three at-home determinations. So fecal occult blood testing has best been studied using a regimen of home-based testing of three stools. A single digital FOBT has poor sensitivity and therefore cannot be recommended as the sole test for screening for colon cancer. Because of the concerns about sensitivity and specificity with the FOBT, new tests have been developed. Immunochemistry tests, which are more specific than the guaiac tests, cost approximately two to five times as much, but are not affected by diet or drugs. Fecal DNA tests are being developed, but presently there is not sufficient data to recommend their use for screening. If sufficient numbers of cancer cells from a colon cancer are sloughed off into the lumen, one or more of the mutant genes (and/or long DNA) can be discovered, allowing for the noninvasive detection of colon cancer.

Imaging
Pelvic floor disorders refer to a group of clinical conditions that include pelvic organ prolapse, urinary and fecal incontinence, chronic constipation, and pelvic pain. There are various imaging modalities available, including fistulograph, defecography, ultrasound (US), and MRI. There have been considerable advances in several imaging techniques over the last decade. High-resolution US and MRI not only help to understand pathology and functional changes but also provide superior depiction of the pelvic anatomy. MRI can also be used for a multicompartmental dynamic assessment of the pelvic floor (dynamic MRI defecography) and for the analysis of the sphincters (static MRI).

Investigations

79

Fistulography (Fig. 7.1)


For many years radiologists have attempted to help answer the surgical questions related to Fistula-in-ano, with varying degrees of success. Contrast materialenhanced fistulography was the first modality used. In fistulography, the external opening is catheterized with a fine cannula, and a water-soluble contrast agent is injected gently to define the fistula tract. Coronal image shows that it is obvious that there are several high extensions (arrows) surrounding the anorectal junction. Though the exact anatomic location of these is unclear because the pelvic floor (i.e. levator ani in this case) cannot be directly visualized.

Fig. 7.1: Fistulogrammale patient

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For a surgeon, preoperative definition of extension location (supra- or infralevator) is central to surgical management. Unfortunately, fistulography has two major drawbacks: 1. First, extensions from the primary tract may fail to fill with contrast material if they are: Plugged with debris Are very remote or There is excessive contrast material reflux from either the internal or external opening. 2. Second, the sphincter muscles themselves are not directly imaged, which means that the relationship between any tract and the sphincter is not reported and has to be presumed. Furthermore, because it is difficult to visualize the levator plate. It is accepted fact that it can be difficult to decide whether an extension has a supra- or an infralevator location. Similarly, the exact level of the internal opening in the anal canal is often impossible to determine with sufficient accuracy to help the surgeon. The net result is that fistulographic findings are both difficult to interpret and unreliable. Because the modality is fraught with many errors. Very little has been written on fistulography for fistula in ano. There are contradictory studies some reporting it to be unreliable and others useful. One study interprets that the internal opening and associated extensions were demonstrated and correctly interpreted in only (16%) subjects. Moreover, false-positive diagnoses of rectal openings and supralevator extensions were made in (12%) patients, which would have resulted in serious surgical errors if acted on. The authors concluded that fistulography was inaccurate and unreliable, although they admitted prior bias against the technique. In contrast, in another study authors found fistulography to be more useful in that it provided helpful information in nearly half of the 27 subjects in their study.

Investigations

81

Prime reason for the fistulograph being not helpful is that the radiologists are not familiar with the concepts of fistula pathogenesis and anatomy and the relevant surgical questions. In some instances the contrast agent refluxes up from the internal anal opening and these type of situations have been misinterpretated as a direct rectal opening merely because there is contrast material in the rectal lumen. Such radiology reports only encourage the surgeon to look for nonexistent openings and extensions, which can result in iatrogenic secondary tracts.

Defecography
Defecography also known as evacuation proctography is a dynamic fluoroscopic examination (Fig. 7.2). History can be traced to 1964 with Burhennes dynamic barium studies of the defecation process. Defecography is used to examine the dynamic changes of the perineum and the evacuation of the anorectum. This test is indicated in patients with constipation to identify an outlet obstruction caused by either anatomic or functional disorder. Rectal opacification is required for this procedure. In some instances in women vaginal opacification, or small bowel opacification, may be performed. A cystography can be performed along with defecography in a one-session examination. If bladder dysfunction is suspected, (cystodefecography).

Normal Findings
In a normal healthy individual following are the findings in defecogram: At rest, the anorectal junction is located above the ischium. The anorectal junction is elevated and located less than 3.5 cm below the pubococcygeal line, during squeezing. The puborectalis muscle opens widely without anal or rectal prolapse and the anorectal junction descends below the pubococcygeal line, during the defecation process.

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Fig. 7.2: Defecogram

Less than 2.5 cm in size, a rectocele is inconsequential provided it empties completely at the end of defecation.

Pathology and Clinical Use


Defecography is important in the sense that it can reveal several structural abnormalities. The most frequent abnormal findings are perineal descent at rest or during squeezing. Rectocele (significant if >3.5 cm in depth and with residual barium at the end of defecation) Rectal prolapse Paradoxical contraction of the puborectalis muscle (dyssynergia) Enterocele Sigmoidocele.

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Defecography from various studies has been shown to be good for the diagnosis of rectocele and enterocele but inadequate for perineal descent. Functional findings are also important. For example, an incomplete and prolonged contrast evacuation seems more specific of dyssynergia than an inappropriate puborectal contraction.

Indications
When some of the aforementioned abnormalities are clinically suspected, but not proved at clinical examination or in patients with an unexplained anorectal disorder, defecography is indicated. When the patient did not respond to the first-line treatment, in cases of dyschezia (in complete or difficult rectal emptying), defecography can be useful. If a pelvic static disorder (e.g. a rectal prolapse) is suspected, in patients incontinent for solid stools defecography can be suggested as a confirmatory tool before surgery. Finally, it can be performed in patients with pelvic pain to rule out an enterocele. Defecography is especially important when surgical treatment is being considered for a problem, such as rectal prolapse to rule out existence of an entrocele as an association of an enterocele can modify the surgical option. The relevance of defecography findings, however, remains controversial. In many instances, normal individuals show abnormal findings and hence the link between a clinical symptom and an abnormal defecography finding is difficult to establish.

Procedure and Films to be Taken


In young women during menstruation and pregnancy, defecography is contraindicated. To obtain full cooperation from the patient, the exact procedure should be clearly explained in a simplified manner.

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Privacy in these type of procedures is of utmost importance, so a quiet radiology suite is important, and the patient should be hidden from the view of the technologist to provide privacy during the act of defecation.

Procedure
A barium meal should be administered atleast 1.5 hours before the examination. If you are suspecting an enterocele. Vaginal opacification with barium is recommended before rectal opacification, in women. This can be done with a mixture of 150 to 200 ml of barium and a starchy component.

Following Views and Films are Taken


To localize the bony landmarks and to check the quality of the various opacifications (small bowel, vagina, and rectum), a lateral view is taken in the upright position. A special commode for filming the dynamic process of defecation is used after the initial film has been taken. Dynamic images are performed at: Rest During squeeze During straining. The pubococcygeal line is drawn on the lateral view. Then, the distance between this line and the anorectal junction is measured.

Radiology in Patients with Anorectal Disorders


For the evaluation of patients with pelvic floors disorders, several imaging modalities are available ranging from fluoroscopic techniques to ultrasonography and MRI. High-resolution ultrasonography and MRI not only provide superior delineation of the pelvic floor anatomy but also reveal pathology and functional changes.

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Pelvic floor disorders refer to a group of clinical conditions that include pelvic organ prolapse, urinary and fecal incontinence, chronic constipation, and pelvic pain.

Anal Endosonography
With the advent of the newest transducer technology. Ultrasound imaging is gaining a key role in the understanding of pelvic floor disorders. The most commonly used technique is endoanal ultrasound but endovaginal and transperineal US techniques are being developed and represent potential new uses. Additionally, the use of three-dimensional software may provide an accurate diagnosis of complex diseases. Anal endosonography is one of the latest diagnostic aid that is specially adapted for the examination of anal sphincters. The main indication is the diagnosis of anal sphincter defect in the investigation of patients with fecal incontinence. It is also useful in the assessment of: Anal sepsis Anal cancer Perineal pain.

Anal Sonography How and What to


A few hours before the examination, a rectal enema is recommended. Basic equipment: An ultrasound machine equipped with an anorectal transducer is required. The rigid cylindric transducer provides: 360-degree high-resolution image with A frequency ranging from 6 to 16 MHz. Throughout the examination, the patient is placed in the supine (or left lateral) position. The anal transducer is gently introduced and slowly withdrawn to obtain: Several images of the anal canal and surroundings

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At the upper part of the anal canal the puborectalis muscle is identified Then both the external anal sphincter Internal anal sphincter are visible Finally at the lower end, only the external anal sphincter is visible. The patient may be asked to contract voluntarily during the examination. 12 oclock being the anterior midline point. The Location and size of abnormalities are based on quadrants using a standard clock face. The thickenss of the external anal sphincter and internal anal sphincter is also assessed.

Normal Findings
A good knowledge of the anatomy of anal sphincters and pelvic floor is required. From the surface outward, several layers can be identified. Mucosa and submucosa usually appear hyperechoic. The 2 to 3 mm thick internal anal sphincter (IAS) is in continuity with the circular muscular layer of the rectum (Figs 7.3A to C). It is clearly delineated, homogeneously hypoechoic, and its thickness increases with age. The hyperechoic longitudinal muscle layer of rectum is difficult to distinguish from the hyperechoic external anal sphincter (EAS) (Figs 7.3A to C). At its upper part, the EAS is in continuity with the puborectalis muscle. It appears annular, thick, and symmetric in men and it is thinner and anteriorly opened in women. Its subcutaneous part is highly hyperechoic. Its mean thickness is 6 to 8 mm. Other elements can be identified: The U-shaped puborectalis muscle The hypoechoic anococcygeal ligament The ischioanal fatty spaces

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Figs 7.3A to C: Anal endosonography. (A) Upper level showing the U-shaped pubirectalis muscle (arrows); (B) Medial level showing both the EAS (Upper arrow) and IAS (Lower arrow); (C) Superficial level showing the EAS alone (arrow)

The vagina The urethra.

Pathology and Clinical Use


Anal endosonography is commonly performed to identify an EAS or IAS defect that may cause fecal incontinence. An IAS defect is diagnosed based on a segmental loss of circumference and retraction of the torn ends. An EAS defect is diagnosed based on a sharply delineated hypoechoic area that interrupts the normal echostructure.

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Both IAS and EAS defects can be present. The anterior part of the EAS in women needs to be analyzed carefully; it often appears thin and slightly heterogeneous because of its muscular insertion (tendinous arch of the pelvis). The anococcygeal ligament is responsible for a hypoechoic triangle, which should not be misdiagnosed as a pathologic defect. Anal endosonography can detect sphincter defects with great accuracy. The sensitivity and specificity of anal endosonography for the diagnosis of anal sphincter defect is over 90%. Obstetric trauma remains the main cause of sphincter disruption and represents a major health problem. Anorectal trauma is a consequence of surgery for fistula in ano, hemorrhoids, or anal fissure. In these iatrogenic situations, the location of the defect correlates well with the surgical procedure. Anal endosonography is clinically useful in patients with fecal incontinence when an anal sphincter disruption is suspected. Therapy can be directed based on US findings, such as the type (external or internal) and the size of the defect often expressed in degrees or percentage of the anal circumference. EAS defects that occupy less than 120 degrees of the anal circumference can be surgically corrected by overlapping sphincter repair. Anal endosonography can also be performed after a sphincteroplasty to assess the morphology of the EAS and to correlate surgery with the functional results. In patients with surgical repair of the EAS, the outcome was more favorable when there was evidence that the sphincter ends were overlapping. Anal endosonography can accurately demonstrate abnormal IAS thickness because the borders of this smooth muscle are sharply limited. In contrast, EAS atrophy is more difficult to identify by means of two-dimensional anal endosonography. Recently, three-dimensional anal endosonography has been described and seems promising.

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CT Colonography
Few patients with growth have a second synchronous tumor and upto half of them have concomitant multiple adenomatous polyps. A complete examination should be performed for this reason during colonoscopy. Although this is not always possible a full inspection from the rectum through the cecum is advised. The hinderance to full examination is caused by: Stenosing tumors Acute diverticulitis Adhesions from previous pelvic surgery Postradiation stenosis Strictures due to Crohn disease or ulcerative colitis obstructing the lumen of the intestine and making it difficult for the endoscopist to reach the cecum. Though less sensitive than colonoscopy, in some cases, a doublecontrast barium enema is necessary to complete an examination, for detecting tumors and polyps. Computed tomographic (CT) colonography is extremely attractive and prominent. Among a number of new techniques with which to image the colon, because it is noninvasive and also relatively simple for patients to undergo. CT colonography is a noninvasive method for evaluating interior of colon by using CT scanning, that is, otherwise, only seen with a more invasive procedure with an endoscope. CT colonography (CTC), is also known popularly among medical and lay personnel as virtual colonoscopy. Virtual colonoscopy uses spiral CT scanning and computers to simulate colonoscopy by generating high-resolution multidimensional views of the colon. The procedure involves: Helical computed tomographic scanning of the colon after cathartic preparation and colonic distention. Clear liquid diet for 24 hours, bowel preparation night before and day of exam. Complete scan of the colon in prone and supine positions.

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2.5 to 5 mm thick slices; reconstruction with 3-D fly-throughs. CTC is ideally suited for population screening of asymptomatic adults. Colorectal cancer remains a major killer because of poor compliance with existing screening strategies. Although largely preventable or at least curable if detected early.

Indications
The major indication for performing CT colonography is to screen for polyps or cancers in the large intestine. The goal of screening with colonography is to find these growths in their early stages. It is recommended that patients older than 50 years should be screened for polyps every seven to 10 years. Individuals at increased risk or with a family history of colon cancer may start screening at age 40 or younger and may be screened at shorter intervals: every five years. A history of polyps A family history of colon cancer or The presence of blood in the stool, where common benign conditions have been ruled out. Other indications include: Failed colonoscopy Evaluation of colon proximal to an obstructing lesion Screening in patients with contraindications to colonoscopy Patients who refuse other screening options Staging of cancers.

Relative Contraindications to CT Colonography


CT colonography has few contraindications, however, it should not be performed in patients for whom perforation is a concern. Severe allergy to administered contrast (CTC can be performed without contrast) Suspected colonic perforation or peritonitis

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Walled off colonic leak/pericolonic abscess Medically highly unstable patient (e.g. unstable angina, uncontrolled sepsis) Acute lower gastrointestinal bleeding Pregnancy Inability to tolerate pneumocolon Highly uncooperative patient Inability to undergo colonic preparation: congestive heart failure, severe electrolyte imbalances, severe dehydration Refusal to undergo colonic preparation Abnormal anorectal anatomy (e.g. imperforate anus, tight anal stricture) Severe colonic disease (toxic colitis, toxic megacolon, severe colonic pseudoobstruction) Acute colonic infection (acute diverticulitis, severe infectious colitis) Complete mechanical colonic obstruction Very recent colonic surgery (<1 week)

Preparation of the Colon for CTC


Proper bowel preparation is very essential and important. As residual fecal material can mimic or obscure polyps. 24 hours before CTC a low-residue and/or clear liquid diet is advised. Bowel preparations include colonic lavage solutions, such as polyethylene glycol, and cathartics, such as magnesium citrate or phospho-soda (sodium phosphate), some studies recommend combonation of usually bisacodyl tablets or suppositories. The selection of a cathartic agent will depend on patient factors as well as physician preferences. Patient factors include underlying conditions that lead to contraindications for electrolyte shifts, uid shifts, or phosphate ingestion. The patient should be advised to take the entire colonic preparation of polyethylene glycol, sodium phosphate or magnesium citrate as prescribed.

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When compared to than either magnesium citrate or sodium phosphate preparations, polyethylene glycol, the standard preparation for conventional colonoscopy, leaves less residual fecal material but more residual fluid in the colon at barium enema or CTC. Residual fluid can be eliminated during conventional colonoscopy by colonoscopic aspiration but cannot be eliminated during CTC and can limit CTC sensitivity, but this generally does not cause diagnostic problems if the patient is scanned in two positions to permit redistribution of colonic uid. Though some schools recommend, a dry prep with a saline laxative of phospho-soda or magnesium citrate, combined with bisacodyl tablets the night before CTC and a bisacodyl suppository the morning of CTC to eliminate residual fluid. Oral sodium phosphate-based agents are easier to ingest for many patients, because of the smaller volume that must be consumed, but can result in electrolyte shifts when doses exceeding 45 ml daily are employed. Patients administered phospho-soda require adequate hydration. This preparation is absolutely contraindicated in patients: Who have renal insufficiency or Congestive heart failure and is relatively contraindicated in patients: Who have large ascites or Ileus because of potentially large fluid and electrolyte shifts or induction of renal failure. Magnesium citrate is a useful alternative in such patients, as it is a milder saline cathartic preparation, which performs similarly to polyethylene glycol for CT colonography when combined with fecal tagging agents. The patient evacuates any residual colonic fluid just before CTC.

Tagging with Oral Contrast


By obscuring the contrast between the bowel wall and the air-filled lumen, residual colonic fluid decreases polyp detection.

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Prior to CT examination, tagging of colonic uid and stool can be achieved with oral contrast agents. Fecal and uid tagging may permit identication of submerged polyps and reduce false-positive examinations because of residual stool. Fluid tagging requires ingestion of substantial amounts of liquid. Administration of iodinated oral contrast theoretically opacifies residual fluid, allowing for the detection of otherwise invisible polyps submerged in intraluminal fluid. Polyp detection can be increased without fluid tagging also by, techniques such as dual-position image acquisition. To tag particulate stool, barium is usually used. For this stool tagging several days before CTC, small amounts of barium are ingested during several meals to become incorporated into fecal material. The contrast-enhanced stool is identified and is differentiated easily from colonic mucosa by its high attenuation. Barium contrast with a reduced bowel preparation may yield sensitivity and specificity at least equal to that of a standard bowel preparation without barium. Tagging of liquid or solid stool precludes colonoscopy for removal of an identified colonic polyp immediately after CTC.

Colonic Distention
Adequate colonic distention is essential to make the polyp clearly visible. Because air has low-density compared to polyp and masses, it provides a low-density background to help identify medium-density colonic polyps or masses. Position: Decubitus position on the CT scanning table is the most acceptable. To distend the colon, a small plastic or rubber catheter is introduced into the rectum and air or carbon dioxide is delivered by either a handheld bulb pump or automated insufflator. Room air is inexpensive and simply administered manually.

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Carbon dioxide is more expensive, requires a gas tank, and is administered automatically. A potential safety benefits of automated insufflation is that it: Permits control of the rate of insufflation and Provides a maximal intraluminal pressure And is associated with automatic shut-off capabilities. A scout CT film with the patient in the supine position is used to justify the adequacy of colonic distention, and more carbon dioxide is administered as needed. During the procedure, the patient discomfort with carbon dioxide insufflation is similar to that with room air insufflation. But because of the rapid absorption of carbon dioxide from the colonic lumen, there is less discomfort afterwards. Colonic perforation during CTC is extremely rare, though most reported colonic perforations have involved room air and manual insufflation, but several perforations have involved carbon dioxide and automated insufflation. Advanced age and underlying colonic pathology are common risk factors for perforation.

Role of Spasmolytics
CTC sensitivity is reduced to an extent with patient discomfort which in turn can limit colonic distention. Smooth muscle relaxants are used to relieve patient discomfort. Commonly used is glucagon which helps by: Improving bowel relaxation Decreasing patient discomfort Improving colonic filling during barium enema Enhancing the reflux of colonic air into the small intestine by relaxing the ileocecal valve.

Scanning
A thin-section abdominopelvic CT is performed with a multidetector row CT scanner with thin collimation, with the patient first in the supine and then in the prone position, from the level of the diaphragm to the level of the perineum, after colonic insufflations.

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Images are obtained in both the supine and prone positions with an aim to: 1. Differentiate fixed lesions such as polyps or cancers from particulate stool. 2. Because the air is redistributed with a change in patient position. Distend adequately colonic regions poorly distended in one position. 3. Because fluid is redistributed with a change in patient position. Evaluate adequately colonic regions obscured by residual fluid. The optimal scanning technique should: Minimize radiation exposure Minimize scanning time Maximize image quality.

Role of Intravenous Contrast


The role is generally reserved for the following and similar other indications: Especially in a suboptimally prepared colon, intravenous contrast increases bowel wall clarity and visibility and improves detection of medium-sized polyps. In patients who have newly diagnosed colorectal carcinoma, intravenous contrast helps detect synchronous colonic lesions and lymph node involvement. For colorectal cancer it improves the accuracy of preoperative T-and-N staging. During colon cancer surveillance it aids in the detection of local recurrence or distant metastases. IV contrast is helpful in evaluating patients who have had an incomplete conventional colonoscopy because of obstructive colon cancer. In patients with prior colonic resection for carcinoma because of their frequently inadequate colonic distention.

Disadvantages of Intravenous Contrast


Increased cost Increased invasiveness Occasional contrast reactions

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Higher radiation dose Increased interpretation time. Because intravenous contrast administered simultaneously with oral contrast enhances both colonic mucosa and colonic lumen and results in a decrease in contrast between the two surfaces, simultaneous administration of both should be avoided.

Pitfalls of CT Colonography
Residual stool/inadequately prepared colon Residual fluid Inadequate colonic distention Colonic spasm Uncooperative patient Motion artifacts from respiration Image noise Metallic artefacts Old CT machine (single-detector CT scanner) Inadequate radiologist training Failure to read study using both 2D and 3D imaging Flat (nonpolypoid) colonic lesions that are hard to detect by CTC Blind spots Pitfalls in evaluation Cost factor Increased patient discomfort Poor sensitivity for small polyps Inability to obtain biopsy or perform a polyp removal, resulting into compulsion for additional studies. Preparations that minimize: Residual stool and fluid The use of oral stool markers Improvements in CT protocols and 3D visualization, as well as CAD all help to achieve high sensitivity and specificity. The use of combined 2D and 3D imaging techniques A good knowledge of the nature and appearance of colonic lesions and pseudolesions will help improve reader performance and reduce the rate of false-positive findings.

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The future of colon imaging holds virtual colonoscopy as a safe and relatively noninvasive addition.

Interventional CT
CT scans are usually indicated for: The staging of colorectal cancer Evaluation of abdominal complaints Evaluation of postoperative complications. Having a specific question in mind when ordering the scan will allow the scan to be tailored to the appropriate parameters. The lack of contrast resolution of CT when compared with US or MRI is the primary reason CT is not commonly used for the diagnosis of pelvic floor disorders. There is adequate radiation exposure of the patient during CT examination. Yet CT can provide useful information in certain situations, like identifying the Alcocks canal to infiltrate the pudendal nerve. In patients with refractory voiding disorders, such as urinary urge incontinence and fecal incontinence. CT can be used for sacral nerve stimulation. For this procedure, an electrode is implanted in the third sacral vertebra and attached to an implantable pulse generator. The exact position of the device can be checked by CT. The implantation of the sacral electrode can also be performed under CT guidance. A pelvic CT is the most common method for staging rectal cancer before definitive surgical resection. The CT results must be interpreted in the clinical context of the patient.

Dynamic MRI Defecography


With the advances in development in radiology and imaging in the assessment of pelvic floor disorders. MRI has come out as an innovative technique that does not expose the patient to ionizing radiation and along with it provides excellent depiction of the surrounding soft tissues of the pelvis.

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When it comes to the assessment of the pelvic floor dynamic MRI is similar to defecography, with the advantage that MRI overcomes some of the limitations of a radiograph examination. A standard MRI machine can be used to perform a dynamic MRI or otherwise an open device that allows assessment of the subject in a seated position can be used. For the diagnosis of clinically relevant abnormalities, MRI defecography using a conventional MRI machine is a safe alternative. For the analysis of the three compartments of the pelvis, realtime dynamic sequences are performed (dynamic MRI). A study of the rectal evacuation also known as MRI defecography is also possible.

MRI Normal Findings


Dynamic MRI is unique imaging technique in the sense that all three compartments of the pelvis can be analyzed within one session. At rest, the anterior pelvic organs lie above that pubococcygeal line, where as during straining, they are displaced posteriorly, but remain above the pubococcygeal line. There is no major difference in visualization of anorectal changes when compared to those observed with standard defecography. The muscles are directly visualized, however, especially the levator ani and its iliococcygeal and puborectalis portions.

Pathology and Clinical Use


MRI helps in diagnosing several anorectal anomalies. Various associations of prolapse can be identified, at the genitourinary level. To differentiate between the normal and the prolapsed position of organs. Two imaginary lines, pubococcygeal and pubohymenal have to be drawn. MRI findings in the posterior compartment, can be grossly compared with those of standard defecography. However, MRI provides additional information regarding the fatty spaces and muscles. Abnormality of the levator ani muscle is easily identified by MRI.

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MRI Defecography in Clinical Practice


Rule out any contraindication for the MRI test. An evacuating enema is advocated before MRI examination. The patient needs to be explained about the procedure as his/ her cooperation and comfort is essential for a successful dynamic MRI examination. The patient is given instructions regarding the different maneuvers (rest, squeezing, straining). The patient should be asked not to empty the bladder as it may require further filling. In women, hydric sterile paste is introduced into the vagina. Similarly, the rectum needs to be distended by 100 to 200 ml of hydric paste. Followed by two types of sequences recorded by a pelvic coil, a dynamic study of the rectal evacuation is performed. While the patient is instructed and encouraged to expel the rectal contents, images are reconstructed in real time. To enhance the understanding between the structural and functional changes of the pelvic floor. Special marks are placed on images (e.g. the inferior pubococcygeal and pubohymeneal lines). MRI can reveal: The relative position of various pelvic organs during different maneuvers The type and degree of anterior, medial, or posterior prolapse The morphology of the levator ani muscle. MRI defecography has been shown to alter the surgical approach in more than two-third of cases, in patients suffering from fecal incontinence. MRI of the pelvic floor is promising for several conditions.

Static MRI
MRI is also of great help in assessing pelvic floor disorders, the analysis of anal sphincters and their surrounding structures, especially in the clinical context of fecal incontinence.

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Sphincter defects are defined by: A disruption of the sphincter ring Scar tissue appears as a hyposignal deformation. EAS atrophy appears as global thinning or fatty replacement. MRI can be used to identify pelvic venous dilatation, In women with chronic perineal pain.

Anal Manometry
The Anorectum
The normal function of anorectum is storage and release of intestinal waste products. The volume of the rectum is 650 to 1200 ml. The innervation of the rectum is via the sympathetic (L13) and parasympathetic (S24) nervous systems. The internal anal sphincter is innervated with sympathetic and parasympathetic fibers. Both are inhibitory and keep the sphincter in a constant state of contraction. The external anal sphincter is skeletal muscles innervated by the pudendal nerve with fibers from S24. Manometry of the anal canal is an index of the resistance of sphincters to the passage of feces. Resting pressure is due mainly to the internal anal sphincter whereas voluntary contraction is due mainly to the external anal sphincter. Anorectal manometry is essential in measuring the length of the anal canal and in establishing the presence of the rectoanal inhibitory reflex. Several techniques are employed to evaluate anorectal manometry which is useful in the investigation of patients with fecal incontinence and constipation. Although anorectal manometry has become a routine investigation for the evaluation of patients with anorectal disorders. Controversy exists over the utility of manometry in the management of fecal incontinence and there is some debate

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about its value in clinical practice, yet recent studies indicate that anorectal manometry can reveal pathology not detectable by physical examination alone. The clinical utility of manometry ultimately depends on its power to discriminate between normal and abnormal function. Anorectal tonometry is a test performed to evaluate patients with constipation or fecal incontinence. This test measures the pressures of the anal sphincter muscles. Anorectal manometry provides a comprehensive assessment of: The pressure activity in the rectum and anal sphincter region together with An assessment of rectal sensation Rectoanal reflexes Rectal compliance. It is important to recognize that there are significant intercenter differences with regards to: The methodology Test performance Test interpretation. Most recently, an international consensus panel under the auspices of the American and European motility societies has proposed uniform standards for performing and interpreting anorectal manometry.

Elements of Anorectal Manometry (I)


Anorectal manometry measures the resting and squeeze pressures generated by the sphincter complex of the anus. Resting pressure is 85% internal anal sphincter +15% external anal sphincter, (normally 4080 mm Hg). Voluntary squeeze pressure is 100% due to the external anal sphincter, (normally 80160 mm Hg). The test measures pressure gradients all along the anal canal both radially and longitudinally.

Elements of Anorectal Manometry (II)


Sphincter length (usually 3 cm) and symmetry. Minimum sensory volume (usually 1015 ml).

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Determined by instilling volume into rectal balloon until sensed by urge to defecate. Resting anal inhibitory reflex (RAIR)corresponds to a decrease resting pressure attributed to balloon distension in the high pressure zone (HPZ) with an associated EAS contraction.

Use of Anorectal Manometry


Anorectal manometry can define hypo/hyperfunctional disorders of the sphincter complex. Manometry can compare objective function with patients subjective sensation of rectal fullness. Often performed in conjunction with other clinical and diagnostic modalities: DRE Video defecography Anal manometry with EMG.

Indications
Fecal incontinence Constipation Pre/Postsurgical evaluation Other: Functional anorectal pain Pelvic floor dyssynergia Hirschsprungs disease To decide, if lateral sphincterotomy is needed or not Sphincter damage due to disease, malignancy, trauma or iatrogenic Decide closure of stomas Continence of sphincter after high fistula surgery Continence of stomas and sphincter after replacement with artificial sphincter.

Technique and Procedure


Bowel preparation 2 to 4 hours prior to test. Insert solid state or water-perfused probe with radial transducers or ports.

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Allow return to baseline pressure (~5 min). Patient asked to squeeze, relax, and strain while pressures are measured within the anal canal. Anal manometry provides a direct measurement of anal canal pressures at rest and during voluntary contraction of the external anal sphincter. This information is quite useful for understanding the pathophysiologic characteristics of incontinence and for designing an effective treatment regimen. Anal manometry also can be used to measure the responses of the internal and external anal sphincters to rectal distention. Several manometry systems have been devised, including: Perfused catheters Microtransducer arrays Microballoon devices Large balloons, which do not provide accurate pressure readings, can be used to assess the rectoanal reflexes. Minimum standards for the performance of anorectal manometry have been promulgated. Anal canal pressures vary radially and longitudinally along the anal canal. With a sufficient number of recording sites, it is possible to map the three-dimensional pressure profile of the anal canal, but it is unclear whether such data are of more clinical benefit than are simpler measurements of average basal and average squeeze pressures. Other methods of analyzing pressure records include: Calculation of an anorectal manometry index Measurement of a strength-duration curve Determination of fatigue rate Identification of the location of the highest mean resting pressure segment, but none of these methods has been adopted widely. Regardless of the method of analysis, pressures differ substantially between men and women, presumably as a result of anatomic differences (Tables 7.1 and 7.2).

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Table 7.1: Anal tonometry findings male subjects Age 1020 2030 3040 4050 5060 6070 7080 8090 Mittlewert Number of patients 0 3 11 16 19 11 5 3 68 Relaxed pressure 0 39 47 49 42 47 48 40 39 Max. contraction pressure 0 201 155 110 170 150 136 131 132

Table 7.2: Anal tonometry findings female subjects Age 1020 2030 3040 4050 5060 6070 7080 8090 Mittlewert Number of patients 1 1 4 8 15 13 2 2 46 Relaxed pressure 25 35 34 38 40 32 31 36 34 Max. contraction pressure 210 117 93 113 95 90 64 64 106

Anal canal pressures decrease with aging, but whether this reduction results from normal aging or the accumulation of subclinical pathologic damage is unclear.

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Basal anal pressure results largely from tonic contraction of the internal anal sphincter. Basal pressure is well maintained even after a nerve block that paralyzes the external anal sphincter. The component of squeeze pressure that exceeds basal pressure results from active contraction of the external anal sphincter and is abolished by a nerve block. Because the internal and external sphincters are coaxial over most of their lengths, anal canal pressure reflects the blended activity of both sphincters. Only at the anal verge can the pressure generated by the subcutaneous external anal sphincter be recorded by itself. As a group, patients with fecal incontinence have significantly lower basal and squeeze pressures than age- and sex-matched controls. The difference is more pronounced in women than in men. However, the range of pressures among incontinent patients is considerable, and many patients have normal sphincter pressures. Anal manometry is most valuable when it demonstrates abnormally low pressures and thus confirms the presence of a sphincter defect. An isolated decrease in basal pressure or squeeze pressure suggests a problem with internal or external anal sphincter function, respectively, but does not distinguish pathogenically primarily neurogenic from primarily myogenic processes.

Purpose of Performing Anal Tonometry


Measurement of the strength of the voluntary contraction and function of the anal sphincter. Anal tonometry measures how strong the sphincter muscles are and whether they relax as they should during passing stool. It provides helpful information to the doctor in treating patients with fecal incontinence or severe constipation. Anorectal manometry can define hypo/hyperfunctional disorders of the sphincter complex.

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Manometry can compare objective function with patients subjective sensation of rectal fullness. Often performed in conjunction with other clinical and diagnostic modalities: DRE, video defecography, and anal manometry with EMG.

Criteria for a Reliable Anal Tonometry Device (Fig. 7.4)


Main unit and sensor should be connected with an electric cable only. The sensor should have a cylindric shapenot balloon shaped (oral or distal expansion when pressure increases). The device must be easy to handle and portable. Must measure the anal tonus or anal relaxed pressure (ARP) and the anal maximum pressure (AMP)value up 300 mm Hg. Device should run with batteries with possibility to connect to a PC. The measurement should last only a few minutes. Right after the sensor is inserted, it should show the anal tonus and immediately deliver the maximal anal pressure when asking the patient to squeeze.

Fig. 7.4: Anal tonometer

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It can be assumed that the measurement values differ depending on the type of equipmentvalues are not objective. The sphinctometer consists of a cordless handheld unit with measuring probe and the main station unit with its charging function. Pleasant and safe measuring technique for both doctor and patient. Objective determination of the anal tone and the voluntary contraction force of the sphincter in mm Hg. Comfortable documentation via optional PC printer port. Measuring values are repeatable at any time. Also available as training device for patients.

The Sphinctometer in Use (Fig. 7.5)


As soon as the probe is inserted, clear and intelligible instructions lead the operator through the operating menu, within a few seconds the measured values will be shown.

Fig. 7.5: Anal tonometer in use

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The use of disposable protective covers for the probe ensure a fast access to sphinctometer measuring systemanytime. Complicated disinfection of the probe after each use is not necessary. Simple connection to a PC will enable to transmit or import data. Additionally, it is possible to program patients sphinctometer trainer with his/her own sphinctometer, prescribing training models and goals. Important data compiled in the training phase can be easily stored and recalled giving easy access during therapy.

Limitations
However, limitations of the sphinctometer are that it can only help evaluate muscle insufficiency. But, a neurogenetic damage of the sphincter cannot be diagnosed using anal pressure measurement.

Risk
Anorectal tonometry is a safe, low-risk procedure and is unlikely to cause any pain. Complications are rare: it is possible that bleeding could occur. Equipment failure is a remote possibility. If patient is allergic to latex, he/she should inform the nurse/ technician before the test so that a latex free probe can be used. Significant manometric variations have been described in normal subjects chiefly with regard to gender and age. Males have been found to have greater squeeze pressures, greater resting pressures, and longer sphincters compared with females. The effect of age on the anal sphincter becomes evident around the sixth decade with decreased resting and squeeze pressures as well as prolongation of pudendal nerve conduction. In contrast to differences based on gender and age, the effect of parity on anorectal manometric parameters has not been well described.

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Interpretations
Manometry helps to detect abnormalities such as (Table 7.3): Hirschsprungs disease Dyssynergic defecation. In patients suffering from Hirschsprungs disease there is absence of rectoanal inhibitory reflex. Normally, there is a rise in intrarectal pressure. When a subject attempts to defecate, this in turn is synchronized with a fall in anal sphincter pressure due to relaxation of the puborectalis and external anal sphincter. Primarily a learned response, this maneuver is under voluntary control. The chief pathophysiologic abnormality in patients with dyssynergic defecation is the inability to perform this coordinated maneuver. This inability may be due to: Impaired expulsion forces Paradoxical anal contraction or Impaired anal relaxation or A combination of these mechanism(s). Largely because of the laboratory conditions, some subjects may not produce a normal relaxation, during attempted defecation. Hence, the occurrence of this pattern alone should not be considered as diagnostic of dyssynergic defecation. In more than half the patients with dyssynergic defecation, rectal sensory testing has revealed that the threshold for first sensation or a desire to defecate may be impaired. There are significant differences in: Test methodology both with regards to: Test performance and Interpretation of data. There is no generally acceptable method of identifying dyssynergia, the reason being concept of dyssynergic defecation as a cause of constipation has only been recognized over the last decade.

Table 7.3: Manometric findings seen with specific diseases Resting P (IAS) Normal (good tone) High Squeezing P (EAS) Comments

Clinical situation

A. Normal

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B. Fecal incontinence (multiple etiologies) Low Low The extent of the P drop can often correspond to the extent of disease/debititation RAIR difficult to assess given low resting and squeezing pressures Low Low It is often helpful if not essential to utilize EMG studies to evaluate neurogenic causes of fecal incontinence, although diagnosis can often be made on history alone.

1. Overflow incontinence d/t: a. Retal fecal impaction Decreased sensation Obtuse anorectal angle Chronic stimulation of RAIR b. Neoplasm

2. Abnormal pelvic floor d/t: a. Neurogenic causes pudendal nerve disruption/weakness Neuropathy (dm, scleroderma, multiple sclerosis) Generalized neuropathy or cord lesion

Contd...

Contd... Resting P (IAS) Squeezing P (EAS) Comments

Clinical situation

b. Sphincter disruption Obstetrical trauma Surgical trauma Trauma (other) Normal High In the absence of obstructive pathology, failure for sphincter relaxation during pushing often contributes to constipation Negative RAIR is pathognomonic for Hirshsprungs

C. Constipation

D. Hirshsprungs Low Low

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In one study, the prevalence of dyssynergia was: 63% with manometry 38% with electromyography 36% with defecography. Thus, the sensitivity for detecting this abnormality may vary depending on the type of test. The presence of dyssynergia or Impaired rectal sensation that was not detected clinically. Manometric tests have yielded new information, which has formed the basis for a change in the patients management. The diagnosis of dyssynergia requires more than the mere presence of dyssynergic pattern and because manometry only detects the presence of a dyssynergic pattern of defecation, one should interpret the results of manometry with caution. Thus, anorectal manometry provides confirmatory evidence for the diagnosis of dyssynergic defecation in a patient with functional constipation and may pave the way for biofeedback therapy.

Rectal Balloon Manometry


Rectal balloon manometry can be performed with a threeballoon probe or with a balloon mounted at the end of a perfused or transducer-based anal manometry array. This study can provide information about rectal sensation, rectal compliance, the rectoanal inhibitory reflex, and the rectoanal contractile response. Rectal sensation is assessed by inflating a rectal balloon with increasing volumes of air or water. The threshold for conscious sensation of rectal distention is the volume at which the patient first reports the sensation of something in the rectum. Most normal persons can sense a volume as small as 10 ml. Some incontinent patients have a higher sensory threshold, and others are unable to sense rectal distention at all. Some incontinent patients have delayed perception.

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These disturbances suggest dysfunction of the afferent pathways that carry the sensation of distention to consciousness but also may occur with megarectum. Measurement of rectal pressure during inflation of the rectal balloon generates a rectal compliance curve (dV/dP). This curve must be corrected for the compliance characteristics of the balloon itself by subtracting an extracorporeal pressurevolume curve obtained by inflating the balloon outside the body. Patients with incontinence often have low rectal compliance (i.e. production of higher rectal pressures by lower rectal volumes than in normal persons). The continence mechanisms are stressed more as stool enters the rectum. Conditions that are particularly likely to produce problems with rectal compliance include those that are associated with rectal fibrosis, such as rectal ischemia and radiation proctitis. By monitoring pressure in the upper anal canal during rectal distention, reflex relaxation of the internal anal sphincter (rectoanal inhibitory reflex) can be demonstrated. This reflex is mediated by intramural neurons with nitric oxide as a probable neurotransmitter. The volume of distention required to achieve reflex relaxation is approximately 20 ml and usually is slightly higher than the threshold for conscious sensation of rectal distention. The amplitude and duration of relaxation of the internal anal sphincter are related directly to the distending volume. With entry of stool into the rectum, this relaxation allows stool to reach the sensitive anal canal mucosa, thereby reinforcing rectal sensation. The rectoanal inhibitory reflex is absent in patients with Hirschsprungs disease and may be difficult to demonstrate if the basal anal sphincter pressure is very low. When the rectum is distended, pressure in the distal anal canal increases as a result of contraction of the external anal sphincter. This rectoanal contractile response is essential if automatic defecation is to be prevented.

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It is a learned response (probably at the time of toilet training in childhood) and is often missing in patients with fecal incontinence from a variety of causes. Absence of the rectoanal contractile response may result from interruption of rectal sensory pathways, damage to the pudendal nerves, weakness of the external anal sphincter muscle as a result of injury or skeletal muscle disease, or loss of memory of this learned response. Loss of this response most often correlates with, but is not diagnostic of, pudendal neuropathy. Relearning this response is an important objective of biofeedback training for the treatment of fecal incontinence.

Electrophysiologic Tests
Electrophysiologic tests can be used to assess the integrity of the sensory and motor innervation of the rectoanal region. Electromyography (EMG) with standard concentric needles or with more sophisticated single-fiber techniques can be used to assess the viability and reactivity of skeletal muscle. Because skeletal muscle activity is dependent on intact innervation, these tests provide information about the innervation of these muscles. Because these studies involve placement of needles or wires into the perineal region and have gained the reputation among patients of being unpleasant, alternative methods such as quantitative surface EMG have been tried. These methods may be more tolerable but provide less specific information than the more invasive techniques. Information about the motor nerves innervating the external anal sphincter can be obtained by pudendal nerve terminal motor latency testing. In this test, the examiner wears a special glove with a stimulating electrode over the fingertip and a recording electrode at the base of the finger. The gloved finger is introduced into the anus, and the fingertip is placed between the ischial spine and the edge of the sacrum, where the pudendal nerve passes.

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The recording electrode is then at the level of the anal sphincter. The time for the electrically stimulated nerve impulse to travel down the pudendal nerve from the stimulating electrode to the recording electrode is measured. Pudendal nerve terminal motor latency also can be measured by an external technique using magnetic stimulation. Pudendal nerve terminal motor latency is prolonged in patients with pudendal neuropathy as compared with normal persons. Studies show that this measurement is reliable and correlates with results of anorectal manometry. However, in practice this test has proved to be less useful in predicting the results of therapy than originally anticipated. Mucosal sensitivity can be assessed by gradually increasing electrical stimulation of the anal mucosa with an electrode until the impulse is felt by the patient. This test is of limited value clinically because electrosensitivity diminishes with aging and is abnormal in many anorectal diseases. All of these electrophysiologic tests are of most use in research settings. In clinical practice there is little to be gained by these tests unless surgery is planned and one needs to know whether denervation is so severe that repair of a sphincter defect is unlikely to be successful. Clinical evaluation may be better than electrophysiologic testing for predicting postoperative continence, but this finding is controversial. Anal manometry is a commonly used test that objectively assesses the resistance to spontaneous defecation provided by the anorectal sphincter mechanism and the sensory capabilities of the rectum to provide a feeling of imminent defecation. Anal manometry is helpful for patients who have had prior surgery to the anorectal canal or radiation therapy that could have altered the rectal storage function. In patients who, by history, report a normal sensation to defecate, anal manometry has been largely replaced by transanal ultrasound and PNTML or sphincter EMG alone.

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Although these studies do not give information on rectal function, they are more accurate in assessing the neuromuscular function of the anal sphincters. Anal manometry uses a rectal balloon to assess: Rectal sensation Rectal compliance The rectoanal inhibitory reflex (RAIR) Maximal tolerable rectal volume. The RAIR is a reflex response to increased pressure in the rectum from gas or stool. Normally, the IAS relaxes to allow a sampling of the rectal contents by the anal canal to determine if the contents are gas or stool and whether it is an appropriate time to defecate or pass flatus. At the same time, the EAS squeezes to prevent incontinence. Anal manometer, is a four-channel perfusion catheter with balloon tip. There are many different types and methods for performing anal manometry. A balloon or probe is inserted into the rectum, and a pressure transducer relays information to a recorder or computer. Important manometric parameters include sphincter length, resting and squeeze pressures, rectal sensation, and the presence of the anorectal inhibitory reflex (RAIR). The balloon is placed in the rectum and inflated by 10 cm3 increments to determine rectal sensation and compliance. The presence of the RAIR is determined with balloon inflation and seeing the IAS relax and the EAS contract to allow for the sampling of rectal contents. The four radical ports are perfused with sterile water, and resting and squeeze pressures around the anal canal are measured at centimeter intervals along the anal canal. The catheter can be pulled at a constant rate to determine the length of the sphincter and high pressure or incontinence zone. In addition to rectal function, resting and squeeze pressures in the anal canal are obtained by pulling a perfusion catheter with radial ports (four or eight) through the anal canal.

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Although objective documentation is useful for diagnosis or preoperative baseline, normal resting and squeeze pressures can be accurately assessed on rectal examination by most experienced clinicians. A single-channel recording of the resting pressure of the anal canal (R) and the squeeze pressure (S). The IAS contributes 80% of the resting pressure. Voluntary contraction or squeezing of the EAS should double the resting pressure.

Electromyography
EMG is used for mapping of the EAS defect and for determining the presence and degree of neuropathy and denervation and reinnervation. EMG evaluates the bioelectrical action potentials that are generated by depolarization of skeletal striated muscle. EMG evaluation consists of: Systematic examination of spontaneous activity Recruitment patterns The waveform of the motor unit action potentials (MUAP). Performance and interpretation of EMG of the EAS requires special training and experience. A needle electrode is inserted into the skeletal muscle of the EAS. First, spontaneous activity is heard and seen. Next, the patient voluntarily squeezes his/her pelvic floor and recruitment activity is recorded. Straining should decrease activity and coughing should increase recruitment. The final step in analysis is evaluation of the MUAP waveform. Following nerve damage, as seen with a vaginal delivery, reinnervation of the muscle fibers leads to a single motor unit innervating multiple muscle fibers. On single-fiber EMG the MUAPs have larger amplitudes, longer duration, and more phases or crossings of the baseline.

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Pudendal Nerve Terminal Motor Latencies


Nerve conduction studies measure the time from stimulation of a nerve to a response in the muscle it innervates. The pudendal nerve terminal motor latency (PNTML) is determined by using a glove-mounted electrode known as a St Marks pudendal electrode, connected to a pulsed stimulus generator and, with the examiners index finger in the vagina or anus, the pudendal nerve is stimulated at the ischial spine. The latent period between the pudendal nerve stimulation and the electromechanical response of the muscle is measured. Normal PNTML is 2.0 + 0.2 msec. A normal PNTML is the measurement of the fastest response of the pudendal nerve and does not necessarily mean the entire nerve is normal. Prolonged PNTMLs have been found in patients with idio-pathic fecal incontinence and in patients with rectal prolapse and may be predictive of continence following surgical repair. Neither does an abnormal latency indicate abnormal muscle function. A damaged nerve can heal and reinnervate the muscle, and although the PNTML may be slightly prolonged, the muscle functions normally. PNTML measurement is particularly important in suspected neurogenic incontinence and prior to sphincter repair. PNTML has been found to be the most sensitive predictor of functional outcome of overlapping EAS repairs. Gilliland and colleagues found in reviewing 100 patients at a median of 24 months after surgery that pudendal neuropathy was the only significant predictor of surgical success. Not patient age, parity, prior sphincteroplasty, cause or duration of incontinence, extent of EMG damage, size of the endoanal ultrasound defect, or pressures on anal manometry successfully predicted postoperative continence. However, 62% of 59 patients with bilaterally normal PNTMLs had a successful outcome compared with 1 of 12 patients with unilateral or bilateral prolonged PNTMLs (<0.01).

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The high failure rate seen with prolonged PNTML may occur for several reasons. First, prolongation of the PNTMLs is associated with increased mean fiber density of the EAS, resulting in a less efficient sphincter. Second, as the pudendal nerves also convey sensory nerve fibers from the levator muscles, the sensation of rectal distention may be diminished. Loss of rectal sensation leads to rectal distention and decreased anal resting tone leading to incontinence.

Endoscopy
Anoscopy
Anoscopy is the examination of the anal canal. The lower part of the rectal mucosa, upper anal mucosa, anoderm, dentate line, internal and external hemorrhoids can be seen through this examination. There are basically two types of anoscopes (Figs 7.6 and 7.7): 1. Beveled type 2. Side-opening scope.

Indications and Contraindications


To evaluate a patient for anal and low rectal pathology. Anoscopy may be used as an adjunct to the digital rectal examination. This is the best method of viewing the anal canal. Anoscopy allows visualization of: The anal canal Dentate line Internal hemorrhoids Foreign bodies Distal anorectal masses.

Indications
Hemorrhoid evaluation Fistula-in-ano evaluation

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B
Figs 7.6A and B: Anoscope

Rectal bleeding Rectal prolapse Anorectal pain Perianal condyloma Anal trauma or foreign body, including sexual assault Suspected anorectal malignancy.

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Figs 7.7A to C: Anoscopes

Contraindications
Severe rectal pain Acute fissure-in-ano An imperforate anus (Absolute contraindication) Anal canal stenosis Acute cardiorespiratory compromise.

Equipment and Setup


The anoscope is a clear plastic or stainless steel tube with a beveled end and with a removable obturator, usually having a 2 cm diameter (though smaller ones are available).

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It may have an integrated light source or require an external light or head lamp. Following things are required apart from an anoscope to perform anoscopy: A suitable examination table, topical anesthetics, lubricant jelly, and gauze and forceps. The lubricated anoscope is inserted slowly as the examiner applies gentle pressure on the end of the obturator once the instrument has been fully advanced.

Position
The lateral decubitus position with knees and hips flexed is the most appropriate position and is better tolerated (Fig. 7.8A). Knee-shoulder and prone positions are also suitable and advised in certain conditions (Figs 7.8B and C). In the lateral decubitus position, if the examiner is right-handed, place the patient on the left side (Fig. 7.8A).

Procedure (Figs 7.9A to C)


The first and foremost step is to explain the procedure to the patient in a simple to understand terminology. Relieve any apprehension the patient has by reassuring specially in painful conditions. Put the patient in a comfortable position and assure privacy. Apply a topical anesthetic such as 2 or 5% lidocaine ointment for at least 30 minutes before the procedure for painful conditions such as thrombosed hemorrhoids or anal fissures. If patients do not tolerate anoscopy because of pain, or if they have conditions that are not limited to the anus, offer them sigmoidoscopy or colonoscopy, examination under anesthesia. Hold the buttocks apart. Perform a routine digital rectal examination to identify sources of bleeding or pain and to locate any palpable masses before performing anoscopy.

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Figs 7.8A to C: Different positions for anoscopy

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Figs 7.9A to C: The three important steps of anoscopy

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Carefully and gradually introduce the scope into the anus. After the DRE and with the obturator inserted completely into the anoscope. If you face resistence, from involuntary contraction of the external anal sphincter. Use gentle and constant pressure to overcome it, never push the scope hard. While asking the patient to bear down slightly, gently advance the instrument. Gently pass the anoscope into the anorectum. In case of resistence being offered by the patient and if the obturator falls back during insertion, remove the anoscope completely and replace the obturator so that the anal mucosa is not pinched. Gently advance the anoscope until the outer flange is in contact with the anal verge. Remove the obturator only after the anoscope has been completely inserted. If the anoscope does not have an internal light, use an external light source or pelvic examination light. Visualize the anal canal, simultaneously and gradually withdraw the anoscope as the entire circumference of mucosa is inspected and the entire area which includes the distal rectum, followed by the upper anal canal, down to the anoderm is inspected. To visualize the anal canal clearly for mucosal lesions, swab away blood or debris. Culture any abnormal discharge that is found. Observe for any rectal bleeding proximal to the reach of the anoscope. Look for foreign bodies beyond the reach of the anoscope. Look for distal sources of pain or bleeding such as hemorrhoids, rectal fissures, ulcerations, abscesses, or tears. Masses or polyps that are visible through the scope can be biopsied using a small biopsy forceps (Fig. 7.10). The reflex spasm of the anal sphincter, may cause the anoscope to be expelled quickly when the last stage of withdrawal approaches.

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To prevent such a rapid expulsion, always use firm counterpressure, and if need be it is advisable to repeat the procedure to obtain an adequate view of the anal verge. Always replace the obturator when there is need to rotate the anoscope while it is in the canal. The obturator again must be replaced, to reinsert the scope and view another area. Internal hemorrhoids can be seen bulging above the dentate line or prolapsing downward. Internal fistulous openings may be viewed, particularly along the dentate line. When the external skin is compressed, pus may be seen to bubble from the internal opening of a fistula. Occasionally a low rectal polyp that cannot be removed through a flexible endoscope because of: The low position of the polyp in the rectum or A difficult angulation on retroflexion of the endoscope the anoscope can be used to remove such low rectal polyp.

Fig. 7.10: Anoscopy demonstrating normal mucosa and polyps

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Complications
Anoscopy is a relatively safe procedure and the incidence of the complications is very rare. Some patients do complain of increased pain after the examination but that is momentary. Local mucosal irritation which can lead to slight subsequent bleeding is the most common complication. Anal tear, especially at the posterior midline, can occur in patients with anal stenosis. Sterilize instruments after each use or in case of disposable ones, dispose the instrument after single use to prevent infection being transmitted.

Rigid Sigmoidoscopy
Rigid sigmoidoscopy is usually performed in an outpatient or a theater setting in conjunction with a digital rectal examination to help facilitate the diagnosis and the management of rectal and anal pathology. Though flexible sigmoidoscopy has largely replaced rigid sigmoidoscopy, it is yet used in evaluation of the anal canal and the rectum. The main advantage of this is that any blood clots or residual stool can be washed away. The prime indication of rigid sigmoidoscopy is massive GI bleeding to rule out any bleeding in the anorectal region. It is also useful in identifying the precise location (distance from anal verge) and size of rectal neoplasm. When any of the following conditions is suspected rigid sigmoidoscopy scores over flexible one: Nonspecific proctitis Radiation proctitis Prior to anorectal procedures in clinic or operating theater To obtain biopsy of any bowel condition within the reach of the instrument

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Conservative treatment of sigmoid volvulus During anterior resection of rectum to gauge the lower resection margin Anorectal ulcer Anorectal neoplasm Infectious proctitis Anorectal Crohns disease. Contraindications to rigid sigmoidoscopy are divided into absolute and relative, the latter can be further divided into surgical and medical groups.

Absolute Contraindications
Suspected or known bowel perforation Anal stenosis.

Relative Surgical Contraindications


Acute peritonitis Colonic necrosis Fulminant colitis Toxic megacolon Acute severe diverticulitis Diverticular abscess Recent colonic surgery Anal fissure.

Relative Medical Contraindications


Severe coagulopathy Severe thrombocytopenia Severe neutropenia. Patients with severe anal pain from an acute fissure, thrombosed external hemorrhoids, and perianal abscess may not allow a rigid sigmoidoscopic examination and the examination should be postponed to some other suitable date, when the patient is more comfortable.

Three Sizes of Rigid Proctosigmoidoscope are Available (Fig. 7.11)


The standard size 19 mm 25 cm scope used for:

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Fig. 7.11: Rigid sigmoidoscope in different sizes

General examination For polypectomy or Electrocoagulation. A 15 mm 25 cm endoscope: Also idea size for general examination. Better tolerated by the patient Causes less spasm of the rectum Minimal air insufflations needed Enables adequate examination comparable to the standard-size endoscope. 11 mm 25 cm scope used for examining the patient who have anal or rectal stricture, such as Crohns disease.

Procedure
Usually performed without sedation or anesthesia except in very apprehensive patients intravenous sedation may be used.

The Equipment (Figs 7.12 and 7.14)


Sigmoidoscope with obturator Eyepiece Bellows

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Fig. 7.12: Rigid sigmoidoscope

Light source Air filter Lubricant jelly Linen and disposable gloves.

The biopsy forceps supplied with a rigid sigmoidoscope are cumbersome and obtain a large piece of tissue, so it is wise using biopsy forceps that accompany the flexible sigmoidoscope.

Position
The left lateral (Sims) position is the most convenient and most commonly used position for rigid sigmoidoscopy (Fig. 7.13). The patient lies on his or her left side with the hips and knees flexed and parallel.

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The buttocks overhang the edge of the bed in this position. The patients trunk should be angled obliquely across the bed. The more transverse across the bed, the easier the examination. To ensures that the head of the sigmoidoscope can be depressed below the level of the bed. A small sandbag may be placed under the left thigh or hip to provide elevation.

This position aids the full maneuverability of the scope.

Jackknife Position
This is an alternate position, also known as the prone knee-elbow position (Fig. 7.8 C). The patient lays prone in an inverted position on a specialized table. These positions are particularly helpful to permit a considerable degree of maneuverability of the scope. A cooperative patient can still be placed in the knee-chest position, even if the specialized bed is not available, and the procedure demands this position as a desired position.

Fig. 7.13: Position for sigmoidoscopy

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A regular left lateral position can also be used and is advised in conditions such as pregnancy, severe hypertension, retinal detachment or postoperative eye surgery, and some apprehensive patients.

Important Steps
Assemble the rigid sigmoidoscope, before giving the most optimum and comfortable position to the patient. Insert the stylet through the open eyepiece window into the scope and assure that the tip of the stylet protrudes through the tip of the scope. Apply adequate amounts of a lubricant anesthetic jelly to the scope. Start with inspection of the anus and the perianal area for any abnormalities. Always perform a digital rectal examination, before a rigid sigmoidoscopy. It is important to appreciate the general anatomy of the distal rectum, any palpable lesions, and the contents of the rectum, on rectal examination. Always attempt to empty the rectum with a laxative suppository or enema. If the rectum is found to be loaded with feces prior to performing rigid sigmoidoscopy. This would aid in having a clear view of the mucosal lesions. Insert the scope 4 cm into the anus in the direction of the patients umbilicus. Remove the stylet at this juncture, and seal the eyepiece with the glass window. Advance the scope under direct vision once the stylet is removed. Gently insufflate air into the rectum intermittently as the scope advances, using the belows. Knowledge of the three-dimensional anatomy of the rectum is important for further advancement of the scope. The rectum angulates posteriorly over the puborectalis sling into the hollow of the sacrum, at 4 cm from the anus (Figs 7.15 and 7.16).

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Fig. 7.14: Rigid sigmoidoscope

A special care should be exercised at this point (4 cm from the anus), the general direction of the scope should change from pointing anteriorly to pointing posteriorly. Again keep gently insufflating air into the rectum to expand the rectum in front of the scope. Under direct vision, advance the scope into the middle of the expanded segment, to avoid inadvertently injuring the mucosa. Keep insufflating air as you advance and as the scope moves along. Note for presence of any abnormalities. To maneuver the rectal valves, slight lateral angulation of the scope is used (Fig. 7.15). The sacral promontory produces a sharp angulation of rectum anteriorly, at the 12 cm level. Change the direction of the scope to point anterosuperiorly at this point, i.e. at the 12 cm level. Fifteen to twenty centimeter of examination is usually considered comfortable examination, any further examination may be performed using a flexible scope.

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Fig. 7.15: Rectal valves

Any significant pain is an indication to terminate the examination. Keep following the above steps backwards, as the scope is withdrawn. Keep changing directions while maintaining direct vision of the lumen of the rectum and insufflate air even while withdrawing. A more complete examination is possible with small circular motions while withdrawing and this in turn aids in revealing lesions missed during insertion of the scope. When examination is complete and the scope removed, return the patient to a more comfortable position and suitable environment, after the perianal area has been wiped clean.

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Fig. 7.16: Angulation of rectum

At the level of peritoneal reflection, i.e. above 8 cm, real risk of perforation exists. So obtaining a biopsy of any flat lesion or surface, especially above this level, is unwise.

Complications
Rigid sigmoidoscopy in experienced hands performed by trained clinicians is usually tolerated by most patients and has a low incidence of serious complications. However, some adverse effects and complications do occur. Again most of these reported adverse effects are of low magnitude. Moderate to severe discomfort during rigid sigmoidoscopy (Experienced by up to 30% of patients.) Pain Discomfort from rectal preparation Uncomfortable desire to defecate

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Discomfort associated with patient positioning Abdominal discomfort due to insufflations of the rectum Transient bacteremia occurs occasionally Rarely significant bleeding Perforation from diagnostic rigid proctosigmoidoscopy though extremely rare, a few cases have been reported in some studies, so due care should be exercised especially in inexperienced hands.

The pain experienced from proctosigmoidoscopy is from stretching the mesentery of the rectosigmoid colon when the scope is pushed against the rectal wall, and from the air insufflation.

Important Points to Keep in Mind


When the rigid sigmoidoscope is inserted to a depth of 20 cm. Negotiating the rectosigmoid angle, is the most likely cause of major patient discomfort. A complication that is usually related to concomitant rectal biopsy, is significant bleeding that requires transfusion or further procedural intervention, though this occurs in approximately 1 out of 9,400 rigid sigmoidoscopies it is better to be cautious when biopsy is taken with the sturdy forceps that accompanies the rigid sigmoidoscopy set. Most patients are fearful of the examination because of past bad experience with the procedure or from what they have heard from other patients. Usually a few words of reassurance will be helpful. If a biopsy is performed, the location, level, number of biopsies, and whether electrocoagulation is necessary should be noted. During the entire procedure, suction and water irrigation should be available. Lesser diagnostic yield is generated by rigid sigmoidoscopy as compared to a flexible sigmoidoscopy. In one study, when the examination was performed with flexible sigmoidoscopy, in patients who had undergone rigid sigmoidoscopy, 33.9% of the examinations declared normal, were found to have significant lesions.

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Flexible Sigmoidoscopy
With passage of time flexible sigmoidoscope has evolved into a flexible video sigmoidoscope, there is no need to attach a camera to the scope now, the inbuilt camera transmits image and video through a processor to the monitor which can be captured by a computer. An ideal sigmoidoscope is 60 cm long, the entire sigmoid colon can be visualized in up to 85% patients and in some cases the splenic flexure (Figs 7.17A and B). Data suggests that, flexible sigmoidoscopy has a 3 to 6 times greater yield than does rigid proctosigmoidoscopy in detecting colonic and rectal abnormalities, especially neoplasms, for selective screening examination. Many clinicians have discontinued performing rigid proctosigmoidoscopy. Because of this higher yield and better exposure.

Indications
There is thin line of differences in indications for flexible sigmoidoscopy and rigid sigmoidoscopy. In acute diarrhea, to rule out: Clostridium difficile colitis Acute bacterial colitis Amoebic colitis. To rule out ischemic colitis particularly after aortic aneurysm repair. To evaluate patients with bright red rectal bleeding to detect its cause such as: Nonspecific proctitis Radiation proctitis Anorectal Crohns disease Rectal ulcer Anorectal neoplasm Unexplained anemia Persistent abdominal pain Alteration in bowel habits, constipation (particularly unexplained new onset), diarrhea, altered stool diameter

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B
Figs 7.17A and B: (A) Sigmoidoscope; (B) Video sigmoidoscope

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Unexplained weight loss, fever Follow-up of treatment regimens (e.g. for ulcerative colitis, irritable bowel disease) Screen patients for colorectal cancer screening in conjunction with positive tests for fecal occult blood To complement a barium enema examination in patients where anorectal noeplasms are suspected CO2 may be used instead of air insufflation if a barium enema is to follow a flexible sigmoidoscopic examination. Severe anal pain from anal diseases Anorectal stricture Colorectal anastomosis less than 2 weeks postoperatively Acute sigmoid diverticulitis Toxic colitis Patients with an acute abdomen.

Contraindications

Preparation
Regular but light meals on day of examination. Two enemas given within 2 hours of examination is adequate for bowel preparation. Patients with diarrhea do not require the enemas.

Position
Left lateral is the best and usually adopted.

Procedure
Sedation is unnecessary. Place the patient in a left lateral position with knees flexed upward toward the chest. Initial digital rectal examination is always advisable as it helps in identifying: anal fissures, polyps, and lesions, as well as allowing for initial application of lubricant.

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Always perform anoscopy in all cases in which palpable abnormality is identified. A well-lubricated flexible sigmoidoscope is then inserted. With the index finger placed behind the advancing tip. Initially advance the scope at an acute angle. It is always safe to advance the endoscope under direct vision. Never try to push the endoscope through a bend in the bowel as this is a poor technique. Instead, withdraw the endoscope to straighten the bowel. As the scope advances into the rectum, gently rotate the scope in line with the anal canal. The key of successful sigmoidoscopy lies in: Short withdrawal and advancement of the endoscope or A to and-fro movement Together with rotating the instrument clockwise and/or counterclockwise as needed. Keep the use of air insufflation to a minimum. Insert air to see the rectal vault and find the opening to the lower sigmoid. Once the scope is inserted approximately 15 cm. Try to complete the procedure within 5 to 10 minutes. A complete colonic investigation should be advised. If a lesion is detected to be a neoplasm and proved by biopsy. The ideal suggestion will be total colonoscopy at some other date. A polyp that is up to 8 mm in size can be sampled with coagulation biopsy forceps or biopsy followed by electrocoagulation should be performed. Air should be exchanged in the colon and rectum with repeated insufflations and suction. To prevent possible explosion, because of hydrogen or methane gas in the lumen. Colonoscopy may be preferred as first line of investigation to examine the entire colon in patients with higher risk, for the following conditions: Follow-up for history of polyps or cancer Any person with a high-degree risk factor for cancer or other disease in the colon

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Positive fecal occult blood test Unexplained weight loss High suspicion of cancer.

Complications
The complications of flexible sigmoidoscopy though rare are often serious. They can be immediately apparent or delayed. Acute abdominal distention and abdominal pain caused by excessive air insufflation is the most common. Reinsert the endoscope and perform aspiration of excessive air to relieve the patient of abdominal distention and pain. Bleeding from the site of a biopsy. Improper technique and rough handling can cause perforation and other injuries. The distal sigmoid colon where it is angulated from the relatively fixed rectum at promontory of the sacrum, is the most common site of perforation in flexible sigmoidoscopy.

Colonoscopy
Colonoscopy is an endoscopic procedure which enables visual inspection of the entire large bowel from the distal rectum to the cecum (Fig. 7.18). The procedure is relatively a very safe and effective means of evaluating the large bowel. Advances in the technology for colonoscopy provide a very clear image of the mucosa through a video camera attached to the end of the scope or an inbuilt video camera. The colonoscope or the camera can be connected to a computer, which can store and print color images selected during the procedure. Compared with other imaging modalities, colonoscopy is especially useful in detecting small lesions such as ulcerations and adenomas.

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Fig. 7.18: Video colonoscope

Yet the main advantage of colonoscopy is that it allows for intervention, because the endoscopist can take biopsies and remove polyps. The most common indications for colonoscopy is screening for and follow-up of colorectal cancer. Although colorectal cancer is highly preventable, it is the second most common cancer and cause of cancer deaths in the United States. Both men and women face a lifetime risk of nearly 6% for the development of invasive colorectal cancer. Colonoscopy plays an important role in this effort as proper screening can help reduce mortality rates at all ages.

Indications/Contraindications
Surveillance of asymptomatic people of average risk older than 50 years. Recommendations of colorectal cancer screening for average risk adults above 50 years of age:

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Colonoscopy, every 10 years Annual fecal occult blood testing (FOBT) Periodic flexible sigmoidoscopy with follow-up colono scopy.

Procedure
Instructions
On the days prior to examination, discontinue warfarin, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and iron supplements. Insulin should not be taken while fasting prior to colonoscopy. Foods to avoid on the day prior to the test include those that may be misinterpreted during examination (e.g. red or purple foods, Jell-O, or drinks). On the day prior to colonoscopy and during the night before, patients should drink only clear liquids (no solid foods). The timing of the procedure and the choice of dietary or pharmacologic preparation are influenced by the urgency of the clinical situation as well as concurrent medical illnesses. The preprocedure assessment of the patient and review of medical records should include: 1. History of any medical illnesses 2. Medications 3. Past history of any surgical intervention 4. Previous endoscopies 5. History of drug allergies 6. History of bleeding tendencies. Informed consent should be obtained and documented before the patient is medicated. This must include a discussion of what will be done, expected discomfort, potential risks and benefits of the procedure including those of sedation, alternative methods of investigation or management, and the opportunity to ask questions.

Bowel Preparation
The colon must be completely empty prior to colonoscopy, to maximize the thoroughness and safety of the procedure.

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Several options are available for precolonoscopy bowel cleansing. The most commonly used preparations include: 1. Four liters of polyethylene glycol (PEG) solution administered orally over a 1 to 3 hour period on the evening prior to colonoscopy. A reduced volume lavage regimen comprised of 2 liters of PEG solution plus 4 tablets of delayed-release 5 mg bisacodyl tablets has been introduced in an effort to improve patient compliance. 2. A small-volume, buffered oral sodium phosphate-based laxative is a good option. When compared with the polyethylene glycol lavage solutions, this regimen has been shown to be superior in tolerance and equivalent or superior in efficacy. This regimen is usually given in split 1.5-oz doses the evening before and the morning of the colonoscopy. If the doses are separated by several hours. Both doses can be given the day before the colonoscopy with acceptable results. Although sodium phosphate solutions are better tolerated, nonspecific aphthoid-like mucosal lesions, similar in endoscopic appearance to Crohns disease, have been observed in association with these solutions. The potential for confusion has led some to recommend avoiding sodium phosphate based laxatives in patients undergoing colonoscopy for evaluation of chronic diarrhea or in whom a diagnosis of inflammatory bowel disease is being considered. 3. The third regimen also uses a sodium phosphate-based laxative but in pill form. Sodium phosphate tablets have been developed providing the same dose of salts as found in the solution without the unpleasant taste. The preperation is administered in 7 divided doses of 3 tablets every 15 minutes with 8 ounces of clear liquids the night before the procedure and an additional 20 tablets taken the next morning in a similar fashion beginning 3 to 5 hours before the procedure. When compared with the polyethylene glycol-based preparation, sodium phosphate tablets demonstrated similar efficacy in cleansing of the colon, better patient tolerance, and fewer GI side effects.

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Several studies have also shown that fluid and electrolyte shifts may occur, leading to dehydration and serum electrolyte abnormalities. Regardless of the laxative method used, note that patients must drink at least fourteen 250 ml glasses of water or clear beverages during the day prior to colonoscopy to prevent dehydration. It is not uncommon for patients to report an inability to tolerate the colon-cleansing preparation often secondary to unpalatable taste and large volume of the preparation, nausea and vomiting, or abdominal cramping and bloating. If the patient reports already passing clear liquid stool, discontinuation of further preparation may be considered. Because electrocautery may be performed during colonoscopy. Preparation solutions (oral lavage or enemas) should not contain mannitol or other fermentable carbohydrates that could be converted to explosive gases. Nasogastric infusion is a safe, effective alternative method of administration. If a patient cannot ingest a large quantity of liquid.

Antibiotic Prophylaxis
The rate of bacteremia associated with colonoscopy is 2 to 5%. The rate of bacteremia does not increase with mucosal biopsy or polypectomy. Antibiotic prophylaxis for colonoscopy, with or without biopsy, is only recommended as optional for high-risk patients (e.g. those with prosthetic valves, previous history of endocarditis, joint replacements, etc.). The most commonly used preprocedure and postprocedure prophylaxis regimens are ampicillin/amoxicillin (2 g IV/IM or 1.5 g Orally), gentamicin (1.5 mg/kg).

Sedation
Colonoscopies are routinely performed using sedative medications. Intravenous benzodiazepines have been the usual premedications used for colonoscopy, either alone or with a narcotic. Midazolam (25 mg) and diazepam (510 mg) are most commonly used.

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The combination of benzodiazepines and narcotics may achieve sedation more smoothly but is associated with a greater risk of respiratory depression. In recent years, propofol, a short-acting, intravenous sedative has become commonly used during colonosocopies. It provides little analgesia but leads to a deeper level of sedation with rapid onset and shorter recovery time as relative to conventional narcotic/benzodiazepine combinations. Propofol is generally administered by an anesthesiologist present at the time of the colonoscopy. Patients must be monitored (e.g. blood pressure, pulse, oxygen saturation) for the duration of the procedure, as well as observed for adverse effects of these medications. Administration of sedative drugs at colonoscopy has its inherent drawbacks, including an increased rate of complications, higher cost, and longer recovery periods for patients.

Technique
Position: The patient is always in left lateral decubitus position. Colonoscope after adequate lubrication is inserted through the rectum into the colon. The scope is advanced and maneuvered while the lumen and walls of the colon are visualized by projections onto a television screen. The colonoscope has channels through which instruments can be passed in order to perform biopsies, remove polyps, or cauterize bleeding. Air, water, and suction can be applied to help provide a clearer visual field for inspection. Completion of the procedure is achieved on reaching the cecum and, in some cases, the terminal ileum. Visualization of the appendiceal orifice and the ileocecal valve are standard landmarks that may help to determine if this has been achieved. Transillumination above the right inguinal canal also suggests cecal intubation.

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Complications
Colonoscopy is generally a safe procedure and complications are rare. In a study involving over 25,000 diagnostic colonoscopies, the overall complication rate (primarily bleeding and perforation) was reported to be 0.35%. A preprocedure history and physical examination may show an increased risk of hemorrhage either because of medication use or underlying coagulopathy. The risk of hemorrhage may be increased with use of pure cut current. Right-sided sessile polyps are thought to present the highest risk of perforation because the colonic wall is thinnest in this area.

Prevention of Complications
Proper technique for closing a polypectomy snare requires experience. Using cautious approaches may minimize the risk of complication occurrence. Use of saline solution or epinephrine injected at the base of the polyp or under the polyp in order to raise the polyp is advocated. Careful attention is required to avoid entrapment of normal bowel mucosa when the snare is closed. Consideration should be given to delaying the procedure or correcting the coagulopathy, as appropriate, for patients with coagulopathy. Preparation related complications are rare yet care should be taken while using electrocautery in patients prepared with standard phosphosoda enema preparation for sigmoidoscopy.

Perforation
Colonic perforation during colonoscopy may result from mechanical or pneumatic forces against the bowel wall, barotrauma, or as a direct result of therapeutic procedures like faulty biopsy techniques. The risk of perforation of the colon after diagnostic colonoscopy and with polypectomy is low.

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In patients where hydrostatic balloon dilatation of colonic strictures is needed the rate of perforation is higher. Perforation is more common: 1. In patients who are oversedated or under general anesthesia 2. In the presence of poor bowel preparation or 3. With acute bleeding.

Mechanical Perforation by the Tip of the Instrument Occurs


1. At sites of weakness of the colon wall (e.g. diverticula, transmural inflammation) 2. Proximal to obstructing points (e.g. neoplasms, strictures). Over Enthusiastic distention by insufflated air can cause Pneumatic perforation of the colon or ileum. Faulty technique of electrocautery for polypectomy can also cause perforation. If abdominal viscera become visible, it should warn the endoscopist of a free perforation into the peritoneal cavity during the procedure. A laceration that is large enough, that it can be observed directly through the colonoscope is a surgical emergency. Marked persistent abdominal distention or pain should prompt the ordering of upright abdomen radiographs; which imagery may reveal free air in the peritoneum. CT scans have been shown to be superior to the upright abdomen films. Therefore, an abdominal CT scan should be considered for patients with an unrevealing plain film and in a patient in whom there is a high suspicion of a perforation. If the leak is tiny and well localized. The symptoms may be delayed for several days. Retroperitoneal perforation can give rise to subcutaneous emphysema (This is usually a pneumatic injury). Fever and leukocytosis may eventually develop with any of these perforations. When plain abdominal or chest radiographs show pneumoperitoneum, suggestive of gross extravasation, surgical intervention is required.

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In the absence of leakage, treatment with intravenous antibiotics and close observation may be considered.

Bleeding
Clinically important postprocedural hemorrhage is defined as: 1. Lower GI bleeding requiring transfusion 2. Hospitalization 3. Reintervention (such as a repeat colonoscopy) or 4. Surgery. One in every 1000 colonoscopic procedures, bleeding occurs as a complication. Though most cases resolve spontaneously, transfusions, endoscopic therapy, angiography, and even laparotomy may be required in more severe cases. Bleeding may occur immediately following polypectomy. This bleeding can be treated by resnaring the remaining stalk and tightening the snare for 10 to 15 minutes. Further electrocoagulation is strictly contraindicated. Injection of 5 to 10 ml of a 1:10,000 epinephrine solution into the stalk or the submucosa to achieve vasoconstriction can be of great help if used wisely. Endoscopic hemoclips may also be used. Nonendoscopic treatment modalities include angiographic embolization and surgery.

Postpolypectomy Coagulation Syndrome


Electrocoagulation injury to the bowel wall has been reported to induce a transmural burn in patients undergoing polypectomy, which in turn may result in the postpolypectomy coagulation syndrome. The patients with this syndrome present 1 to 5 days after colonoscopy with symptoms of: 1. Fever 2. Localized abdominal pain

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3. Peritoneal signs 4. Leukocytosis. Radiographic studies do not show free air in the peritoneum. Five of the 6 reported cases in one series had polyps in the right side of the colon and all were sessile lesions. It is important to recognize this entity because it does not require surgical treatment.

Infection
Instances of transmission of infection from one patient to another or to endoscopic personnel are extremely rare. The main preventive measure is disinfection of scopes and accessories. Due care should always be taken to avoid contact with patients blood or bodily fluids.

Abdominal Distention
Air insufflation leading to colonic distention during colonoscopy can cause notable discomfort apart from impairing mucosal blood flow. Carbon dioxide insufflation during colonoscopy may offer some advantages: 1. It is absorbed from the colon. 2. It is nonexplosive. 3. Mucosal blood flow is less affected, which decreases the risk of colonic ischemia.

Miscellaneous Complications
Miscellaneous rare complications of colonoscopy are as follows: 1. Splenic rupture 2. Acute appendicitis 3. Tearing of mesenteric vessels with intra-abdominal hemorrhage 4. Bacteremia 5. Retroperitoneal abscess 6. Subcutaneous emphysema

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7. Snare entrapment 8. Ensnarement of adjacent, normal bowel. Chemical colitis may occur if glutaraldehyde, used during disinfection, has not been adequately rinsed from the endoscope. Death has been reported in very few cases, five cases in a study of 83,725 procedures.

Treatment of Complications
In all cases of free perforation, surgical opinion should be obtained. Nonsurgical management may be appropriate in selected individuals, though perforation often requires surgical repair. Patients with silent perforation or those with localized peritonitis without signs of sepsis, can be considered for nonsurgical management and if they improve with conservative management surgery may be avoided. The so-called mini-perforation is characterized by early presentation (within 6-24 hours after polypectomy), local pain, and tenderness, without signs of diffuse or spreading peritoneal irritation. These patients are treated with bowel rest, intravenous antibiotics, and frequent serial examinations for clinical deterioration. Laparoscopic repair of these perforations may be feasible. Acute postpolypectomy hemorrhage is often immediately apparent and amenable to endoscopic therapy. Postpolypectomy coagulation syndrome is usually managed with intravenous hydration, broad-spectrum parenteral antibiotics, and nothing by mouth until the symptoms subside.

Colonoscopic Tattooing
During colonoscopy if a lesion is found that cannot be removed endoscopically, or if there is a need to relocate it for endoscopic follow-up, permanent dye (e.g. India ink) can be used to mark the same in order to tattoo the colon adjacent to the lesion. This in turn can be of great help localizing the lesion during surgical resection or follow-up colonoscopy.

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Colon Capsule Endoscopy


Wireless capsule endoscopy: One of the newer and accepted means for endoscopically visualizing the small bowel. A small capsule containing a wireless video camera is ingested by the patient. This camera transmits images to a small recording device. High-definition colonoscopy: High-definition wide-angled colonoscopy provides greater detection of colorectal polyps than traditional colonoscopy.

Preoperative Work-up
For Ambulatory Anorectal Surgery

chapter

It has been estimated that 90% of anorectal cases may be suitable for ambulatory surgery. A wide variety of anorectal conditions including condylomata, fissures, abscesses, fistulas, tumors, hemorrhoids, pilonidal disease, and various miscellaneous conditions have been shown to be appropriate for surgery on an outpatient basis. A reduction in hospital charges of 25 to 50% can be achieved by ambulatory surgery. Patient history and physical examination are the key elements of an appropriate preoperative evaluation. Routine preoperative investigations that are not warranted on the basis of history and physical examination seem to provide little further information. The use of routine preoperative laboratory profiles is becoming a subject of historical interest. Patients undergoing ambulatory colon and rectal surgery, as with all ambulatory surgical patients, should have preoperative laboratory tests, only as needed, specific to the patient, diagnosis, and proposed surgery. The patient must undergo a preoperative work-up once the decision to proceed with surgery has been made and the appropriate location and setting for surgery has been selected. All patients must have a complete history and physical examination prior to surgery. All organ systems should be evaluated with a thorough review of systems. Physical examination should also include all organ systems.

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Most institutions have specific guidelines and requirements for ambulatory and major surgery yet here are some essentially needed. These guidelines apply to adult patients undergoing colorectal surgery who have no specific comorbidities. All patients should have a preoperative complete blood count (CBC) within seven days of surgery. Many patients over the age of 50 will also undergo a basic metabolic panel [BMP] prior to surgery if comorbid conditions are present, although the basic metabolic panel (BMP) is officially reserved for all patients over the age of 65. Electrolyte evaluation, especially potassium levels is advised in patients who undergo mechanical bowel preparation. This may be performed in the morning of surgery. If the potassium is low, it is replaced prior to or intraoperatively. Diabetic patients should undergo blood glucose levels on the day of surgery. Unless the patient has a personal or family history of bleeding disorders or the patient is taking anticoagulants such as warfarin, routine coagulation studies including prothrombin time (PT) and partial thromboplastin time (PTT) are not necessary. Unless there is a significant concern over the patients platelet function. Bleeding time is rarely assessed prior to surgery. Other hematology or chemistry studies are usually not necessary. Despite the clear lack of need for routine preoperative laboratory values for all patients, both surgeons and primary care physicians continue to order and anesthesiologists demand these tests. Better education is required for all members of the health-care team to help reduce the number of unnecessary tests and thus reduce costs. A urine or serum pregnancy test should be performed on the day of surgery or within a few days prior to surgery, for female patients of child bearing age.

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Table 8.1: Exceptions to pregnancy testing Absolute Total hysterectomy Bilateral oopherectomy Menopause Relative Consistent oral contraceptive use and normal menses Consistent intrauterine device or levonorgestrel implants Bilateral tubal ligation

Though many institutions have adopted a policy of mandatory pregnancy testing, except for the postmenopausal women and women who have had a hysterectomy. Exceptions to this testing exist as shown in the Table 8.1. Although an electrocardiogram (ECG) is orderd based on age and gender. All males over the age of 40 are required to have an ECG as are all females over the age of 50. Any patient with a cardiac history or pulmonary history should also undergo an ECG prior to surgery. Patients with many other comorbidities including obesity and diabetes mellitus should also undergo ECG.

Patient Evaluation
Except to aid in confirming the diagnosis for the proposed surgery, radiologic studies for ambulatory surgery are usually unnecessary. In patients over the age of 75, a preoperative chest X-ray for ambulatory surgery patients should only be performed. Similarly all patients with significant cardiac and/or pulmonary disease should also undergo a preoperative chest X-ray. The surgeon should be aware of the proper medical preoperative work-up of patients. As there is no specific age at which patients

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should have a medical work-up prior to surgery; however, patients over the age of 40 are usually referred to a primary care physician for evaluation prior to elective surgery. Based on the patients history, cardiac evaluation prior to surgery is determined. Patients with a history of a recent cardiac evaluation with either invasive or noninvasive testing which was normal or unchanged compared with prior evaluation should require no further workup prior to elective ambulatory surgery. No further work-up other than a normal ECG in patients who have excellent functional status and report no cardiac or pulmonary symptoms should also require. Unless deemed necessary by the cardiologist, patients with poor functional status and a normal/stable ECG undergoing a low-risk ambulatory procedure should require no further work-up. Following simplified guidelines which should be tailored to each patient individually. Patients with cardiac symptoms including congestive heart failure, prior myocardial infarction, valvular disease, or significant arrhythmias should have a full cardiac work-up prior to an elective ambulatory procedure. This work-up should include evaluation by a cardiologist, ECG, noninvasive studies, and cardiac catheterization, if indicated. The anesthesiologists evaluation prior to surgery is essential in high-risk patients. All patient medications should be taken into account during the preoperative evaluation. Anticoagulants should ideally be stopped five days prior to surgery, unless contraindicated. Aspirin and other antiplatelet agents should be stopped at least 7 to 10 days prior to the proposed surgery. Surgery should be postponed, if possible in a patient with a history of cardiac drug-eluting stents which often requires that

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the patient remain on the antiplatelet agents, especially for the first 9 to 12 months. Or else, a discussion should be undertaken with the cardiologist regarding the discontinuation of these agents prior to surgery. Based on the risks/benefits of the surgery compared with the risks/ benefits of discontinuing these agents, a decision should be made. As many of these agents can cause increased bleeding tendencies. The use of herbal supplements should also be omitted from the patient. Thus, depending on the agent, they often must be discontinued prior to surgery. As the patient will be discharged home postoperatively in ambulatory surgery. A very important aspect of the patient evaluation is preoperative counseling regarding the postoperative expectations. Give the patients as realistic expectations as possible of the level of pain to expect; for example, patients should be told that significant pain should be expected for at least one week after hemorrhoidectomy. All aspects of postoperative recuperation including wound care, bowel regimes, analgesics, and postoperative follow-up should be discussed with the patient. A detailed discussion with the patient prior to ambulatory surgery will lead to a better postoperative experience and faster recovery. Apart from the overall medical evaluation, a dedicated preoperative anorectal assessment is required. Inspection of the anus and perianal area Detailed digital examination Endorectal ultrasonography [in some fistula-in-ano and perianal abscesses] Computerized tomography scan for complete evaluation, especially in patients with Crohns disease or immunosuppressive disorders. Preoperative and/or intraoperative evaluation to determine the fistulous tract in order to guide the optimum surgical approach in patients with anorectal fistula.

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Anorectal ultrasonography with hydrogen peroxide injection through the external opening Magnetic resonance imaging with or without anorectal probe Fistulogram. Intraoperatively, injection of hydrogen peroxide, normal saline, or methylene blue via the external opening will aid in the identification of the internal opening allowing the safe introduction of a fistulous probe through the tract and further direct management of the fistula. An ultimate examination under anesthesia is helpful in some cases of fistula-in-ano [This examination is necessary before surgical intervention, especially if outpatient evaluation causes discomfort or has not helped delineate the course of the fistulous process.]

Anal Manometry
Pressure evaluation of the sphincter mechanism is helpful in certain patients Decreased tone observed during preoperative evaluation History of previous fistulotomy History of obstetrical trauma High trans-sphincteric or suprasphincteric fistula (if known) Very elderly patients If decreased, surgical division of any portion of the sphincter mechanism should be avoided.

Conclusion
The cost-effectiveness of ambulatory colorectal surgery has been well established. Nonetheless, these procedures can only be safely performed after adequate preoperative evaluation and cautious patient selection.

chapter

Constipation

Constipation is not a single disease but a polysymptomatic disorder. Actually it represents many symptoms that affect colonic and anorectal function. Individuals with constipation, in clinical practice present to health care providers when symptoms are sufficiently severe, and to surgeons when first-line, conservative measures have failed. Constipation may result from structural, mechanical, metabolic, or functional disorders that affect the colon or anorectum either directly or indirectly The estimates of the prevalence of constipation are not very precise. Affecting approximately 15% (228%) of the US population, amounting to nearly 40 million Americans, chronic constipation is a common disorder. Also, the number of patients with this condition who seek medical care and the costs of diagnostic tests or treatment are not accurately known. The prevalence of constipation is higher in women than in men. In persons of color And in the elderly. The term constipation most accurately describes a symptom with a variety of definitions. When asked for defining, physicians use frequency of bowel movements to define constipation. Patients however, are more likely to define constipation as: Straining to have a bowel movement A sensation of incomplete evacuation Hard stools or The need for digital maneuvers. Constipation means different things to different people.

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Usually for most individuals, constipation is intermittent and they have a feeling that it requires no or minimal intervention such as fiber supplements or other dietary modifications. On the other hand for some, constipation can be challenging to treat and have a negative impact on quality of life. In such cases it is always advisable to rule out, specific causes of constipation, such as systemic or structural diseases especially in patients presenting with the new onset of constipation. Even though it is acceptable that constipation most commonly results from disorders of function of the colon or rectum. A clear understanding of the pathophysiology of constipation is essential for effective management.

Risk Factors for Chronic Constipation


Advanced age Female sex Nonwhite ethnicity Physical inactivity Low socioeconomic status Low level of education Medications Fluid intake Dietary intake Depression. Lifestyle modifications, if appropriate is the start point in management of chronic constipation, and then followed by therapy with fiber. To treat refractory constipation osmotic and stimulant laxatives, stool softeners, emollients, and enemas are required sometimes. Further options for the treatment of constipation are available in form of newer agents and non-pharmacological approaches.

Definition
A definition that does not address the heterogeneity of symptoms that affect a patient with constipation is not only inaccurate, but also may lead to inadequate management.

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Most people when asked to describe what do they really mean when they say they are constipated there are different explanations provided. Though most individuals are describing a perception of difficulty with bowel movements or a discomfort related to bowel movements. Generally infrequent defecation has usually been used to define constipation. But some equally important and perhaps more common symptoms as: excessive straining, passage of hard stools, or feeling of incomplete evacuation have only recently been recognized. The most common terms used by young healthy adults to define constipation are: 1. Straining 2. Hard stools 3. Inability to have a bowel movement. Because the definition of constipation varies among doctors and other health care providers and in an attempt to standardize the definition of constipation, a consensus definition was developed by international experts in 1992 (Rome I Criteria)and was subsequently revised in 1999 (Rome II Criteria), and lately as Rome III Criteria. By broadening the definition of constipation, more patients can be identified and treated. The recently revised Rome III Criteria address these issues.
Rome I Criteria Two or more of the following for at least 3 months: 1.Straining with >1 of 4 defecations 2.Lumpy or hard stools with >1 of 4 defecations 3.Sensation of incomplete evacuation with >1 of 4 defecations Rome II Criteria At least 12 weeks, which need not be consecutive, in the preceding 12 months of two or more of the following: 1. Straining with >1 of 4 defecations 2. Lumpy or hard stools with >1 of 4 defecations 3. Sensation of incomplete evacuation with >1 of 4 defecations Contd...

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Contd... Rome I Criteria 4.Two or fewer bowel movements in a week Rome II Criteria 4. Sensation of anorectal obstruction or blockage with >1 of 4 defecations 5. Manual maneuvers to facilitate evacuation with >1 of 4 defecations (e.g. digital evacuation, support of the pelvic floor) and/or 6. <3 defecations per week Abdominal pain is not required, loose stools are not present, and there are insufficient criteria for IBS These criteria may not apply when the patient is taking laxatives Loose stools are not present, and there are insufficient criteria for IBS

Rome III criteria primarily define functional constipation on the basis of symptoms alone, whereas dyssynergic defecation is defined both on the basis of symptoms and objective physiological criteria. A combination of: Objective symptoms like stool frequency, manual maneuvers needed for defecation Subjective symptoms like straining, lumpy or hard stools, incomplete evacuation, sensation of anorectal obstruction are used in the Rome III Criteria for constipation.

Epidemiology
Experts in colorectal speciality have come to a consensus, that in the absence of warning symptoms, such as: Weight loss Bleeding Recent change in bowel habit Significant abdominal pain or Secondary causes

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Rome III Criteria for functional constipation Must include 2 or more of the following: Straining during at least 25% of defecations Lumpy or hard stools in at least 25% of defecations Sensation of incomplete evacuation for at least 25% of defecations Sensation of anorectal obstruction or blockage for at least 25% of defecations Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor) Fewer than three defecations per week Loose stools are rarely present without the use of laxatives. There are insufficient criteria for irritable bowel syndrome. Note: Criteria must be fulfilled for the last 3 months, with symptom onset at least 6 months before diagnosis.

Such as drugs Metabolic disorders Colorectal cancer or Local painful lesions, such as anal fissure. Most patients with a complaint of constipation have a functional disorder affecting the colon or anorectum.

Pathophysiology
Importance of Functions of Right and Left Colon
The right colon performs several complex functions that include: Mixing Fermentation and salvage of the ileal effluent Secretion, and desiccation of the intraluminal contents to form stool. The left colon: Serves as a conduit for desiccation More rapid transport of stool. The rectosigmoid region serves as a: Sensorimotor organ that facilitates the awareness Retention Evacuation of stool when socially acceptable.

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These functions are regulated by: Neurotransmitters, such as serotonin, acetylcholine, calcitonin gene-related peptide and substance P Intrinsic colonic reflexes A plethora of learned and reflex mechanisms that govern stool transport and evacuation. Most of these are incompletely understood. Involuntary and voluntary muscle contractions maintain the continence. When stool enters the rectum the involuntary resting tone of the internal anal sphincter decreases. The external anal sphincter is under voluntary control. When stool comes into contact with the mucosa of the lower rectum the urge to defecate is triggered. If an individual does not wish to defecate, he or she tightens the external anal sphincter and squeezes the gluteal muscles. These actions can push feces higher in the rectal vault and further reduce the urge to defecate. If the individual avoids defecating frequently, the rectum eventually stretches to accommodate the retained fecal mass, and the propulsive power of the rectum is diminished. The longer the feces remains in the rectum, the harder it becomes. And ultimately passage of a hard or large stool may cause a painful anal fissure. The cycle of avoiding bowel movements because of a fear of painful defecation may progress to stool retention and infrequent bowel movements, a condition that is termed functional constipation. Most children who present with constipation have functional constipation. Yet not to forget rarely, however, constipation has a serious organic cause. For confident diagnosis of functional constipation, family physicians should be alert for warning signs that may indicate the presence of a pathologic condition.

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Pelvic Floor Dysfunction


In understanding constipation it is essential to realize the importance of the contribution of the pelvic floor to defecation. The functional anatomy of the pelvic floor consists of: The pelvic diaphragm (levator ani and coccygeus muscles) (Fig. 9.1) Anal sphincters. And is innervated by the sacral nerve roots (S24) and pudendal nerve. The efficient elimination of stool from the rectum is the result of normal functioning of this neuromuscular unit. Although the exact prevalence of pelvic floor dysfunction is unknown in constipation, some studies in tertiary care centers have demonstrated a prevalence of as high as 50% and above. Abnormalities of pelvic floor function are frequent in the elderly, especially in older women.

Fig. 9.1: Functional anatomy of the pelvic floor

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Pelvic floor dysfunction is more common in patients with a history of anorectal surgery or other pelvic floor trauma (including childbirth). Pelvic floor dysfunction manifests with disorders of urinary and sexual function apart from its manifestations in defecatory dysfunction. Pelvic floor dysfunction is also more appropriately termed a functional defecation disorder, as it relates to constipation and it can be characterized by: a. Paradoxic contractions or inadequate relaxation of the pelvic floor muscles, or b. Inadequate propulsive forces during attempted defecation. Subcategories of constipation have been identified in some studies. Constipation is classified into two: Either a primary disorder or Secondary to an underlying disease state or medications. To identify and rule out these possible secondary causes. A careful history and physical examination is of paramount importance, though it is not a practical option to discontine causative medications. In general, the prevalence is lowest when the Rome II Criteria for constipation are applied and is highest when constipation is selfreported. The effect of gender, race, socioeconomic status, and level of education on the prevalence of constipation is lower when the Rome II Criteria are used to diagnose constipation. There is no clear understanding for the female predominance. In women with severe idiopathic constipation, reduction in levels of steroid hormones has been observed. It has also been reported that an overexpression of progesterone receptors on colonic smooth muscle cells works to down-regulate contractile G-proteins and up-regulate inhibitory G-proteins.

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Medical causes of secondary constipation Advanced renal disease Central nervous system disorders Neuromuscular disorders Progressive systemic sclerosis Amyloidosis Dermatomyositis Multiple sclerosis Parkinsonism Spinal cord injury Autonomic neuropathy Chagas disease Intestinal pseudo-obstruction Stroke Shy-Drager syndrome Endocrine disorders Hypothyroidism Diabetes mellitus Hyperthyroidism Obstructing lesions Strictures, tumors (benign and malignant) Colon cancer Rectocele or sigmoidocele Stricture Extrinsic compression Anal stenosis Other medical causes Hypokalemia Hypercalcemia Pregnancy Pheochromocytoma Panhypopituitarism Porphyria Heavy metal poisoning (e.g., lead, mercury, arsenic)

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Medications as a cause of chronic constipation Antacids: Calcium-containing antacids and supplements Anticholinergics Antihypertensives: Calcium channel blockers, -agonists Cation-containing agents (e.g. aluminum) Iron salts and supplements Diuretics Opioids and -opioid agonists Resins Calcium channel blockers (e.g. verapamil) 5-hydroxytryptamine3 antagonists Nonsteroidal anti-inflammatory agents (e.g. ibuprofen) Antineoplastic agents (e.g. vinca derivatives)

Constipation in Elderly
In the elderly patients a decrease in stool frequency is not an important cause but constipation in elderly is most commonly the result of excessive straining and hard stools due to any or all of the following causes: Decreased food intake Reduced mobility Weakening of abdominal and pelvic wall muscles Chronic illness Defecatory dysfunction Degenerative disease Dementia Dependence on others for assistance Decreased privacy Dehydration Psychological factors Medications, particularly pain-relieving drugs.

Constipation in Children
Constipation in children usually is functional and the result of stool retention.

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However, it is always wise to be alert for red flags that may indicate the presence of an uncommon but serious organic cause of constipation, such as: Hirschsprungs disease (congenital aganglionic mega colon) Pseudo-obstruction Spinal cord abnormality Hypothyroidism Diabetes insipidus Cystic fibrosis Gluten enteropathy or Congenital anorectal malformation.

Socioeconomic Status
In North America constipation is reported more commonly by nonwhites than whites, where as in rural Africa, constipation appears to be rare. The socioeconomic status of an individual has influence on the prevalence of constipation. Subjects with a lower income status have higher rates of constipation as compared with those who have a higher income. Both men and women of higher socioeconomic status were less likely to report constipation than, were those of lower socioeconomic status. As compared with those who have more education, persons who have less education tend to have an increased prevalence of constipation.

High Fiber Diet


There is adequate data to suggest that increased consumption of fiber decreases colonic transit time and increases stool weight and frequency, though cross-sectional studies have not linked low intake of fiber with constipation. Results from trials designed to test the hypothesis for the protective effect of physical activity on constipation are conflicting, supported by a study in healthy sedentary subjects, where a 9-week program of progressively increasing exercise had

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no consistent effect on whole-gut transit time or stool weight, yet there are other observational studies that support the hypothesis of a protective effect of physical activity on constipation.

Fluid Intake
Dehydration has been identified as a potential risk factor for constipation. The benefit of increased fluid intake has not been investigated thoroughly even then the patients with constipation are advised routinely to increase their intake of fluid.

Medications
Individuals who use certain medications are at a substantially higher risk of constipation. Medications that are considered significantly associated with constipation are: Opioids Diuretics Antidepressants Antihistamines Antispasmodics Anticonvulsants Aluminum antacids In the elderly population, the use of aspirin or other non steroidal anti-inflammatory drugs is associated with a small but significantly increased risk of constipation. After the secondary causes have been ruled out, the primary constipation can be classified into the following: Normal transit Slow transit Pelvic floor dyssynergia or dysfunction Irritable bowel syndrome (IBS) with constipation.

Normal-Transit Constipation
The stool in normal-transit constipation, travels along the colon at a normal rate. Most important feature is incomplete evacuation.

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Though not a predominant feature, abdominal pain may be present. These patients often exhibit psychosocial distress and may have a misperception about their bowel frequency. Though some patients do have abnormalities of anorectal sensory and motor function which cannot be clearly distinguished from those in patients with slow-transit constipation. The debatable issue is: whether increased rectal compliance and reduced rectal sensation are effects of chronic constipation or if these factors contribute to the failure of the patients to experience an urge to defecate. The majority of patients have normal physiologic testing. Abdominal pain is the predominant symptom in IBS and this symptom differentiates IBS with constipation from normaltransit constipation.

Slow-Transit Constipation
Although, recent studies have shed more light. The pathophysiology of constipation continues to evolve, because colonic motor activity is intermittent, variable, and influenced by sleep, waking, meals, physical and emotional stressors, and differences in regional colonic motor function. Slow-transit constipation is most common in young women and is characterized by infrequent bowel movements (less than one bowel movement per week). Associated symptoms include abdominal pain, bloating, and malaise. Symptoms are often intractable, and usually do not respond to conservative measures such as fiber supplements and osmotic laxatives. The onset of symptoms is gradual and usually occurs around the time of puberty.

Characteristic Features
1. Infrequent stools (e.g. 1 a week). 2. Lack of urge to defecate.

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3. Generalized symptoms, including malaise and fatigue. 4. More prevalent in young women. 5. Retention in the colon of >20% of radiopaque (Sitz) markers 5 days after ingestion. Slow-transit constipation arises from disordered colonic motor function. Three levels of spectra are identified for this type of constipation: Patients who have mild delays in colonic transit have symptoms similar to those seen in IBS. The pathophysiology includes delayed emptying of the proximal colon and fewer HAPCs after meals, in patients with more severe symptoms. Patients with symptoms at the severe end of the spectrum suffer from what is known as colonic inertia. In these individuals, after a meal, after ingestion of bisacodyl, or after administration of a cholinesterase inhibitor such as neostigminecolonic motor activity fails to increase.

Patients with Slow-Transit Constipation


Significant impairment of phasic colonic motor activity both in stationary and in prolonged 24-hour ambulatory colonic motility recordings. The gastrocolonic responses following a meal and the morning waking responses after sleep are also significantly diminished. The diurnal variation of colonic motor activity is preserved. In contrast, periodic rectal motor activity significantly increases in patients with slow transit constipation. Periodic motor activity is a three-cycles-per-minute activity that predominately occurs in the rectum and rectosigmoid region and is invariably seen at night time. This excessive uninhibited distal colonic activity may serve as a nocturnal break and retard colonic propulsion of stool. The high amplitude, prolonged duration, propagated contractions (HAPCs) are significantly decreased in constipated patients. The velocity of propagation is slower, waves have a greater tendency to abort prematurely, and their amplitude is also decreased.

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There is decreased colonic tone and phasic responses to a meal. Slow transit constipation may also be associated with autonomic dysfunction. Several recent studies have demonstrated a paucity of interstitial cells of Cajal, suggesting the possibility of an underlying neuropathy in these individuals. Occasionally, slow transit constipation may be associated with a more generalized dysmotility and forms part of a pseudoobstruction syndrome. The colonic absorptive function seems to be relatively well preserved in patients with constipation, yet there are hypothesis supporting the fact that excessive absorption of water from stool may desiccate colonic contents. The reason being constipation is associated with hard stools. Because, more women than men in younger adults, seek medical help for constipation, suggests a possible role for endocrine or hormonal imbalance. Though it has not been confirmed, a decreased level of ovarian and adrenal steroid hormones has been reported. In fact, routine estrogen and progesterone levels are not impaired in most women with constipation. Again, the relationship between menstrual cycle and gut transit remains controversial. Both slower transit during the luteal phase and normal transit have been reported. A decrease in vasoactive intestinal polypeptide levels and an increase in serotonin levels in the circular muscle have been reported. G-proteinmediated smooth muscle contractility: Women with slow transit constipation show down-regulation of progesterone-dependent contractile G proteins and upregulation of inhibitory G proteins when compared with those from nonconstipated controls. These changes were probably due to an overexpression of progesterone receptors. This fact offers some mechanistic insights as to why women are more prone to constipation.

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Pelvic Floor Dyssynergia or Dysfunction or Defecatory Disorders


These type of defecatory disorders are also known as anismus, dyssynergia, pelvic floor dyssynergia, spastic pelvic floor syndrome, descending perineum syndrome, obstructive defecation, or outlet obstruction (Box 8.1).

Characteristic Features
Frequent straining Incomplete evacuation Need for manual maneuvers to facilitate defecation Abnormal balloon expulsion test and/or rectal manometry Because of an inability to coordinate the abdominal, rectoanal, and pelvic floor muscles, result in failure to empty the rectum effectively, defecatory disorders arise. Quite some patients with defecatory disorders also have slowtransit constipation These disorders appear to be acquired and may start in childhood. In the setting of active anal fissures or inflamed hemorrhoids, there may be a learned behavior to avoid some discomfort
BOX 8.1: Criteria for dyssynergic defecation A. Patients must fulfill the symptomatic criteria for functional con stipation as defined in above. B. Constipated patients must fulfill two or more of the following physiologic criteria: 1. Dyssynergic or obstructive pattern of defecation which is defined as paradoxical increase of anal sphincter pressure or less than 20% relaxation of the resting anal sphincter pressure during attempted defecation, with or without an increase in intrarectal pressure. 2. Inability to expel a balloon or stool-like device, such as a fecom, within 3 minutes. 3. A prolonged colonic transit time (i.e. > 5 markers on a plain abdominal radiograph taken 120 hours after ingestion of one sitzmark capsule containing 24 radiopaque markers). 4. Inability to expel barium or greater than 50% retention during barium defecography.

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associated with the passage of large hard stools or pain associated with attempted defecation. Patients with defecatory disorders commonly have inappropriate contraction of the anal sphincter, when they bear down. This phenomenon can occur in asymptomatic subjects, even though it is more common among patients who complain of difficult defecation. Some patients with a defecatory disorder are unable to raise intrarectal pressure to a level sufficient to expel stool. A disturbance that manifests clinically as failure of the pelvic floor to descend on straining. Defecatory disorders are particularly common in: Elderly patients with chronic constipation Excessive straining. Most of these patients do not respond to standard medical treatment. Rarely Defecatory disorders are associated with structural abnormalities such as: Rectal intussusception Obstructing rectoceles Megarectum or Excessive perineal descent. Patients with defecatory disorders may report: Infrequent bowel movements Ineffective and excessive straining The need for manual disimpaction. However, symptoms, do not correlate with physiologic findings, particularly in the case of pelvic floor dysfunction. A Rome working group specified criteria that is listed below, is used as a guideline for a diagnosis of pelvic floor dyssynergia. The patient should have atleast two of the mentioned symptoms for more than 12 weeks in last 12 months to label it as defecatory disorder. In patients with this disorder, as determined by physiologic tests, constipation is functional and caused by dysfunction of the pelvic floor muscles.

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Despite the presence of adequate propulsive forces in the colon and rectum. Pelvic floor dyssynergia accounts for incomplete evacuation.

Functional Fecal Retention


Functional fecal retention (FFR) is the most common defecatory disorder in children. It is a learned behavior that results from withholding defecation, often because of fear of a painful bowel movement. The symptoms are common and may result in secondary encopresis (fecal incontinence) because of leakage of liquid stool around a fecal impaction. FFR is the most common cause of encopresis in childhood.

Irritable Bowel Syndrome (IBS) with Constipation


Unfortunately neither has a clear cut etiology, eventhough both irritable bowel syndrome (IBS) and chronic constipation are disorders of recurrent colonic symptoms. IBS is a common disorder of the intestines with characteristic symptoms, such as abdominal pain, bloating, and mucus in feces.

Rome II Criteria for pelvic floor dyssynergia Straining with greater than one-fourth of defecation Lumpy or hard stool with greater than one-fourth of defecation Sensation of incomplete evacuation with greater than one-fourth of defecation Sensation of anorectal obstruction or blockage with greater than one-fourth of defecation Manual maneuvers to facilitate greater than one-fourth of defecation Fewer than three bowel movements per week Insufficient criteria for irritable bowel syndrome: Manometric, EMG, or radiologic evidence for inappropriate contraction of or failure to relax pelvic floor muscles during defecation Evidence of adequate propulsive force during attempts to defecate Evidence of incomplete evacuation Criteria for functional constipation

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The symptoms in IBS are produced by altered motility, abnormal visceral sensation, and psychosocial factors. It is really difficult for clinicians to distinguish between IBS and chronic constipation, because IBS can cause chronic constipation.

Characteristic Features
Abdominal pain With or without bloating With altered bowel habit These subjects may or may not have slow transit or dyssynergia.

Constipation in Pregnancy
Constipation during pregnancy is attributed to somewhat inhibited gastrointestinal motility during this period. This inhibition may directly promote constipation or in-directly exacerbate underlying disorders of bowel habits. Hormones, particularly progesterone, decrease smooth muscle contractility and slow gastrointestinal transit.

Factors Contributing to Constipation D uring Pregnancy


Dietary
Poor fluid intake with nausea and vomiting Iron supplements.

Behavioral
Decreased physical activity Psychosocial stress.

Hormonal Changes (Slowed Gastrointestinal Transit)


Increased progesterone Increased estrogen Decreased motilin.

Other
Enlarging gravid uterus Painful hemorrhoids.

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Evaluation of an Individual with Constipation


Clinical Features
Expression and perception of the term constipation varies from individual to individual, as a result it becomes very important to determine exactly what the patient means when he or she reports constipation. Constipated patients present with a constellation of symptoms that include: 1. A feeling of incomplete evacuation 2. Excessive straining 3. Passage of hard, pellet-like stool 4. Digital disimpaction or vaginal splinting 5. A lump-like sensation or 6. Blockage in the anal region 7. Apart from these the patients may report infrequent defecation 8. Often less than three bowel movements per week 9. Abdominal or anorectal discomfort 10. Pain 11. Bloating. Some patient have to use digital maneuvers to disimpact stool, but because of the social stigma the patients may misrepresent their symptoms or may feel embarrassed to admit the use of digital maneuvers to disimpact stool. Anyway a healthy doctor-patient relationship full of trust can encourage the patient to reveal the history and help in establishing the nature of bowel dysfunction. Another method of coming to a conclusive bowel dysfunction is through the use of symptom questionnaires or stool diaries. A detailed history for the following: 1. The nature of the problem 2. Precipitating events 3. The duration and severity of the problem

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4. Its onset, whether from childhood or following surgery 5. Frequency of bowel movements 6. Associated symptoms such as abdominal discomfort and distention 7. An assessment of stool consistency 8. Stool size 9. Degree of straining during defecation may all prove beneficial. The presence of warning symptoms or signs, such as un intentional weight loss, rectal bleeding, family history of colon cancer, change in the caliber of the stool, and severe abdominal pain, should be elicited. A long duration of symptoms that have been refractory to conservative measures is suggestive of a functional colorectal disorder. In contrast, the new onset of constipation may indicate a structural disease. Physicians should always evaluate the patient for a structural disease in this situation. The history should not miss any of these important details: 1. An assessment of stool frequency 2. Stool consistency 3. Stool size 4. Degree of straining during defecation 5. A history of ignoring a call to stool. The Bristol Stool Scale not only correlates with transit time but is also the best descriptor of stool form and consistency, thus is an invaluable tool in the assessment of constipation. A history regarding the diet of the patient should include: 1. An assessment of the amount of fiber and fluid intake 2. The number of meals 3. When they are consumed. A common observation in many patients is that they tend to skip breakfast as a result of the early morning rush. This can be hazardous in the sense that skipping breakfast and not devoting time toward bowel function in the morning may

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deprive the colon of an important physiological stimulus because there is a two to threefold increase in colonic motility after waking and after a meal. The laxative dependence history should also include: 1. The number and type of laxatives 2. Frequency of their use 3. A family history of using laxatives 4. A family history of bowel dysfunction. As these are very important. Obstetrical, surgical, and drug history is also useful. A history of back trauma or neurological problems may provide additional clues regarding the etiology of constipation. In the elderly, fecal incontinence may be a presenting symptom of stool impaction. However, symptoms alone do not appear to differentiate constipated patients into the three common pathophysiologic subgroups. There are studies which have evidently shown that: Two or fewer stools per week, laxative dependency, and constipation since childhood were associated with slow transit constipation. Backache, heartburn, anorectal surgery, and a lower prevalence of normal stool frequency were reported by patients with pelvic floor dysfunction. To know why the patient has sought help for constipation at this point in time. A detailed social history may provide useful information. Potentially relevant behavioral background information also may be obtained. The frequency of a history of sexual abuse is increased as compared with healthy controls, in patients with IBS. It has been justified that symptoms are good predictors of transit time, but poor predictors of pelvic floor dysfunction. As a result symptom assessment should be combined with objective testing to better assess the nature of a patients complaint. Constipation symptoms seem to differ in the elderly, from those observed in younger populations, with the elderly reporting:

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More frequent straining Self-digitation Feelings of anal blockage Fecal seepage [This is usually an underappreciated condition that is frequently misdiagnosed as fecal incontinence.]. Patients often have a history of constipation with the sensation of poor rectal evacuation with frequent, incomplete bowel movements and excessive wiping. They commonly present with anal pruritus and staining of their undergarments. In the infirmed fecal impaction and overflow incontinence may be associated findings. Though, the problem is one of obstructed defecation than true incontinence. Especially in those with altered cognitive function, a thorough history and examination are essential. Fecal impaction in addition to fecal seepage and incontinence, can lead to stercoral ulceration and bleeding. In addition to urinary and sexual dysfunction, chronic constipation may be associated with pelvic floor laxity and accompanying rectal prolapse. Suppression of defecation has been shown to slow gastric emptying and right colon transit. Patients with chronic constipation have been shown to have prolonged mouth-to-cecum transit time. It follows that reflex slowing of more proximal gut function can precipitate symptoms. Constipated patients do have an increase in dyspepsia, abdominal cramping, bloating, flatulence, heartburn, nausea, and vomiting.

1. 2. 3. 4.

Physical Examination
Rather than focusing on set criteria, it is important to establish the patients understanding and characterization of what constipation means to them. Various strategies for the initial diagnosis and treatment of constipation have been employed.

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To exclude major central nervous system disorders, especially spinal lesions, the general physical examination should be done minutely. The sacral dermatomes should be examined for loss of sensation, if spinal disease is suspected. Few Medical causes like hypothyroidism, parkinsonism, or depression are reflected in the patients general appearance or voice. The abdomen should be examined for distention, hard feces in a palpable colon, or an inflammatory or neoplastic mass. If the abdomen appears distended, a hand should be passed under the lumbar spine while the patient is lying supine to exclude anterior arching of the lumbar spine as a cause of postural bloating. The rectal examination is paramount in evaluating a patient with constipation. The left lateral position is most convenient for performing a thorough rectal examination. Painful perianal conditions and rectal mucosal disease should be excluded, and defecatory function should be evaluated. First, the perineum should be observed both at rest and after the patient strains as if to have a bowel movement. Normally, the perineum descends between 1 and 4 cm during straining. Descent of the perineum below the plane of the ischial tuberosities usually suggests excessive perineal descent, with the patient in the left lateral position (i.e. >4 cm). Excessive perineal descent may indicate descending perineum syndrome, whereas a lack of descent may indicate the inability to relax the pelvic floor muscles during defecation. Because of lack of straightening of the anorectal angle. Patients with descending perineum syndrome strain excessively and achieve only incomplete evacuation. Previous childbirth or excessive straining usually results into excessive laxity or descent of the perineum. Excessive descent of the perineum causes stretching and may result in injury to the sacral nerves, which leads to reduced rectal sensation. Ultimately what results is incontinence from sacral nerve denervation.

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When the patient is asked to strain rectal prolapse may be detected. The rectal area should be examined for scars, fistulas, fissures, and external hemorrhoids. Not to forget, a digital per rectal examination should be performed to evaluate the patient for the presence of a fecal impaction, anal stricture, and rectal mass. A patulous anal sphincter may suggest prior trauma to the anal sphincter or a neurologic disorder that impairs sphincter function. Elevated anal sphincter pressure is suggested specifically if there is inability to insert the examining finger into the anal canal and pelvic floor spasm if there is tenderness on palpation of the pelvic floor as it traverses the posterior aspect of the rectum. The degree of perineal descent can be assessed from the amount of descent of the perineum during attempts to strain and expel the examining finger while performing a digital rectal examination. Most secondary causes of constipation can be excluded by a thorough history and physical examination. Table 9.1 gives a list of other important functions that should be assessed during the digital examination.

Diagnostic Tests
Investigations may be indicated when the symptoms are unresponsive to simple treatment, to exclude a systemic illness or structural disorder of the gut as a cause of constipation and to elucidate the underlying pathophysiologic process. 1. Measurement of the hemoglobin level 2. Erythrocyte sedimentation rate 3. Thyroid function 4. Serum calcium 5. Serum glucose In some cases [If there is a high index of suspicion]: 1. Serum protein electrophoresis 2. Urine porphyrins 3. Serum parathyroid hormone 4. Serum cortisol

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Table 9.1: Assessment protocol for evaluation of patient with constipation Assessment protocol for evaluating patient with constipation History Prolonged straining to pass stool Assuming different unusual postures on the toilet to facilitate stool expulsion Manual evacuation, support of the perineum, or application of pressure to the posterior vaginal wall to disimpact stoll Inability to expel enema fluid at will Constipation after subtotal colectomy for constipation Obstetric and surgical histories are particularly important A carefully taken drug history A detailed social history Digital per rectal examination (with patient in left lateral position). Inspection While attempting to simulate strain during defecation anus is pulled forward During attempts to simulate straining at defecation the anal verge descends <1 cm or >4 cm (or beyond the ischial tuberosities) Rectal mucosa partially prolapses through anal canal and perineum balloons down during straining. Palpation In absence of a painful perianal condition such as an anal fissure. High resting anal sphincter tone precludes easy entry of examining finger Anal sphincter pressure during voluntary squeeze is minimally higher than anal tone at rest During simulated straining at defecation, perineum and examining finger descend <1 cm or >4 cm Puborectalis muscle is tender to palpation through the rectal wall posteriorly, or palpation reproduces pain Defect in anterior wall of the rectum and palpable mucosal prolapse during straining, suggestive of rectocele. Anorectal manometry and balloon expulsion (with patient in left lateral position) Average resting anal sphincter tone >80 cm water (>59 mm Hg) Average anal sphincter squeeze pressure >240 cm water (>177 mm Hg) Failure of balloon expulsion from rectum despite addition of 200 g weight to the balloon.

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5. Assessment of colonic transit [Normal transit: Less than five markers remaining in the colon Slow transit: Six or more markers scattered throughout the colon Functional obstructive or dyssynergic defecation pattern: Six or more markers in the rectosigmoid region with a near normal transit of markers through the rest of the colon.] 6. A plain radiograph of the abdomen 7. A barium enema study 8. A flexible sigmoidoscopy or 9. A full colonoscopy 10.  Per rectum examination: Per rectal examination is best done with the patient in the left lateral position, and following evaluations are of clinical significance (Fig. 9.2): a. Presence of spasm and resting sphincter tone b. Sensation, including the presence of pain c. The ability to squeeze

Fig. 9.2: Per rectal examination/Digital rectal examination

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11.

12.

13.

14. 15. 16. 17.

d. Coordination of the pelvic floor and rectal muscles and extent of perineal descent during simulated defecatory straining (best judged by expelling the examiners finger). Anal manometry: Average tone of anal sphincter at rest of greater than 60 mm Hg (or >80 cm water). Average pressure of anal sphincter during contraction of greater than 180 mm Hg (or >240 cm water). Balloon expulsion test: Failure to expel balloon, Provides measurements that relay key information about the motor and sensory control of the anorectum and pelvic floor. Simulated defecation: It allows assessment of synergy and propulsive force. Rectoceles are common but may be considered clinically significant if they fill preferentially or fail to empty during simulated defecation. Defecography: Attempts to identify any anatomic or functional abnormalities that may contribute to outlet obstruction. Histology to rule out Hirschsprungs disease. Electromyographic testing of striated muscle activity. Rectal sensitivity and sensation testing.

Management of Constipation
Essential in management of constipation are the following: No single agent or management protocol is best for all patients or situations. The rst step is to exclude a secondary cause for constipation. Treatment needs to be tailor made not only to the cause, but to medical history, medications, overall clinical status, mental and physical abilities, tolerance to various agents, and realistic treatment prospects.

Reassurance
The upbringing of some people makes them believe that a daily bowel movement is essential for health. Even media paper or electronic play an important role in helping patients derive this opinion from advertisements. This belief generated by any means makes the patient start worrying if their bowel habit is irregular or less frequent.

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Through a healthy counseling, they can be assured by being told that an irregular bowel habit and other defecatory symptoms are common in the healthy general population and that their symptoms are not harmful. Such reassurance may be all that some might need. For those patients who are concerned that their symptoms may indicate disease, may be helped by appropriate investigation to relieve their fear.

Lifestyle Modifications
Lifestyle modifications like encouraging patients to avoid postponing defecation. Asking the patient to monitor bowel habits by means of a daily diary of bowel frequency and characteristics. Observe if there are any abdominal symptoms. Stress should be given on the necessity to set aside a relaxed and, if possible, regular time for defecation and always to respond to a defecatory urge. Advise to place a support of around six inches in height under the feet when sitting on a toilet seat to simulate a squatting position with flexed hips to all patients experiencing difficulty in expulsion of stool. Activity should be encouraged to persons with an inactive lifestyle, and the use of constipating drugs should be avoided.

Fluid Intake
Against the common belief that regularised fluid intake corrects constipation, there are no data to support the idea that increasing fluid intake improves constipation. Dehydration or salt depletion generally leads to increased salt and water absorption by the large intestine, and in turn leads to the passage of small, hard stools. Unless a person is clinically dehydrated fluid correction plays little role in day-to-day practise, even though dehydration is generally accepted as a risk factor for constipation. In the elderly dietary patterns, a sedentary lifestyle, and inadequate fluid intake may contribute to the risk of constipation.

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Though except in patients who are dehydrated, increases in fluid intake and physical activity do not appear to relieve constipation.

Exercise
The fact that most patients who have a normal bowel pattern usually empty stools at approximately the same time every day, suggests that the initiation of defecation is in part a conditioned reex. To encourage patients to establish a regular pattern of bowel movement, ritualizing bowel habit may be useful and advisable. Colonic motor activity is more active after waking and after a meal. Usually within the rst 2 hours after waking and after breakfast. Is the optimal time for bowel movement. Timed toilet training: Other general measures include timed toilet training: The patient should be educated to attempt a bowel movement at least twice a day Usually 30 minutes after meals and to strain for no more than 5 minutes. Patients must be instructed to push at a level of 5 to 7 during attempted defecation, and should be warned against exceeding straining above maximum recommended level of 10. The physiologic events that stimulate colonic motility, such as waking and the postprandial gastrocolonic responses should also be encouraged in these type of constipated patients.

Dietary Modifications
There is a well documented study which documents that a deficiency in dietary fiber was contributing to constipation and other colonic diseases in Western societies. A strong clinical observation is that when nonconstipated persons increase their intake of dietary fiber, stool weight increases in proportion to their baseline stool weight and frequency of defecation and correlates with a decrease in colonic transit time.

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Every gram of wheat fiber ingested yields approximately 2.7 g of stool expelled. With increased fiber input, bowel frequency increases from a mean of two to three bowel movements weekly. Dietary fiber appears to be effective in relieving mild to moderate, but not severe, constipation. There is apparently no response of dietry fiber if severe constipation is associated with slow colonic transit, evacuation disorders, or medications. Although dietary modification may not succeed, all constipated subjects should be advised initially to increase their dietary fiber intake as the simplest, most physiologic, and cheapest form of treatment. Patients should be encouraged to take about 25 g of dietary fiber daily by eating whole wheat bread, unrefined cereals, plenty of fruit and vegetables, and, if necessary, a supplement of raw bran, either in breakfast cereals or with cooked foods. Specific dietary counseling often is needed to achieve a satisfactory increase in dietary fiber. Review all medications, both over-the-counter and prescribed. Substitute medicines that are likely to cause constipation, Wherever possible, with alternative medications. An important step in managing constipation is to exclude a secondary cause for constipation. The first line of management should be based on non pharmacologic interventions. Pharmacologic agents may be employed only if these measures fail. Initial treatment should include biofeedback, If a defecatory disorder is present; as up to 75% of patients with disordered evacuation respond to biofeedback Many patients do not respond well to fiber supplementation or oral laxatives The initial treatment should include increased fluid, exercise, and intake of fiber, either through changes in diet or commercial fiber supplements.

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Patients who do not improve with fiber should be given an osmotic laxative, such as milk of magnesia or polyethylene glycol. The dose of the osmotic laxative should be titrated until soft stools are attained. Stimulant agents, such as bisacodyl or senna derivatives, should be reserved for patients who do not respond to fiber or osmotic laxatives. Evidence-based treatment of constipation and encopresis Conventionally and typically consists of four components: Education Disimpaction Maintenance therapy (preventing the reaccumulation of stool) Behavioral treatment. Elective education is an important first step in treatment as a truly holistic approach to constipation and encopresis must engage the child and establish his or her personal interest in and motivation for resolving this condition.

Laxatives
The mainstay of treatment for constipation still remain the Laxatives, World Over millions are spent on over-the-counter laxatives. Laxatives are commonly classied on the mode of their action. Laxatives are classified into four groups: 1. Bulk forming laxatives This category refers to laxatives which help form bulky stools and promote peristalsis in the colon for easier passage of stools. Bulk forming laxatives are indigestible, hydrophilic colloids They may be natural or synthetic. 2. Stool softeners This category also referred to as lubricant laxatives soften the stools for easier passage. They are available in the form of pills, liquids, suppositories and enemas.

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Fecal softeners can be divided into: Lubricants Surfactant agents. 3. Osmotic laxatives: Osmotic laxatives are soluble nonabsorbable compounds that enter in the substance of stools, exert osmotic pressure and increase fluid content of stools leading to softening and increased bulk. 4. Stimulant laxatives They stimulate intestinal motility: Although there are a variety of preparations, including several over-the-counter compounds, the laxatives that are frequently recommended include milk of magnesia, lactulose, senna compounds, bisacodyl, and polyethylene glycol (PEG) preparations.

Bulk Forming Laxatives


Patients should be instructed to increase fiber intake to 20 to 30 g daily, accomplished with dietary adjustments, and supplements. A fiber supplement is generally added in western diet, Because this is hard to accomplish on a Western diet. Patients should increase the dose of fiber slowly over several weeks to prevent gas and bloating. Maintaining adequate fluid intake is essential with fiber supplementation to avoid excessive bulk, which inturn may exacerbate chronic constipation, even though increasing water intake on its own has not been shown to improve constipation. The ultimate goal to be achieved is a well-formed, softer stool that is easier to pass. In patients with cardiac or renal disease, fluid intake needs to be monitored, and the need to maintain adequate hydration may be a limitation for some. Empiric fiber supplementation is a common and reasonable first step in the management of chronic constipation, even though there is little to no relationship between dietary fiber intake and whole gut transit time.

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Increasing the dose of fiber carefully over several weeks to a month may lessen common side effects (bloating, gas, and distention) and enhance compliance. Synthetic supplements are often tolerated better than others. Patients with severely delayed colonic transit respond poorly to dietary fiber.Trials looking at bulking agents are of suboptimal design and most are plagued by small sample sizes and short study duration.

Specific Agents
Ispaghula (Psyllium husk): Ispaghula is derived from the husks of an Asian plant, specific characteristics include: It has very high water-binding capacity It is fermented in the colon to a moderate extent It increases bacterial cell mass.

Formulations
It is available in different forms like effervescent suspensions, granules, and a powder individually or in combination with other natural ingredients. Most easily available are the suspensions, these need to be drunk quickly before the husk absorbs water. The granules may be stirred briskly in a half a glass of water and swallowed at once; carbonated water may be preferred. Some people like to swallow the solid granules and then drink a glass of water.

Mechanism of Action
Ispaghula has been shown to increase fecal bulk to the same extent as methylcellulose 1 to 4 g daily in constipated subjects. The total weekly weights have found to remain less than those of a healthy control group without treatment, Although both dry and wet stool weights have been found to increase. Recommended in doses of 15 to 30 g daily, for a period of at least 6 weeks. Most patients without abnormal physiologic testing results improved or became symptom free.

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The response to treatment in patients with slow colonic transit or a disorder of defecation is relatively poor. Though rare but in some patients Ispaghula taken by mouth can cause an acute allergic response, with facial swelling, urticaria, tightness in the throat, cough, and asthma. Methylcellulose: Methylcellulose is a semisynthetic product. Methylcellulose is available as a liquid or as 500 mg tablets and the recommended dose is up to 3 g twice daily taken with plenty of water. Guar gum: Guar gum is a natural high-molecular-weight poly saccharide that is extracted from the seeds of a shrub. It hydrates rapidly to form a highly viscous solution.

Osmotic Laxatives
Magnesium sulfate, and magnesium phosphate compounds: Because of poor absorbtion by the gut, magnesium, sulfate, and phosphate ions create a hyperosmolar intraluminal environment. Their primary mode of action appears to be osmotic. Regular use of magnesium hydroxide has been found to be a useful and safe laxative, in mildly constipated patients. Recommended doses of magnesium hydroxide contain 40 to 80 mmol of magnesium ion. Onset of action: Produces a bowel movement within 6 hours. Magnesium sulfate is a more potent laxative but has an inherent drawback that it tends to produce a large volume of liquid stool, as a result patients may complain about this compound.

Adverse and Side Effects


Abdominal distention Sudden passage of a liquid foul-smelling stool Flatulence, abdominal cramps, and magnesium toxicity in elderly patients In children and in patients with renal failure hypermagnesemia can occur Rarely complications induced by hypermagnesemia like paralytic ileus, and hypermagnesemia with coma have been noted, specially the later one in children.

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Lactulose: Lactulose is a nonabsorbable synthetic disaccharide. It consists of a bond linking galactose and fructose which is resistant to lactase. Because of the above-mentioned bond lactulose is not absorbed by the small intestine but undergoes fermentation in the colon to yield: Short chain fatty acids Hydrogen Carbon dioxide. Resulting into lowered fecal pH. When taken in larger doses, some amount of sugar passes though the colon without any changes and acts as an osmotic laxative. For adults the recommended dose of lactulose is 15 to 30 ml to be taken once or twice a day. Compared with that for other osmotic laxatives, the onset of action is longer and it usually takes 2 to 3 days for lactulose to achieve a desired effect. Because the gut flora is altered in response to the medication, Some patients may report that lactulose loses its effect after the initial effect. Adverse effects related to lactulose include abdominal distention or discomfort, presumably as a result of colonic gas production. Cases of lactulose-induced megacolon have been reported. In a group of young, chronically constipated volunteers who reported fewer than three stools a week, lactulose increased bowel frequency and percentage of stool moisture and softened the stools compared to a control syrup that contained only sucrose. The effectiveness of lactulose was dose dependent. The effect of lactulose among elderly patients has been studied in two double-blind, placebo-controlled trials. In one trial, only about one half of the patients were found to be truly constipated and among these patients, lactulose was successful in 80%, as compared with 33% of those who received placebo (glucose) (P <.01). The second trial was conducted in a nursing home over 8 to 12 weeks in 42 elderly patients with constipation.

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The initial dose of lactulose was 30 ml/day, and the dose was reduced temporarily or permanently to 15 ml depending on bowel frequency. Lactulose showed an advantage over placebo (a 50% glucose syrup) by increasing the mean number of bowel movements each day and markedly reducing episodes of fecal impaction (P <.015) and the need for enemas. Sorbitol: Sorbitol is as effective as lactulose and less expensive. Recommended dose is 21g/day Lactulose and sorbitol are apparently and comparatively equally efficient as far as frequency or normality of bowel movements or patient preference are concerned. Except for nausea, which was more common with lactulose, the frequency of side effects is similar. Polyethylene glycol: Used in day-to-day practice to prepare the bowel for colonoscopy and other diagnostic examinations and surgery on colon, polyethylene glycol (PEG) has also been promoted as a safe and effective treatment for chronic constipation. The main characteristic of this molecule is that: It is an iso-osmotic laxative It is metabolically inert It is not metabolized by colonic bacteria Able to bind water molecules Increase intraluminal water retention It is excreted unchanged in the feces. To prepare the colon for diagnostic examinations or surgery. Solutions containing PEG and electrolytes are administered orally. For regular use to treat constipation, PEG (with electrolytes) is also available as a powder that is mixed in smaller doses with water. Polyethylene glycol (PEG) leads to an increase in stool volume and softer stools, depending on the volume of PEG consumed stool may become liquid. To avoid the potential adverse effects associated with drinking large volumes of a fluid, such as dehydration and electrolyte imbalance, electrolytes are added to PEG solutions that are used for colonic lavage before colonoscopy.

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The efficacy of PEG in the treatment of chronic constipation has been demonstrated in several studies. The following effects of PEG treatment have been observed on bowel functions: Bowel frequency increases to normal Hard stools are uncommon Most patients get their first stool within one day of initiating PEG treatment Stool consistency relatively improves Straining on defecation was experienced by fewer patients, as compared before treatment. The lowest dose of PEG produced the most normal stool consistency, whereas higher doses produced more liquid stools. Low-dose PEG appears to be more effective than lactulose in the treatment of chronic constipation. Polyethylene glycol (PEG) is a potentially useful treatment for chronic constipation in children, provided that the dose is adjusted to the childs age and is approved by the FDA. Polyethylene glycol (PEG) solutions have also been advocated for the short-term treatment of fecal impaction. The treatment is highly effective, and most patients pass moderate or large volumes of soft stool, with resolution of impaction. Successful treatment with PEG has been described: In outpatients with refractory constipation The elderly (with administration of PEG by mouth or a nasogastric tube) Children with fecal impaction, although children have had difficulty drinking the large volume of fluid.

Adverse Side Effects


Though the medication is generally well tolerated, difficulty in drinking large volume of fluids, and taste are limiting factors. Except for abdominal rumbling, abdominal bloating and cramps no other major adverse side effects have been known. Cases of fulminant pulmonary edema have been reported after administration of PEG solution by nasogastric tube.

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Polyethylene glycol (PEG) also may delay gastric emptying.

Stimulant Laxatives
Stimulant laxatives work by: Stimulating intestinal motility By increasing intestinal secretion. Typically they begin working within hours and often are associated with abdominal cramps. Stimulant laxatives include Anthraquinones (e.g. cascara, aloe, and senna) Diphenylmethanes (e.g. bisacodyl, sodium picosulfate, pheno lphthalein). Castor oil is used less commonly because of its side-effect. The effect of stimulatory laxatives is dose dependent: Low doses prevent absorption of water and sodium On the other hand high doses stimulate secretion of sodium, followed by water, into the colonic lumen. There is a wide variation in clinical effectiveness, and some patients with severe constipation are not helped by stimulant laxatives. Even though at high doses stimulatory laxatives have only a minimum effect on calorie absorption, they are sometimes abused, especially in patients with eating disorders. Cathartic colon (i.e. colon with reduced motility) has been attributed to prolonged use of stimulant laxatives. As a matter of fact, cathartic colon described in patients undergoing barium enema is more likely, a primary motility disorder. However, stimulant laxatives are well tolerated if used in doses that produce normal, soft, formed stools. They are particularly suitable for use in a single dose for temporary constipation, as they act rapidly. Recommending indefinite daily dosing of stimulant laxatives for chronic constipation is advocated only with great caution. Large doses produce abdominal cramping and liquid stools.

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Anthraquinones: Anthraquinones are produced by a variety of plants, to name a few cascara, senna, aloe, and frangula. The compounds are inactive glycosides that, pass down the small intestine, unabsorbed and unchanged when ingested, and are hydrolyzed by colonic bacterial glycosidases to generate active metabolites. These active metabolites: Increase the transport of electrolytes into the colon Stimulate myenteric plexuses to increase intestinal motility. After an oral dose the anthraquinones induce defecation within 6 to 8 hours. A condition described as pseudomelanosis coli has been reported with anthraquinones, the pathogenesis is that anthraquinones cause: Apoptosis of colonic epithelial cells These are then phagocytosed by macrophages and Appear as a lipofuscin-like pigment That in turn darkens the colonic mucosa. There is no documented evidence on the long-term usage of anthroquinones causing any adverse functional or structural changes in the intestine. An association between use of anthraquinones and colon cancer or myenteric nerve damage leading to the development of cathartic colon has not been established. Senna: The mechanism of action is: By softening stools Increasing stool frequency Wet and dry weight. Available for clinical usage in different forms like: Crude vegetable preparations Purified and standardized extracts Synthetic compound. Castor oil: Castor oil is prepared from the castor bean. After oral ingestion:

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In the small intestine it is hydrolyzed by lipase to ricinoleic acid Which inhibits intestinal water absorption Stimulates intestinal motor function. By damaging mucosal cells and releasing neurotransmitters. The most common side effect known is cramping and staining of undergarments. Diphenylmethane derivatives: Diphenylmethane compounds include: Bisacodyl Sodium picosulfate Phenolphthalein. After oral ingestion, the mode of hydrolysis differs for bisacodyl and sodium picosulfate even though they are hydrolyzed to the same active metabolite. Bisacodyl can act on both the small and large intestine, Because it is hydrolyzed by intestinal enzymes. Sodium picosulfate is hydrolyzed by colonic bacteria. The action of sodium picosulfate like anthraquinones, is confined to the colon, and because its activity depends on the bacterial flora, it is unpredictable. The effects of bisacodyl, and presumably sodium picosulfate, on the colon are similar to those of the anthraquinone laxatives. In both healthy and constipated subjects bisacodyl, on contact with the colonic mucosa, induces: An almost immediate, powerful, propulsive motor activity It also stimulates colonic secretion. Similar to the anthraquinone laxatives, bisacodyl also leads to: Apoptosis of colonic epithelial cells, the remnants of which accumulate in phagocytic macrophages, Unlike anthraquinones. These cellular remnants are not pigmented. Apart from these changes, there is no evidence that bisacodyl causes adverse effects with long-term use. Especially in patients with temporary constipation, bisacodyl is a useful and predictable laxative, suitable for single-dose use.

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In contrast to anthraquinones and sodium picosulfate, Its possible effect on the small bowel is a disadvantage. In patients with chronic severe constipation, long-term use of bisacodyl or related agents is sometimes necessary, though in the doses used, liquid stools and cramps tend to result and as a matter of fact it is difficult to adjust the dose to produce soft, formed stools. Phenolphthalein acts by inhibiting water absorption in the small intestine and colon by effects: On eicosanoids Na+/K+-ATPase pump present on the surface of enterocytes. Because the drug undergoes enterohepatic circulation, its effects may be prolonged.

Stool Softeners and Emollients Docusate Sodium


Although the detergent dioctyl sodium sulfosuccinate (docusate sodium) is available as a stool softener, its efficacy is not documented. The compounds mechanism of action is by stimulating fluid secretion by the small and large intestine but does not increase: The volume of ileostomy output The weight of stools in normal subjects. Docusate sodium has been found to be less effective than psyllium for the treatment of chronic idiopathic constipation.

Mineral Oils
Mineral oils alter the stool by: Being emulsified into the stool mass Providing lubrication for the passage of stool. Long-term use is not advocated as it can cause: Malabsorption of fat-soluble vitamins Anal seepage Lipoid pneumonia in patients predisposed to aspiration of liquids.

Enemas and Suppositories


Enemas and suppositories are compounds that may be introduced into the rectum:

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To stimulate contraction: By distention Chemical action To soften hard stools (or both). Extravasation of the enema solution into the submucosal plane, can result into serious damage to the rectal mucosa. The site most vulnerable to trauma from the tip of a catheter introduced through the backward-angulated anal canal, is the anterior rectal mucosa. After the anal canal has been passed, the enema nozzle should be directed posteriorly.

Phosphate Enemas
Hypertonic sodium phosphate enemas are often effective. They act by causing both distention and stimulation of the rectum. The mucosa on proctoscopic examination is abnormal in most cases but returned to normal within one week. Therefore, superficially damaged mucosa appears to heal rapidly. Scanning electron microscopy showed: Patchy denudation of the surface epithelium With exposure of the lamina propria Absence of goblet cells. Though the Phosphate enemas are used widely, there is no conclusive evidence to support their use. If given to a patient who cannot evacuate it promptly, phosphate enemas can lead to dangerous hyperphosphatemia and hypocalcemic tetany. In children with normal renal function after retention of two phosphate enemas, severe hyperphosphatemia, hypocalcemia, and seizure have been reported. The use of phosphate enemas in children 3 years of age and younger is not recommended.

Saline, Tap Water, and Soapsuds Enemas


Saline, tap water, or soapsuds enemas are also effective and act mainly by:

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Distending the rectum Softening feces. Following administration, stool evacuation typically occurs in 2 to 5 minutes. A saline enema is safer and effective as it does no damage to the rectal mucosa. Water enemas and soapsuds enemas also may be used, but dangerous water intoxication can occur if the enema is retained with large volumes. Large-volume water or soapsuds enemas also can lead to hyperphosphatemia and other electrolyte disturbances if the enema is retained. Rectal mucosal damage and necrosis can occur with soapsuds enemas.

Stimulant Suppositories and Enemas


Glycerin administered as a suppository is often clinically effective. It stimulates the rectum by an osmotic effect. The effect of glycerin, on the rectal mucosa is unknown. Bisacodyl, is also available as a suppository in strength of10 mg. It is presumed to act topically by stimulating enteric neurons. With bisacodyl suppository the epithelium of the surface and within the crypt (to varying depths) is altered; where as with the enema. The surface epithelium is damaged. For this reason the regular use of bisacodyl suppositories appears unsafe.

Prokinetic Agents
Prokinetic agents act by inducing increased contractility in a segment of the gastrointestinal tract. The observation that stimulation of the 5-hydroxytryptamine4 (5-HT4) receptor on afferent nerves in the wall of the gastrointestinal tract induces peristaltic contraction of the intestines, led to testing of several 5-HT4 agonists for the treatment of constipation. Cisapride, a benzodiazepine, has had variable results in treating constipation.

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It has been withdrawn from the commercial market from 2000 because of its potentially lethal cardiac dysrhythmias. Newer 5-HT4 agonists such as tegaserod appear promising in the treatment of chronic constipation.

Tegaserod
Tegaserod, is structurally different from cisapride and: A partial 5-HT4 agonist It is an aminoguanidine indole derivative of serotonin. Tegaserod has been advocated extensively in women with constipation-predominant IBS. It has been approved by the FDA for the treatment of chronic constipation, for men and women younger than the age of 65. As compared with baseline the response is defined as an increase of one or more complete spontaneous bowel movements (CSBMs) per week. In patients treated with tegaserod: The median time to first CSBM is significantly shorter The frequency and consistency of stools is improved Straining is reduced. No rebound effect is seen after withdrawal of tegaserod. Diarrhea is one side effect with tegaserod. No electrolyte imbalance or ischemic collitis have been observed.

Prucalopride
Prucalopride, is a benzofuran derivative and a full 5-HT4 agonist. It accelerates colonic transit in healthy humans and in patients with functional constipation. It is not used clinically because of the concerns about carcinogenicity of the drug in animals.

Other Agents
Colchicine, a drug used for gout Misoprostol, a prostaglandin analog, have been used to treat patients with severe chronic constipation. Cholinergic agents also have been used to treat constipation.

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Patients in whom constipation results from therapy with tricyclic antidepressants; Bethanechol, a cholinergic agonist, appears to relieve symptoms. A single intravenous dose of neostigmine, a cholinesterase inhibitor, has been shown to be remarkably effective in decompressing the colon in patients with acute colonic pseudo-obstruction. Side effects, such as bradycardia, increased salivation, vomiting, and abdominal cramping, are common.

Clostridium botulinum Type A (Botox)


A potent neurotoxin which has the ability to inhibit presynaptic release of acetylcholine, has been used to treat defecatory disorders by injecting it intramuscularly into the puborectalis muscle.

Lubiprostone
A novel bicyclic fatty acid that acts by activating the chloride-two channel, increases intestinal fluid secretion without altering serum electrolyte levels. In patients with chronic constipation as defined by the Rome II Criteria, lubiprostone increases the number of spontaneous bowel movements. Lubiprostone also significantly: Decreases straining Improves stool consistency Reduces overall severity of symptoms. The frequency of spontaneous bowel movements apparently increases in both men and women, as well as elderly patients. Apart from this on withdrawal of the drug, there was no evidence of a rebound effect. The most common known side effects are nausea, headache, and diarrhea.

Peripherally Acting Opioid Antagonists


Have been shown to reverse opioid-induced bowel dysfunction, these agents may be effective in the treatment of constipation.

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Anorectal Biofeedback
Anorectal biofeedback is as good as a normal defecation training. Patients receive visual and/or auditory feedback on the functioning of: Their anal sphincter Pelvic floor muscles. During anorectal biofeedback. Biofeedback can be used to train patients: To relax their pelvic floor muscles during straining To coordinate this relaxation with abdominal maneuvers In turn to enhance entry of stool into the rectum. To perform biofeedback, an EMG or anorectal manometry catheter can be used. Simulated evacuation is commonly taught to patients to emphasize normal coordination of successful defecation. This is performed using a balloon or a silicon-filled artificial stool. Success of biofeedback depends on: Patient education Rapport between the therapist and the patient. If successful the benefit of biofeedback appears to be long lasting. Indicated commonly in patients with defecatory disorders. Biofeedback has been found to be less effective for patients with descending perineum syndrome than for those with spastic pelvic floor disorders. Psychological factors have also been found to influence the response to biofeedback: Bowel frequency Straining Abdominal pain Bloating Use of laxatives. These are the symptoms found to improve with defecation training. That defecation training results in appropriate: Relaxation of the puborectalis and external anal sphincter muscles

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Increase in intrarectal pressure A widened rectoanal angle on straining during defecation An increased rate of rectal emptying An increased rate of colonic transit Increased rectal mucosal blood flow. It has been shown by physiologic measurements before and after treatment. Over and above this defecation training has benefited: Some patients in whom constipation developed after hysterectomy Some patients with solitary rectal ulcer syndrome.

Surgery
For patients with severe constipation the goal of surgical treatment is: To increase bowel frequency Ease of defecation. In turn it is expected that surgery will relieve: Abdominal pain Distention. Surgical procedures can be categorized into three groups: 1. Partial or total colectomy 2. Construction of a stoma 3. Anorectal operations undertaken to improve defecatory function.

Colectomy
Colectomy for constipation has been used frequently, but it produces variable results. Small bowel obstruction, diarrhea, and incontinence, are the most common complications following surgery. Before planning colectomy it is always better to go for the following work-up to obtain the best possible postoperative results: Because poor results are common among patients with psychological disturbances, preoperative psychological assessment is essential.

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Again, it is essential that slow colonic transit be demonstrated by an objective method, the reason being the aim of surgery is to increase bowel frequency. Inability to expel stool from the rectum being one of the major factor in causing symptoms, it is important to assess defecatory function. Exclude a generalized intestinal dysmotility or pseudo-obstruction syndrome by appropriate radiographic study of the small intestine and, finally not to forget studies of gastric emptying and small bowel transit, when possible.

Procedure Variants
A subtotal colectomy with an ileorectal anastomosis has been shown to be offer better results compared to colectomy with caecorectal or ileosigmoid anastomosis. Usually following failure of colectomy and ileorectal anastomosis, proctocolectomy with ileoanal anastomosis and construction of an ileal pouch is advocated. Laparoscopic subtotal colectomy appears to be as effective as an open approach.

Construction of a Stoma
Because colostomy is reversible The results of colectomy are uncertain A colostomy is sometimes performed for slow-transit constipation or for neurologic disease with subjective improvement. Though good number of patients continue to require laxatives or regular colonic irrigation. Patients with: A generalized disorder of gut motility With a psychological disturbance. These are the ones who are not likely to benefit from colectomy with ileorectal anastomosis. Similarly, an ileostomy occasionally is performed after failure of colectomy and ileorectal anastomosis for slow-transit constipation. Patients with paraplegia and severe constipation and incontinence can benefit from creation of a continent catheterizable

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appendicostomy, through which antegrade enemas can be administered, thereby decreasing the time and medication needed for bowel care.

Operations for Defecatory Disorders


In patients with slow-transit constipation, puborectalis or internal anal sphincter muscle division are unsuccessful: In patients who have evidence of retained contrast during defecating proctography In women in whom constipation is relieved with digital vaginal pressure Procedures to correct a rectocele should be considered.

Chronic Constipation in Elderly


Chronic constipation in the elderly is common and has a significant impact on quality of life. A careful history, medication assessment, and physical examination are helpful in obtaining relevant clues that help direct management. Physiologic categorization of the cause leading to patient presentation improves management outcomes, realizing that many causes can be present in one patient, and many factors influence the clinical presentation of an older patient. Fiber supplementation and osmotic laxatives are effective for many patients with chronic constipation. Surgery is rarely indicated.

Obstructed Defecation Syndrome

chapter

10

Defecation is the normal process of evacuating stool from the rectum. It involves a complex interaction of: Normal motility of the gastrointestinal tract Contractile function of the rectum Coordination of the pelvic oor musculature Relaxation of the anal sphincter mechanism. Several causes including slow colonic transit and obstructed defecation, can lead to difculties with bowel function. Because the anatomical and pathophysiological changes associated with these conditions are varying, and often incompletely understood, in most cases there are limited treatment outcomes. Patients present with variable complaints and in an effort to relieve their symptoms have already tried a plethora of over-thecounter medications. To manage these patients optimally, Physicians need an organized approach. Improvements over the past few years in: Our understanding of the complex process of defecation Along with the increasing use of radiological and anorectal physiology studies, have led to improved treatment results. Obstructed defecation is a broad term used to describe the condition of patients with defecatory dysfunction and constipation, it is common problem that adversely affects the quality of life for many patients. To achieve optimal outcomes management of these condition requires an understanding of urinary, defecatory, and sexual function. Though, there is a poor correlation between anatomic and functional results, the ultimate goal of surgical treatment is to restore the various pelvic organs to their appropriate anatomic positions.

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It should be remembered that defects of pelvic support or function frequently affect other pelvic organs because the pelvis contains many structures other than the rectum and that defects of pelvic oor support or function frequently affect the other pelvic organs and can also lead to symptomatic vaginal vault or uterine prolapse, cystocele, or urethrocele. By selecting appropriate treatment modalities that address all of the components of an individual patients problem, Optimal outcomes can be achieved. Yet, obstructed defecation is sometimes troublesome for the patient, and it can be difcult to manage even for the most ex perienced of clinicians. While patients frequently complain of constipation, a condition medically dened as less than three stools per week, they describe symptoms of an inability to initiate rectal emptying, incomplete evacuation, pelvic pressure, or excessive straining at stool. Known causes of obstructed defecation include: Pelvic dyssynergy Rectocele Rectal intussusception Enterocele Pelvic organ prolapse Overt rectal prolapse. All of these conditions represent either a defect of pelvic support or abnormal function of the pelvic oor musculature. The etiology of these defects is controversial but denitely involves damage to: The innervation, and soft tissues of the pelvis as a direct consequence of vaginal childbirth. Endopelvic fascial and pelvic support defects can result from direct trauma to the pelvic soft tissues, the strength of the pelvic connective tissues is affected by the structural and biochemical integrity of the collagen. Because no immediate symptoms are produced by traumatic damage to the pelvic support system, there have to be other important factors as a cause.

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Apart from the cumulative nerve damage from childbirth, conditions that cause chronic and repetitive increases in intraabdominal pressure, such as obesity and chronic cough, have been suggested to play a role in the development of symptomatic defects. The etiology of these defects has therapeutic implications. It would seem reasonable to believe that correction of the pelvic organ prolapse by either resection of the prolapsed organs or repair of the defects of pelvic support by shortening redundant tissue or using prosthetic materials and retraining the pelvic oor using biofeedback techniques to correct musculature discoordination, would result in excellent outcomes. However, a satisfactory anatomic result has been achieved, evaluation of these patients not uncommonly reveals that the patient complains of persistent symptoms, equally often, patients report a marked improvement in symptoms despite a less than ideal anatomic result from surgery. The incidence of these problems is unknown but 11% of women have an operative procedure for a defect of pelvic support before the age of 80 years.

Rectocele
Over the past decade, women have begun to be better educated about the fact that pelvic organ prolapsed can result from a defect in any of the structures contributing to vaginal wall support. Herniation of the anterior rectal wall into the posterior vagina is called a rectocele (Fig. 10.2). The true incidence of this anomaly and its pathogenesis are debated, similarly, there is debate as far as the indications and techniques for surgical repair are concerned, The baseline prevalence of rectocele is not well dened as many women are asymptomatic and do not seek medical help. The normal vagina is stabilized and supported on the following three levels: Superiorly, the vaginal apical endopelvic fascia is attached to the cardinal uterosacral ligament complex (level I) (Fig. 10.1).

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Fig. 10.1: Rectovaginal septumschematic representation with attachments

Laterally, the endopelvic fascia connects to the arcus tendineus fasciae pelvis (level II), with the lateral posterior vagina attaching to the fascia overlying the levator ani muscles. Inferiorly, the lower posterior vagina attaches to the perineal body (level III) lying between the urogenital and anal triangles of the perineum. It is a triangular, bromuscular structure where the following meet: The bulbocavernosus The supercial transverse perineimuscles The supercial part of the external anal sphincter.

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Fig. 10.2: Rectocele

The cervix (or vaginal cuff in the hysterectomized woman) is considered to be the upper attachment site and the perineal body, the inferior point of xation of the rectovaginal septum. This fascia can only be found from the perineal body up to the mid vagina level where it changes its axis of orientation. The importance of this marked difference becomes evident in the various surgical approaches to rectocele repair. The most common defect anatomically, is a transverse separation of the bers of the rectovaginal fascia occurring just proximal to the attachments to the perineal body. This defect may or may not be associated with disruption of the soft tissues of the perineal body resulting from obstetric trauma.

Symptoms
The symptoms associated with a rectocele are as follows:

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Often unrecognized; the functional impact of rectoceles when symptomatic is very limiting to women in their day-to-day activities of living and recreation. They can present with a variety of complaints such as: Obstructive defecation Looseness during intercourse, and more commonly perineal pressure. Symptoms of pressure and difculty with defecation are produced by bulging in the posterior vaginal wall. Especially in patients, participating in activities requiring long periods of standing, this mass effect is usually worse at the end of the day. Classically, women report for a need to splint or digitally reduce the vaginal bulge to evacuate their bowels. However, because the correlation between degree of prolapse and symptomatology is not always a direct one, individual variation comes into play. The need for clinicians to differentiate between pelvic oor motility disorders and obstructive conditions is crucial, as most women seek admission for chronic constipation and/or altered bowel habits, and as the former will often respond only to biofeedback therapy or dietary modications. Although not infrequently present, fecal incontinence is not a symptom that most associate with rectoceles.

Etiology
The process of childbirth remains the most signicant risk factor for any form of pelvic organ prolapse. The etiology is debated but it may be the result of a synchronous defect of the external anal sphincter. Denervation injuries due to traction on pudendal nerve from long-standing, excessive straining to defecate has also been proposed as a cause, also overow type mechanism resulting from the lling of a large rectocele.

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Additionally, the performance of instrumental deliveries (i.e. forceps) increases the risk of third and fourth degree perineal lacerations as well as lateral sulcal tears. Following are some of the treatable conditions which can also contribute to overstretching injury of the pudendal nerve: Obesity Chronic obstructive pulmonary disease (i.e. chronic cough) Chronic constipation By leading to chronic increase in abdominal pressure: Collagen disorders Aging Postmenopausal status are few nonpreventable etiologies. The theory that repeated strain on the pelvic musculature innervation will lead to posterior vaginal wall damage supports the nonrelaxing puborectalis muscle syndrome and the ensuing chronic straining to effectuate a bowel movement.

Clinical Diagnosis
The clinical diagnosis is made by physical examination. A thorough physical exam helps the surgeon plan his or her surgical approach. It is important during the examination to evaluate for the possibility of a coexistent. Enterocele or Prolapse of other pelvic organs. Defecography helps in the following: Assess a rectocele objectively with the size Ability to empty the rectocele can be measured Rule out possibility of pelvic dyssynergy Rectal intussusceptions Prolapse of other pelvic organs. The last three can be judged after opacication of the vagina, bladder, and small bowel is done.

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Never forget to evaluate the following during the physical exam: Vaginal mucosal thickness Status of estrogenation Associated pelvic support defects such as: Vaginal vault prolapse Cystocele Pelvic neuromuscular function.

Management
Dietary management, with adequate uid and ber intake, is the initial management of a symptomatic rectocele. Associated pelvic dyssynergy is present in about sixty percent of patients. Biofeedback can be considered, if available for bowel retraining and treatment. Most surgeons recommend operative repair, if the above measures fail. Recommended indications for surgical repair are: When the rectocele is greater than 3 cm in depth If there is signicant barium trapping on defecography If digital assistance of defecation is frequently necessary for satisfactory emptying. However, no correlation has been observed: Between the size of a rectocele or the extent of barium trapping and the degree of symptoms or outcome of rectocele repair. As against the expectation of the following factors though suggestive of causative factor for rectocele have been observed to be associated with poor results from surgery: The preoperative need for digital assistance for defecation Pelvic dyssynergy. Similarly, the following conditions are predictive of a less favorable outcome following rectocele repair: Delayed colonic transit The long-term use of: Laxatives Stimulants.

Obstructed Defecation Syndrome 217

Rectoceles can be approached by: A transvaginal A transrectal A transperineal approach. Goals in the surgical repair of rectocele include: 1. Endopelvic fascial integrity from apex to perineum 2. Levator plate integrity 3. Anterior rectal wall support 4. Normal vaginal caliber and length 5. Integrity of perineal body. Transvaginal repairs: The traditional technique for transvaginal rectocele repair involves: A posterior colporrhaphy with vaginal mucosectomy Anterior levator plication Repair of any soft tissue defects of the perineal body. The procedure involves following steps: The excision of a diamond-shaped piece of: Vaginal mucosa Perineal skin from the posterior vaginal wall. The puborectalis and transverse perineal muscles are freed from the overlying vagina and perineum through this defect. The rectovaginal fascial defect is plicated longitudinally The repair continues onto the perineal body The puborectalis and perineal muscles are reapproximated Redundent vaginal tissue is excised The vaginal wound is closed. Even though this technique is a nonanatomic longitudinal repair of a transverse defect, there are variable clinical results as far as correcting the vaginal bulge and the need for digital assistance of defecation are concerned. The Postoperative complications include dyspareunia and a recurrent clinical rectocele requiring reoperation. The concept of anatomic defect specic transvaginal repair of rectoceles is in limelight and has been advocated positively.

218 Anorectal Surgery

Steps Involve (Figs 10.3A to D)


An incision is made in the posterior vaginal wall Dissection carried out through this defect The edges of the rectovaginal fascial defect are identified This is then closed transversely Associated defects in the soft tissues of the perineal body are also repaired Redundant vaginal tissue is excised The wound closed. In the short-term, this technique seems encouraging, and longterm results need evaluation. Postoperative results are satisfactory as the procedure has: A very low incidence of recurrent clinical rectocele A low postoperative need for digital assistance of defecation The symptom of constipation is improved in majority of the patients. Though, some patients do complain of postoperative dyspareunia and fecal incontinence because of its inherent advantages of adequate access. Transvaginal rectocele repair has been recommended as the procedure of choice in the following situations: Coexistent Enteroceles Cystoceles Apical vaginal vault prolapse. Vaginal hysterectomy for uterine prolapse or other problems. Transrectal repair: The poor results in terms of bowel and sexual function of the transvaginal repairs led to the rediscovery and popularity of this technique. Transrectal rectocele repair have been found to have significantly less incidence of postoperative dyspareunia. The major advantage of transanal repair is the ability to address the coexistent anorectal pathology that is present in most of the patients, like hemorrhoids, anterior mucosal prolapse, and ssures, associated with rectoceles.

Obstructed Defecation Syndrome 219

Figs 10.3A to D: Steps involved in repair of rectocele

The transrectal, anatomic, defect-specic rectocele repair involves the following steps: The elevation of mucosal aps over the lax rectocele Transverse closure of the defect by an interrupted plication of the muscularis anteriorly [Similar to Delormes procedure for rectal prolapse]

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Trimming of the redundant mucosa and submucosa Closure of the mucosal defect. Because of the following after effects: A relative fore shortening of the anal canal Diminished internal sphincter function Diminshed resting anal pressures. This procedure is considered as a relative contraindication in patients with fecal incontinence associated with rectocele.

Nonanatomic Repair
Involves the following steps: The elevation of mucosal aps over the lax rectocele The defect is repaired longitudinally by Approximating the musculofascial edges of the defect. Redundent mucosa and submucosa are trimmed The mucosal defect is closed. Though, the procedure ends in a repair under tension there are greater chances of: Sepsis Disruption of the wound. But the potential for worsening of fecal incontinence present with the anatomic repair is taken care of as this repair lengthens the anal canal. Most of the differences in results seem to be related to selection of patients. Yet, another repair though not very prevalent is described. It is advocated in patients with relatively asymptomatic rectoceles and good sphincter function and in those, whom the anterior prolapse does not extend distally beyond the dentate line or proximately for more than 5 cm. To incorporate the redundant mucosa and submucosa of small rectoceles an obliterative suture is used. Though this procedure does not require the development of mucosal aps, it does carry the potential for soft tissue necrosis and sepsis.

Obstructed Defecation Syndrome 221

Transperineal Repair
Mostly advocated in the patient with a symptomatic rectocele and incontinence secondary to a sphincter defect. This procedure has only limited data regarding the use and outcome, although the technique has been recommended in combination with a conventional sphincteroplasty or levatorplasty or both. Short-term results of this combined procedure show an improvement in evacuation and continence good number of patients. The anatomic restoration of a disrupted rectovaginal septum is achieved by the transperineal insertion of a prosthetic mesh, this has been documented with: A signicant reduction in the need for digital assistance of defecation Reduction in the size and amount of barium retained in rectoceles.

Laparoscopic Rectocele Repair Technique


Laparoscopic rectocele repair involves the following steps: Opening the rectovaginal space Dissecting inferiorly to the perineal body The perineal body is sutured to the rectovaginal septum and Rectovaginal fascial defects are identied and closed. The advantages of this procedure are: Better visualization More rapid recovery with: Decreased pain Decreased hospitalization. Disadvantages include: Difculty with laparoscopic suturing Increased operating time/expense Extended time necessary to master the laparoscopic surgical techniques.

222 Anorectal Surgery

Transanal Repair
The use of stapling devices for the transanal approach is gaining popularity because the result from studies looking at the STARR procedure appears promising. The advantages are: An improvement in all constipation symptoms occurs without worsening of anal incontinence No incidence of dyspareunia. Though some patients develop fecal urgency, and incontinence to atus. Another transanal procedure being evaluated is stapled transanal prolapsectomy with perineal levatorplasty (STAPL), This involves only stapling of the anterior rectal wall and the addition of levator plication.

Complications
The patients receiving transvaginal repair had more persistent pain. Apart from this complications include infection and a rectovaginal stula. No attempt should be made for using the transanal approach for enteroceles or high rectoceles, or combining it with transvaginal surgery because the latter has additional risk of infection. Maintaining rectal mucosal integrity appears to signicantly reduce infectious morbidity. These types of complications are not seen with vaginal rectocele repairs, where the rectal mucosa is not incised or excised. Lastly not to forget, dietary modication and smoking cessation are lifestyle changes that can help decrease the incidence of rectocele in women.

Rectal Intussusception
Also known as: Internal procidentia

Obstructed Defecation Syndrome 223

Incomplete or occult rectal prolapse, this entity was in past considered as to be a preliminary stage in the development of: Complete or overt rectal prolapse One of the principal causes of obstructed defecation. As a matter of fact, further research has shown that occult rectal prolapse progresses to overt rectal prolapse in only 2% of patients. Also the fact that some degree of intussusception of: The rectosigmoid Upper rectum. Into the lower rectum is a nding that is noted on defecography in approximately One-third of patients who do not have any symptoms. More than half of the patients with rectal intussusceptions complain of fecal incontinence, apart from their usual symptoms associated with: Obstructed defecation Evacuatory difculty A feeling of incomplete emptying Pelvic pain and pressure Rectal bleeding. The basic possible mechanisms for fecal incontinence include: An occult defect of the external anal sphincter A traction pudendal neuropathy resulting from: Long-standing Excessive straining to defecate. Another theory has also been proposed: Intussusception leads to distention of the lower rectum This distention activates the rectoanal inhibitory reex Which in turn results in relaxation of the internal anal sphincter An overow incontinence. Surgical repair of a rectal intussusception is benecial, in patients with associated incontinence.

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Evaluation
Proctoscopic examination of patients with an occult rectal prolapse may reveal: Hyperemia and edema of the anterior rectal wall Colitis cystica profunda, or a solitary rectal ulcer. A difcult clinical problem that is associated with obstructed defecation is solitary rectal ulcer syndrome. Internal rectal prolapse and pelvic dyssynergy are demonstrated in good number of these patients on defecography. Much better results with ulcer healing and symptom resolution have been found with surgical management of solitary rectal ulcers associated with rectal intussusception and may be the treatment of choice. As against the surgical treatment, the results of dietary measures and pelvic oor retraining using biofeedback are less likely to be successful in patients having a solitary rectal ulcer. Also, despite healing of the ulcer, symptoms persist in one- third of the patients. Rectal intussusception is more a consequence of excessive straining to defecate than a cause. A reasonable initial therapy with symptomatic improvement reported is pelvic oor retraining using biofeedback. Surgical therapy of a rectal intussusception associated with severe, intractable symptoms of obstructed defecation alone should be considered only as the last resort and is considered only for those with an incomplete rectal prolapse that extends distal to the puborectalis sling, and is associated with either fecal incontinence or a solitary rectal ulcer. Abdominal and perineal approaches, as with overt rectal prolapse, have been used to manage rectal intussusception but with inconsistent results. A few good results for repair of rectal intussusceptions following surgery for patients with an incomplete rectal prolapse associated with intractable symptoms of obstructed defecation have been observed after a Delorme procedure.

Obstructed Defecation Syndrome 225

Abdominal approaches with either a suture rectopexy or an Ivalon wrap procedure have been most commonly reported for repair of rectal intussusceptions.

Enterocele
An enterocele is a herniation of the peritoneal cavity between: The uterosacral ligaments at the apex of the vagina That extends distally in the rectovaginal septum separating the rectum from the vagina. The herniated peritoneal sac usually contains small intestine, an enterocele but may contain the sigmoid colon, a sigmoidocele. Although an enterocele may be present alone, the majority are associated with: A rectocele Prolapse of other pelvic organs Abnormal descent of the pelvic oor.

Prevalence
Exactly unknown incidence of symptomatic enteroceles ranges from 18 to 42%. Most common in multiparous women: Older than 65 Those who have had a hysterectomy.

Clinical Features and Physical Examination


Because of the usual coexistence of symptoms of enteroceles with other abnormalities of pelvic support, it is difcult to be certain which symptoms are actually attributable to the enterocele. However, the symptoms of enteroceles are reported to include: Obstructed defecation with a false sense of the need to defecate Evacuatory difculty Pelvic pressure Lower abdominal and back pain Fecal incontinence.

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Occasionally an enterocele may cause: Ulceration of the vaginal mucosa Result into perforation with evisceration. If physical examination may suggest a enterocele, it is always advisable to differentiate it from a rectocele or vaginal vault prolapse. Accidentally found at: Colpocystodefecography Dynamic magnetic resonance imaging (MRI) for evaluation of other pelvic oor conditions. Colpocystodefecography does have the advantage of evaluating coexistent pelvic pathology but it is reported to be too sensitive and can lead to a false-positive diagnosis. Dynamic MRI though more specic is not as readily available.

Classification
Enteroceles are classied according to their etiology. Congenital enteroceles resulting from abnormal development of the rectovaginal septum, do occur but are rare, and represent less than 1% of enteroceles. Acquired enteroceles result from pelvic surgery, most commonly a bladder neck suspension or a hysterectomy, and account for about one fourth of enteroceles. Traction enteroceles: These form the majority of enteroceles and are created when the pelvic cul-de-sac is pulled down by a prolapsing pelvic organ, usually the rectum or uterus.

Management
Treatment of an enterocele should be considered when: It is symptomatic There is evidence of rectal or vaginal ulceration. The initial therapy is: Dietary Lifestyle modication Adequate uid and ber intake The avoidance of straining, as with other pelvic oor conditions.

Obstructed Defecation Syndrome 227

Biofeedback training may also be helpful. The goal of enterocele repair is: Excision or obliteration of the peritoneal sac Approximation of the uterosacral ligaments in the midline. There are two commonly used situations for obliteration of the enterocele sac: In conjunction with an abdominal procedure for coexistent pathology By a vaginal approach at the time of hysterectomy or cystocele or rectocele repair. Indications for surgical repair of an enterocele: Intractable symptoms Rectal ulceration Vaginal ulceration. Prophylactic surgical repair is performed: At the time of hysterectomy In conjunction with the treatment of coexistent pelvic oor pathology, particularly: Rectal Vaginal vault prolapse. This is accomplished by placing sequential purse-string sutures in the peritoneal cul-de-sac with care taken to avoid ureteral injury. Both transvaginal and transabdominal repairs yield excellent anatomic results with successful obliteration of the defect. But apparently there is a less morbidity with the vaginal approaches compared with transabdominal repairs. Relapse rates are increased and dspareunia related to vaginal shortening and decreased vaginal capacity, are the drawbacks of the same. Because the vast majority of enteroceles are associated with other pelvic oor pathology, especially vaginal vault or rectal prolapsed, determining functional outcomes is more problematic. Rectopexy clubbed with vaginal vault suspension have been reported to be more effective for the treatment of symptomatic enterocele, however, it is difficult to assure whether the reported benet is related:

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To the repair of the enterocele Correction of the coexistent pathology. Irrespective of the added advantages with enterocele repair, it is always sensible and reasonable to repair these defects at the time of surgery to correct other defects of pelvic oor support the reason being the low-risk of complications with these procedures.

Total Pelvic Organ Prolapse


Prolapse of all the pelvic organs does occur though the incidence is not known and is documented in small number of patients. The management of this condition does require an understanding of: Urinary Defecatory Sexual function to achieve optimal outcomes. The posterior components of this entity are of concern in manage ment of obstructed defecation syndrome and these include: Rectocele Enterocele Rectal intussusception Overt rectal prolapse, frequently in combination with pelvic dyssynergy. These problems are usually more severe when combined in total pelvic organ prolapse than individual entities.

Symptoms
Symptoms attributed to total pelvic organ prolapse include: Obstructed defecation Pelvic pain and pressure Incontinence As in situations when these conditions are present individually, plus The genitourinary symptoms of urinary incontinence Incomplete emptying of the bladder.

Obstructed Defecation Syndrome 229

Physical Examination
Common findings on physical examination include: Prolapse of multiple pelvic organs Excessive perineal descent Other ndings such as a solitary rectal ulcer, which are usually present in these conditions occurring as individual components. Colpocystodefecography is useful to evaluate the full anatomic extent of the problem, eventhough it is very sensitive and may lead to a false-positive diagnosis. A component of this syndrome that needs special mention and discussion is abnormal perineal descent. The descending perineum syndrome is dened on defeco graphy as: Descent of the anorectal junction below a line drawn from the lower border of the pubic symphysis to the tip of the coccyx during defecation. The cause of abnormal perineal descent is long-standing, excessive straining to defecate. To determine the degree of pelvic dyssynergy following may be useful: Dynamic MRI EMG Urodynamic studies. To exclude the possibility of colonic hypomotility colonic transit studies should be performed.

Management
Surgery: To restore the various pelvic organs to their appropriate anatomic positions, is the goal of surgical treatment. Using either a transabdominal or transvaginal, this can be accomplished by a combination of: Resection of the prolapsing organs Shortening and repair of supporting tissues.

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Transvaginal approaches have been known to result in a surgically induced perineal neuropathy and worse outcomes, eventhough associated with less morbidity. In a direct comparison of the two techniques, the probability of surgical failure requiring reoperation was twice as great with the vaginal approach and the abdominal procedures were associated with improved resolution of symptoms. Prosthetic materials have been used to resuspend and support prolapsing pelvic organs without the necessity of resection. In most patients, symptoms of obstructed defecation and constipation show improvement after a pelvic restoration using prosthetics. Continence was improved in most patients with preoperative fecal incontinence. There are different methods and materials used for prosthetic repair of the descent yet one thing in common is that the procedure includes: Excision of the associated enterocele sac With attachment of one end of a prosthetic mesh to the perineal body, and the other end to the periosteum of the second sacral vertebrae. The vagina and rectum are sutured to this prosthesis. To provide support for the bladder, additional strips can be secured between: The sacroperineal prosthesis and iliopubic ligaments on either side. The outcome of this procedure is that it: Reinforces the rectovaginal septum Corrects existing Rectocele Enterocele Vaginal or rectal prolapse, or excessive perineal descent present. If there is redundancy or hypomotility of the colon, this procedure can be combined with a colon resection.

Obstructed Defecation Syndrome 231

Complications
Infection or erosion of the prosthesis is a major concern, requiring either partial or complete removal of the mesh. Additional procedures for persistent, symptomatic low rectocele or rectal mucosal prolapse may be required. Dyspareunia was reported in some of the patients.

chapter

Biofeedback

11

Dyssynergic defecation is one of the most common forms of functional constipation both in children and adults. It is dened as incomplete evacuation of fecal material from the rectum due to paradoxical contraction or failure to relax pelvic oor muscles when straining to defecate. Up to one half of patients with constipation suffer from the entity known as dyssynergic defecation. This is an acquired behavioral problem and is caused by the inability to coordinate the abdominal and pelvic floor muscles to evacuate stools. In the current scenario, it is possible to diagnose this problem through: History Prospective stool diaries Anorectal physiologic tests. Biofeedback also known as neuromuscular training is: The use of electronic or electromechanical equipment to measure Provide information about specific physiologic functions That can then be controlled in therapeutic directions. Neuromuscular training or biofeedback therapy is an instrumentbased learning process that is based on operant conditioning techniques. The goal of neuromuscular training using biofeedback techniques is to restore a normal pattern of defecation.

A Standard Biofeedback Training Protocol


The mainstay of behavior therapy is to first explain the anorectal dysfunction and discuss its relevance with the patient before approaching the treatment.

Biofeedback 233

The next step includes training the patients on a more effective use of the abdominal muscles to improve pushing effort. Patients are next shown anal manometry or EMG recordings displaying their anal function and are taught through trial and error to relax the pelvic oor and anal muscles during straining. This objective is first pursued with the help of visual feedback on pelvic oor muscle contraction, accompanied by continuous encouragement from the therapist. When the patient has learned to relax the pelvic floor muscles during straining, the visual and auditory help are gradually withdrawn. Biofeedback is often recommended for children who have constipation and encopresis. Associated with specific: Physical Anatomic Postsurgical complications. Also recommended for children who exhibit: Pelvic floor dyssynergia Paradoxical contraction. Biofeedback treatment of constipation and encopresis typically involves some combination of the following: Training in discriminating the sensation of rectal distention Strengthening or controlled relaxation of the external anal sphincter through electromyography (EMG) training Training in the synchronization of internal and external anal sphincter responses Training in the coordination of abdominal and pelvic floor musculature for elimination (For those who have pelvic floor dyssynergia or paradoxical contraction). Pelvic floor dyssynergia is the abnormal closure of the anal canal during straining for defecation. During attempts to defecate, children who have dyssynergia squeeze the buttocks and hips but are unable to relax the external anal sphincter. The child squeezes the anal canal during defecation:

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To control the amount of stool being passed To protect against pain. These abnormal defecation dynamics are thought to develop in response to past painful bowel movements. When any behavior is reinforced, may it be complex maneuver like eating or a simple task like muscle contraction, its likelihood of being repeated and perfected increases several fold. In patients with dyssynergic defecation, the goal of neuromuscular training is two fold: To correct the dyssynergia in coordination of the abdominal, rectal, and anal sphincter muscles to achieve a normal and complete evacuation To enhance rectal sensory perception in patients with impaired rectal sensation. In children, it is essential and prerequisite to decide which type of biofeedback be provided to a particular patient as the type of biofeedback used is a function of the physiologic mechanisms hypothesized to underlie the childs soiling. For example, training aimed at improving rectal sensation is indicated, if a childs soiling is thought to be associated with poor sensation of the urge to stool. Sphincter strengthening through EMG biofeedback would be a better option, if soiling is associated with poor control caused by a weak external anal sphincter. Most available research apparently focuses on biofeedback treatment of constipation and encopresis associated with pelvic floor dyssynergia. Most children who have encopresis contract the external anal sphincter during defecation, thereby impairing their ability to empty the rectum completely and which in turn compounds ongoing impaction. To assess pelvic floor dyssynergia two electrodes are used: 1. Surface EMG electrodes to monitor abdominal muscles 2. An anal sensor (manometric sensor within anal canal or surface EMG electrodes just outside the anal opening).

Biofeedback 235

To evaluate the ability of the child to maintain external anal sphincter relaxation while contracting abdominal muscle. Biofeedback training is used to teach appropriate response. Training varies in type and duration for each response. Improve or correct dyssynergia: If there is dyssynergia between the two muscle regions this training is used. Along with manometricguided pelvic floor relaxation, this training consists of improving the abdominal push effort (diaphragmatic muscle training) lastly followed by simulated defecation training. Rectoanal coordination: The purpose of this training is to produce a coordinated defecatory movement consisting of an adequate abdominal push effort which in turn is reflected by a rise in intrarectal pressure on the manometric tracing that is synchronized with relaxation of the pelvic floor and anal canal as depicted by a decrease in anal sphincter pressure. Ideally the subject should be seated on a commode with the manometry probe in situ, to facilitate this training. Posture and sitting correction needs a special mention before any maneuver: As against the regular posture of keeping the legs together correct the same by keeping the legs apart. Also correct the sitting angle at which the patient will attempt the defecation maneuver (i.e. leaning forward). After this correction the patient is asked: To take a good diaphragmatic breath To push and bear down as if to defecate. Encourage the patient to watch the monitor while performing this maneuver. Throughout the maneuver keep a close watch and correct the patients posture and breathing techniques. An instant feedback of their performance is provided to the patient from the visual display of the pressure changes in the rectum and anal canal on the monitor, this helps them to understand and learn quickly.

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At least 10 to 15 maneuvers are performed. To provide the subject with a sensation of rectal fullness or desire to defecate, the balloon in the rectum is distended with 60 ml of air. While observing the pressure changes in the rectum and anal canal on the display monitor the patient is encouraged to push and attempt defecation, as soon as the he/she experiences this desire to defecate. The breathing and postural techniques are corrected, once again. The maneuvers are repeated approximately 5 to 10 times. Following instructions are passed to the patient during the attempted defecation, to titrate: The degree of abdominal push The anal relaxatory effort Specifically not to push excessively. Reason being this is often counterproductive and leads to voluntary withholding. The balloon is deflated, after each attempt, and reinflated before the next attempt. The balloon is fully deflated and the probe is removed, after completion of this maneuver. In case an EMG device is used either of the following observation during the maneuver is essentially noted by the patient: To reduce the amplitude of electrical wave forms on the monitor To decrease the intensity of sound signals. Simulated defecation training: The patient is trained and taught to expel artificial stool in the laboratory by using the correct technique. Either a 50 ml water-filled balloon or an artificial stool is placed in the rectum to perform this maneuver. The patient is asked to sit on a commode and to attempt defecation, after the balloon is placed in the rectum in the left lateral position. During the attempt to pass the balloon assistance is provided to the patient and he/she is taught: To relax the pelvic floor muscles To correct the posture and breathing techniques.

Biofeedback 237

Apply gentle traction to the balloon, if the patient is not able to expel the balloon, just to add to the patients efforts. Gradually and with repetition of the maneuver, the subject learns how to coordinate the defecation maneuver and to expel the balloon. Sensory training: The main goal of this training is: To improve the thresholds for rectal sensory perception To promote better awareness for the process of passing stool. Intermittent inflation of the balloon in the rectum, is the primary maneuver. The primary objective is to teach the patient to perceive a particular volume of balloon distention but with the same intensity as they had previously experienced with a larger volume of balloon distention. First and foremost the balloon is inflated progressively till the patient experiences an urge to defecate. Note this threshold volume. The balloon is reinflated to the same volume, after deflation and to educate the subject and to trigger appropriate rectal sensations, the maneuver is repeated two or three times. The balloon volume is decreased in a stepwise manner by about 10% with each subsequent inflation, thereafter. During each distention, the patient is encouraged: To observe the monitor To note the pressure changes in the rectum Simultaneously pay close attention to the sensation they are experiencing in the rectum. To use the visual cues for volumes that are either not readily perceived or only faintly perceived. In case if the patient fails to perceive: A particular volume Reports a significant change in the intensity of perception After a 5-second warning the balloon is inflated again either: By using the same volume By using the volume that was previously perceived (higher). By the end of each session, newer thresholds for rectal perception are established:

238 Anorectal Surgery

By repeated inflations and deflations Through a process of trial and error. Depending on their individual needs each training session should be customized for each patient in following aspects: Duration and frequency of training The number of neuromuscular training sessions The length of each training session. Each training session typically takes 1 hour. The visits to the motility lab are planned once in two weeks. Four to six training sessions are required on an average. Though it is not possible predict how many sessions a particular subject needs. Periodic reinforcements at 6 weeks, 3 months, 6 months, and 12 months after completion of neuromuscular training, may provide additional benefit. These periodic reinforcements can improve the long-term outcome of these patients. Devices and techniques for biofeedback: Several devices and methods are available, and newer techniques continue to evolve, the reason being neuromuscular training is an instrument-based learning technique. Some of the devices being commonly used include: Manometric-based biofeedback treatment with a solid-state manometry system EMG biofeedback Balloon defecation training Home training devices. Ideally suited and recommended for biofeedback therapy is, the solid-state manometry probe with microtransducers and a balloon. A visual display of pressure activity throughout the anorectum is provided by the transducers that are located in the rectum and anal canal. This visual display in turn provides visual feedback to the subject. To provide both visual and auditory feedback, surface EMG electrodes can be incorporated on the probe. The same probe can be used to provide sensory training. All in all the system can serve as a comprehensive device for neuromuscular training.

Biofeedback 239

In place of manometric device, an EMG biofeedback system can be used. This EMG biofeedback system consists of: A surface EMG electrode that is mounted on a probe or Affixed to the surface of the external anal sphincter muscle. The EMG biofeedback system provides instant visual feedback, the EMG signals that are picked up from the surface of the anal sphincter muscle are in turn displayed on the monitor. Instant feedback regarding the changes in electrical activity of the anal sphincter, can be generated from the pitch of the auditory signals. Such feedback responses help the patient titrate the defecation effort and in turn can augment the learning process. Home training devices largely use an EMG home trainer or silicon probe device attached to a hand-held monitor with an illuminated liquid crystal display. The pressure or electrical activity of the patients sphincter responses can be displayed on a simple gauge, a strip chart recorder, or a color liquid crystal display and these are used to provide visual feedback for the subject.

Efficacy of Biofeedback Therapy


The symptomatic improvement rate ranges between 44 and 100% in different uncontrolled clinical trials. The results show that biofeedback therapy is superior to controlled treatment approaches, such as: Diet Exercise Laxatives Use of polyethylene glycol Diazepam Placebo Balloon defecation therapy or Sham feedback therapy. Though offered in few centers only and without adverse effects, biofeedback therapy is a multidisciplinary approach and is laborintensive.

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A home-based, self-training program is essential, to treat the vast number of constipated patients in the community.

Other Measures for Treating Dyssynergic Defecation


Injection of botulinum toxin into the anal sphincter has been tried with mixed results. Different surgical procedures like division of puborectalis muscle with varying degree of success have been described for managing dyssynergic defecation. Biofeedback training seems to be a good treatment for lower gastrointestinal disturbances, especially for pelvic floor dyssynergia. The effects of such training may not be limited to the anorectum and might also be useful in other conditions in which pelvic floor dyssynergia plays a role. With biofeedback therapy the symptom improvement is caused by a change in underlying pathophysiology, it is not only efficacious but also superior to other modalities. Use of home biofeedback programs along with development of user-friendly approaches to biofeedback therapy will significantly enhance the adoption of this treatment by gastroenterologists and colorectal surgeons. In children who have pelvic floor dyssynergia and are not showing a positive response to standard medical management, recommended biofeedback protocol is a brief training program of around two to four sessions. Biofeedback training to be more effective needs to be a complete comprehensive package of: Biobehavioral treatment of encopresis Cleanout Medications Sitting schedule Dietary restrictions recommendations. On the basis of cause, severity of incontinence, or initial manometry, a successful outcome could not be predicted. In response to bearing down, most patients could be taught to relax their sphincter.

Functional Anorectal Disorders

chapter

12

A functional anorectal disorder is dened as a variable combination of chronic or recurrent anorectal symptoms not explained by structural or biochemical abnormalities, or in simple terms, Anorectal symptoms, the etiology of which is currently unknown or is related to the abnormal functioning of normally innervated and structurally intact muscles, or is attributed to psychological causes. Chronic anal or perianal pain without evident cause produces maximum mixed reactions among family, friends and physicians as compared to other disorders. Usually the result of common and easily recognized disorders such as: Anal fissure Anal fistula Intersphincteric abscess Thrombosed hemorrhoids or Anorectal cancer. Pain in the anal canal or perineum is easily manageable, but when no cause can be found management is difficult. Often referred from one specialist to another, the patients are then offered a variety of different and yet ineffective treatments. The functional anorectal disorders are dened primarily on the basis of the symptoms. Men and women of all ages are affected by anorectal disorders. Their management is not limited to the evaluation and treatment of hemorrhoids. The spectrum of anorectal disorders ranges from benign and irritating (pruritus ani) to potentially life-threatening (anorectal cancer) disorders. Patients usually present with constipation, but the clinical picture of these disorders includes:

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Rectal pain and bleeding Digitalization Incomplete evacuation A feeling of obstruction. Because many ndings can be seen in normal patients as well, and the symptoms are nonspecific it makes the patient evaluation and diagnosis difcult. A combination of the following work-up helps arrive at the diagnosis: Clinical picture Defecography Pathology Anal tonometry (occasionally) Pudendal terminal motor nerve latency Some of the most common anorectal disorders include: Levator ani syndrome Proctalgia fugax Pruritus ani Solitary rectal ulcer syndrome Fecal incontinence Pelvic floor dyssynergia Anal fissures. With clinical experience it has been concluded that the classification of perianal pain set is inadequate. Not only are there many overlapping features, but also the syndromes as described do not allow recognition of discrete causes in individual patients and so do not lead to effective means of investigation or management. Generally treated medically with dietary changes, these disorders are responsive to biofeedback. Surgical intervention has not been universally successful and is reserved for patients with intractable symptoms. Cardinal features of chronic functional anorectal disorders include the following: Diagnosed mainly by symptoms, objective findings aid in the diagnosis of these disorders

Functional Anorectal Disorders 243

Though discomfort or pain is the predominant symptom; patients may also have dysfunctional voiding or defecation Associated findings frequently include impaired quality of life, anxiety, and depression Though it is presumed that visceral hypersensitivity and pelvic floor dysfunction may play a role, pathophysiology is not properly studied and poorly understood Because therapeutic approaches have not been rigorous, therapy is guided by clinical features.

Levator Ani Syndrome


Irrespective of the fact that several syndromes have been described, the most common question in the mind of a colorectal surgeon is: What is the cause of this idiopathic perianal pain and how can it be relieved? The first reference to anal pain appeared in 1859 when a syndrome called Coccygodynia was described. Ever since a number of different terms have been used, adding to confusion as to the definition of this syndrome. Coccygodynia is said to consist of a: Vague tenderness or ache in the region of the sacrum and coccyx In the adjacent muscles and soft tissues. Often associated with similar rectal and perianal discomfort. The pain radiates to the back of the thighs or buttocks, occasionally. Most patients are women the prevalence ration has been found up to 85%. The syndrome usually presents in the third to sixth decade of their life and symptoms often persist for many years. In course of time it was noted that sitting seemed to induce or exacerbate the pain, and lead to the suggestion that it was referred from chronic spasm of the levator ani muscles either because of infection or trauma to these muscles.

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It was later suggested to the use of the term levator syndrome, and treatment in form of digital massage of the pelvic floor musculature was offered. The levator ani syndrome is also called: Levator spasm Puborectalis syndrome Chronic proctalgia Pyriformis syndrome Pelvic tension myalgia. The pain in this syndrome is usually described as: Vague Dull ache or Pressure sensation high in the rectum Getting worse with sitting or lying down Lasting for hours to days. The prevalence of symptoms compatible with levator ani syndrome is not very high in the general population and it is more common in women. Around one-fourth patients suffering from this symptom consult a physician, yet it is presumed that the associated disability is signicant. More than half of affected patients are aged 30 to 60 years and prevalence tends to decline after age 45.

Pathophysiology
Though the exact etiology is unknown different studies have suggested. Different hypothesis for the pathology of levator ani syndrome, some of which are as mentioned: That levator ani syndrome results from spastic or overly contracted pelvic oor muscles That levator ani syndrome is associated with psychological stress, tension, and anxiety It is unclear if the association between chronic pelvic pain and psychosocial distress on multiple domains (e.g. depression and anxiety, somatization, and obsessive-compulsive behavior) reflects an underlying cause or an effect of pain

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That levator ani syndrome may be due to visceral hyperalgesia or increased pelvic floor muscle tension, supported by the fact that there is tenderness to palpation of pelvic floor muscles in chronic pelvic pain and levator ani syndrome That levator ani syndrome patients may have increased anal pressures or electromyogram activity. Higher anal pressures may reflect increased external or internal anal sphincter tone Inability to relax pelvic floor muscles suggests pelvic floor dysfunction.

Diagnostic Criteria
If the patient complains of atleast 12 weeks consecutively in previous 12 months for the following: 1. Chronic or recurrent rectal pain or aching and discomfort 2. Episodes last 20 minutes or longer 3. Other causes of rectal pain such as ischemia, inammatory bowel disease cryptitis, intramuscular abscess, ssure hemorrhoids, prostatitis, and solitary rectal ulcer have been excluded, then the patient can be labeled as suffering from levator ani syndrome.

Clinical Evaluation
The diagnosis of levator ani syndrome is based on symptoms alone. One important sign which can raise the diagnosis is: Posterior traction on the puborectalis revealing tight levator ani muscles and tenderness or pain Tenderness usually may be predominantly left-sided Massage of this muscle will generally elicit the characteristic discomfort. Depending on the above-mentioned sign and symptom complex the syndrome has been classified into two levels: A highly likely diagnosis of levator ani syndrome if symptom criteria are satised and these physical signs are present, or A possible diagnosis if the symptom criteria are met but the physical signs are absent.

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To exclude alternative diseases, clinical evaluation will usually include sigmoidoscopy and appropriate imaging studies such as defecography, ultrasound, or pelvic CT.

Treatment
Appropriate testing (e.g. sigmoidoscopy, defecography, ultrasound, or pelvic MRI) should be performed as necessary: To exclude other causes of pain (e.g. Crohns disease, anal fissures) To identify associated conditions (e.g. defecatory disorders). Though there is no fullproof therapy, a variety of treatments have been described that aim at reducing tension in the levator ani muscles: Digital massage of the levator ani muscles Sitz baths Muscle relaxants such as: Methocarbamol Diazepam Cyclobenzaprine. Electrogalvanic stimulation Biofeedback training Ultrasound-guided injection of local anesthetics or alcohol for pelvic nerves (e.g. pudendal nerve) has most of the times not resulted in any improvement. In situations where it becomes essential to offer treatment it would be wise to select a modality like biofeedback which has no significant adverse effects and prevent further harm to the patient. Many patients fail to respond to treatment. Yet surgery should be avoided.

Proctalgia Fugax
Proctalgia fugax is an enigmatic disorder. Proctalgia fugax is a condition characterized by recurring attacks of pain deeply inside the rectum.

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Described in 1935, proctalgia fugax as against levator ani syndrome, is a relatively well-defined syndrome of obscure causation. Ever since it was named in 1935, in an article entitled Proctalgia fugax: a little known form of pain in the rectumIt has been a source of controversy. The majority of observations that were made then in 1935, in the article mentioned hold true today. Proctalgia fugax is described as sudden, severe, irregular attacks of rectal pain lasting several seconds or minutes followed by complete resolution without any untoward effects. Proctalgia fugax has also been defined as recurring attacks of distressing rectal pain with no local positive findings in the rectum. Attacks are infrequent, occurring less than ve times a year in more than half of the patients.

Pathophysiology
The etiology remains unknown, however most theories are focused on spasm of the levator ani muscle and sigmoid colon, where as some studies suggest that smooth muscle spasm may be the cause of proctalgia fugax. It has certain features which suggest that it is due to a sustained muscle spasm. Because of the short duration and sporadic, infrequent nature of this disorder, the identication of physiological mechanisms of this disorder is difficult. Many patients on psychological testing have been found to be perfectionistic, anxious, and/or hypochondriacal. It is commoner in men than women, though prevalence rates may vary in men and women. Beginning in early adult life and the symptoms cease spontaneously in late middle life. The ages of the patients varies between 18 and 65 years. Estimated prevalence ranges from 8 to 18%. However only 17 to 20% of those affected report the symptoms to their physicians. Yet a curiously large number of reports have concerned doctors.

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Diagnostic Criteria
1. Recurrent episodes of pain localized to the anus or lower rectum 2. Episodes last from seconds to minutes 3. There is no anorectal pain between episodes. Proctalgia may be classified into severe and mild attacks. Occuring usually between 4 and 5 am; on rare occasions more than one attack occurs in the same night. Attacks may occur on several consecutive nights, during periods of anxiety or fatigue. Commonly there is an average interval of about one month between attacks. The severe attacks have an aura which: It is localized to the lower abdomen It is of a vague nature difficult to describe. About half to one a minute before the attack, the patients becomes aware that the pain will occur, and may wake up from sleep before any pain. The pain itself is: Deep seated or high in the rectum Severe and agonizing Lasts 10 to 15 minutes It is accompanied by marked syncope. No evidence of spasm in the rectum has been noted in most patients, as far as the finger could reach. The mild attack is: Felt lower down in the rectum Lasts much longer (20 to 90 minutes) Mostly not accompanied by syncope Clinical examination during the attack on several occasions showed spasm of the sphincters.

Characteristics of Pain
The pain follows a definite pattern, and no local cause can be found to account for it. In its most common form the disease starts with nocturnal attacks of pain. Other ways of onset are less common and the patients ultimately develop the nocturnal attacks.

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Particularly common at night it can occur at any time. It begins suddenly and progresses to a cramp-like pain which may be very severe, but which usually resolves after less than 30 minutes. The pain is felt at a constant site above the level of the external anal sphincter in the anal canal or rectum. A feature which suggests that it may be due to a cramp-like spasm of the muscles of the pelvic floor is that the pain may sometimes be relieved by flexing the extended legs as far as possible onto the abdominal wall, as when sitting on the floor. There is a high incidence of symptoms of irritable bowel syndrome in patients with proctalgia fugax. However, the pain itself is not accompanied by an acute bowel disturbance. Specific description of pain like gnawing, aching, cramp-like, or stabbing has been reported by some patients. But there are many more vivid accounts: Like a sharp object held up at the rectosigmoid As if the rectum were being squeezed in a vice Like a wire tied tightly round the bowel Like a small ball expanding slowly. Some patients suffering from the descending perineum syndrome also complain of perianal pain. In these patients a dull aching pain in the posterior perineum is associated with: Abnormal descent of the perineum during straining at defecation Sometimes with prolapse of the anterior rectal mucosa. The pain is: Prominent after defecation, or After prolonged standing It is usually relieved by lying down The pain sometimes improves when the abnormal defecation habit is modified, though in these cases pelvic floor repair may be necessary.

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Clinical Evaluation
Diagnosis is based on symptoms alone. There are no physical examination ndings or laboratory tests that support the diagnosis. Examination reveals that the perineum descends below the plane of the ischial tuberosities at rest, or during straining in patients suffering from the descending perineum syndrome. Other endoscopic and imaging modalities are used to exclude other underlying disorders.

Treatment
The real difficulty in treating proctalgia lies in preventing attacks. This is practically impossible and all efforts directed towards this end have failed so far. Treatment for most patients consists only of reassurance and explanation, because episodes of pain are very brief. Before referral most of the patients have been treated without success. Various treatments including tricyclic antidepressants, benzo diazepines, phenothiazines, paracetamol, codeine, dihydro-codeine, and stronger narcotic analgesics are offered to patients. Others have recommended clonidine or amylnitrate. However, a small group of patients who have proctalgia fugax on a frequent basis: Have shown improvement and reduction in the duration of episodes of proctalgia with inhalation of salbutamol (a beta adrenergic agonist). Local measures such as local anesthetic creams, and surgical approaches such as maximal anal stretch procedures, removal of anal mucosal tags, hemorrhoidectomy or pelvic floor repair, were also unsuccessful.

In most cases, in patients considered to be suffering from pain of psychogenic origin, if subjected to psychiatric evaluation, no abnormality other than that attributed to the effect of chronic unrelieved pain is usually found. It is difficult to devise appropriate treatment because the exact pathophysiology is unknown.

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Percutaneous vibration has been used without effect in some patients. Pudendal nerve block relieved the pain on the treated side for a few hours only and that too in small number of patients. Similarly, carbamazepine is also ineffective or only partially effective. Treatment thus remains unsatisfactory. Massage of the pelvic floor musculature was uniformly ineffective. The patient should avoid the kind of food or drug that, in his experience, precipitates the pain. The belief that Proctalgia fugax is a visceral neurosis is supported by the fact that a number of variety of the measures have been selfdevised by the patient and have given good relief in good number of patients. Though in any complaint which is naturally self-resolving and of short duration, it is admitted that this is a common enough happening. Most patients learn from their own experience some maneuver which seems to help them relieve the symptoms. Different maneuvers tried are as follows: The application of warmth, whether: By clothing or By a hot-water bottle Others get respite from change in position To the genupectoral, or To the squatting, or To sitting on the edge of a chair, or Even to a sitting-up position in bed. In some patients the pain may almost disappear on passage of flatus. Similarly the discharge of any particulate fecal material, even in small amounts; may relieve pain in some patients. It is likely that each effort only signals the relaxation of muscle spasm and the end of an attack.

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Fig. 12.1: Genupectoral position

In some instances, the effort of ineffectual straining may only intensify and prolong the spasm because the patient can expel nothing at all from the rectum. Once the attack is impending, postural treatment is considered the most effective. The genupectoral position can be adopted (Fig. 12.1). Or the patient is advised to lie down on the right side with the buttocks slightly elevated on a pillow, and this should be supplemented by firm pressure on the anus using the left hand for that purpose. This may help abort or greatly alleviate a severe attack. It can be relieved most effectively by the immediate taking of food or drink. The mechanism presumed behind this is that the initiation of the gastrocolic reflex inhibits the painful muscle spasm. Most of the other lines of treatment like the ones mentioned below are largely impracticable: The passing of a rectal catheter, or even The giving of a small enema, warm or cold, water or oil, or even air alone. It seems likely that any success in such maneuvers results from engaging the attention and by arousing interest, curiosity, or expectation.

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Use of Clonidine for Proctalgia Fugax


Clonidine works by stimulation of alpha receptors which in turn: Produce relaxation of the rectal smooth muscle (effect on parasympathetic neurones) Relaxation of internal anal sphincter (effect on sympathetic neurones). The antispastic effect of clonidine might possibly inhibit the spasm of levator ani and external anal sphincter. Apart from this, the central sedative and analgesic actions of clonidine also appear to be very useful in producing relief. Clonidine though needs more evaluation, appears to be effective in treatment of proctalgia fugax.

Perineal Descent Syndrome


Perineal descent was rst described by Parks et al in 1966. It was assumed to be the nal outcome of a cycle that included regularly straining with bowel movements which in turn caused the anterior rectal wall to balloon into the anal canal. The hypothetical sequence of events have been documented as follows: Patients usually have a complain of a feeling of inadequate evacuation of stool Which results in more straining Finally ending up with weakness of the pelvic oor musculature. Constant straining and the resulting perineal descent have been reported to stretch the pudendal nerve and ultimately leading to incontinence. Similarly, it has been demonstrated that abnormal perineal descent results in changes to the external sphincter, that are consistent with neuropathy.

Pathogenesis
Perineal descent syndrome has usually been attributed to: Pelvic oor weakness resulting from

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Neuropathy Trauma during: - Pregnancy or - Childbirth Abnormal defecation behaviors. However, the claims that there is relation between increased perineal descent and pudendal neuropathy have been proved otherwise. With increasing number of vaginal deliveries, a prolonged terminal motor latency is seen yet no association between perineal descent and pudendal neuropathy has been demonstrated in these patients. Individuals with descending perineal syndrome present with: Constipation in the early phase Incontinence as damage continues to the pelvic oor.

Diagnosis
Diagnosis of descending perineal syndrome is based on: Clinical symptoms Physical examination Defecography.

Physical Examination
In the left lateral position, on physical examination; the perineum is seen ballooning outward during straining.

Defecography
Despite the variance in the measurements of perineal descent, defecography can be used to: Document descent (>4 cm) Assess for any other pathology.

Treatment
Treatment consists of: Biofeedback High-ber diets for constipated patients.

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Pruritus Ani
Pruritus ani is defined as intense chronic itching affecting perianal skin. Characterized by intense itching around the anus pruritus ani, is a troublesome symptom that is associated with most forms of anal disease, but in some patients with this symptom no etiological anal disease may be found. As good number of patients suffer prolonged intractable symptoms and treatment is often unsuccessful. It is a frustrating condition for both patients and clinicians. Actually the symptoms of itching or irritation of the perianal skin are usually a disorder of mixed etiology: Partly dermatological Partly psychological Occasionally proctological. Yet, the sufferer is frequently referred to a proctologist when simple or homely treatments fail for two prime reasons: Because of the precision of its fundamental location Because the majority of coexisting conditions are anorectal, predominately hemorrhoids and fissures. Even though the dermatological conditions are usually not restricted to the perianal area, the morphology of perianal skin lesions may be atypical for the disease elsewhere. Paradoxically in most patients the problem is due either: To inadequate cleansing of the anus or To over-vigorous attempts to polish it clean. The symptoms usually range from mild to intense, but when these are severe and persistent, depression may result. However, a detailed history and examination are necessary, as 75% of cases have coexisting pathology.

Etiology Prevalence
Affects 1 to 5% of the population. Atleast four times more common in men. It is most frequent between the fourth and sixth decades of life.

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As against the fact that nearly 100 different causes for pruritus ani have been reported, most patients with pruritus ani do not have a discernible cause for their condition, pruritus ani is classified as idiopathic when no cause can be found. Though but not conclusively proved to be of relevance the following factors play an important role in the etiopathology of pruritus ani: Fecal contamination of the perineum In the absence of gross soiling Irritant chemicals in the feces Allergies - Locally applied agents or - Components of diet A psychosomatic etiology has been suggested. Undoubtedly the condition provokes great anxiety in its most severe forms.

Proctological Conditions
A minority of patients have an easily recognizable proctological condition such as: Anal fissures Anal fistulas Papillomas Skin tags Prolapsing hemorrhoids, or Rectal prolapse. Hygiene: Perineal fecal contamination: Fecal contamination causing pruritus ani is because of prolonged contact with a moist substance or a hygiene issue. Small particles of feces accumulate on the perianal skin, in presence of any condition that hampers efficient wiping of the anus and these accumulated particles act as an irritant. Fecal contamination or soiling may be overt or occult. The patients with occult soiling are unaware of the same yet the soiling is good enough to initiate itch and scratching.

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Clothing: Excessive sweating exacerbated by poorly fitting undergarments and poor personal hygiene are also implicated.

Dermatological Conditions
Though easily treatable yet easily overlooked dermatological causes of pruritus ani: Threadworms Pediculosis pubis Scabies Fungal infections. More generalized dermatological disorders, have also been identified as the causes of pruritus ani such as: Psoriasis Intertrigo Lichen planus Ringworm. Quality of perianal skin: Perianal skin also reacts differently from skin elsewhere, skin-patch testing using autologous feces have produced anal symptoms in up to one-third of patients with pruritus ani and around fifty percent plus of asymptomatic individuals, where as only four percent of cases have been reported to develop irritation with a fecal patch test on the arm. Occuring within six hours, the itching usually gets relieved by washing suggesting irritation as the cause rather than an allergy. Any factor which increases occult or overt soiling augments exposure of the perianal skin to irritants and is a potential area of therapy. Quality of stool: Stool consistency and mucous seepage are attributed as etiological factors. Occult or overt soiling. The following two causes have been documented: Anal sphincter relaxation in reaction to rectal distension Coffee by lowering the anal resting pressures. Accidently during anorectal physiology testing exaggerated rectoanal inhibitory reflexes and incontinence are found in patients with pruritus ani.

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A primary or postsurgical problem: Altered anal morphology may lead to fecal soiling. Inability to evacuate their anal canals completely in these individuals results into the retained fecal material to escape later and further with result in itching. Patients with pruritus ani are less able to maintain absolute continence when dealing with: Loose stools An anorectum whose physiology and morphology has been altered primarily by: Food Surgery or Medications.

Perianal Infection
Although occurring in a minority of cases: Bacterial and fungal infection should not be underestimated Fungal infections account for up to 15% of pruritus ani Dermatophytes Candida albicans in diabetic individuals Candida infection may occur via a colonized partner and they too may need therapy Threadworms are known to infect multiple family members Perianal viral infections: There is no evidence for their causative role in idiopathic pruritus ani, even though they commonly cause itch Sexually transmitted bacterial infections -Hemolytic streptococci, Staphylococcus aureus and Coryne bacterium minutissimum infection can lead to itch that lasts long, -Hemolytic streptococci mostly occurs in children and presents as erythematous, edematous and eczema-like skin in the majority of cases. S. aureus is also found in some cases. Allergic contact dermatitis: Contact dermatitis results in erythema, scaly skin and vesicle formation.

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Sensitization by chemicals found in the following is the basic cause: - Cleansing - Therapeutic preparations including: o Creams o Soaps o Wet wipes o Glyceryl trinitrate o Anesthetic o Toilet paper dye o Other topical preparations. Topical steroid preparations known to provide initial relief results have been proved to contain sensitizing agents which are a part of the growing problem. For this reason, patients should avoid contact with the irritant and soap.

Foods
Some form of the following foods have been implicated in idiopathic pruritus ani, the supporting fact being relief in itch of pruritus ani after some days of avoidance of these foods, these foods have also been shown to have a quantity based effect as acceptable levels can be calculated by gradual reintroduction: Caffeinated drinks Alcohol Milk products Peanuts Spices Citrus Grapes Tomato (histamine) Chocolate Though evidently not proved that exclusion of these foods can improve symptoms there is a strong belief that dietary measures should be tried.

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Retrospective studies have shown one of the following as mechanisms by which foods are thought to cause itch: Reduction in anal sphincter pressures Exaggerated anal reflexes Undigested foods sensitizing the perianal skin. Along with: Foods resulting in looser stools Quicker transit time Greater stool frequency and, this in turn resulting into: Increased fecal seepage Anal trauma from recurrent wiping.

Colorectal and Anal Disease


Most coexisting anal conditions have been found to precipitate or exacerbate itch. More than half of the patients with pruritus ani have anorectal disease. The most common anorectal condition being hemorrhoids. Functional bowel disorders may contribute and hemorrhoids may add to sphincter dysfunction and fecal seepage. Literature shows that around one quarter of patients with proctological disease and pruritus ani have by anal or colorectal cancer as the primary pathology. Treatment of all colorectal and anal conditions in these patients have shown some excellent results. Anal surgery contributed to the elimination of perianal fungal infection and together reduced pruritus.

Dermatological Conditions and Neoplasia


Psoriasis: In 5 to 55% of patients with pruritus ani, psoriasis has been found. Perianal plaques: Isolated perianal plaques may not be very characteristic, the reason being they are altered by repeated scratching, but they can occur and have a sharp edge.

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Lichen sclerosus: Perianal skin is white, atrophic, and wrinkled in lichen sclerosis and has typical biopsy features. Pagets disease: More than half of patients have associated itch. Bowens disease: Same as in pagets disease, more than half of patients have associated itch, the skin lesions in both these conditions have well-defined limits. Other skin cancers present with pain and bleeding.

Steroid-Induced and other Medications


Because potent topical steroids can cause: Thinned skin, acute dermatitis and contact dermatitis from sensitization, they are used sparingly. Addiction of topical steroids has been described in patient who use it frequently to control the rebound itch after cessation. Some medications ingested orally, such as: Laxatives Colpermin Colchicine Quinidine Peppermint oil Some antibiotics They can lead to perianal itch. Mechanism of action can be: Direct irritant on the perianal skin or Indirectly by: Loosening stools Increasing anal seepage.

Clothing
Though there is no evidence of clothes as direct causative effect, heat and sweat have been known to exacerbate itch. Clothes and underwear that allow air circulation and dryness, should be worn by the patients as a preventive measure. For the same reason clothes that increase moisture retention or sweating can cause seasonal pruritus.

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Biological enzyme based detergents should be avoided as these may result in itch by the residue that remains after the use.

Systemic Disease and Psychological Factors


Directly or indirectly in combination any of the following illness can lead to pruritus ani, and the most common are: Diabetes mellitus Liver disease Leukemia Lymphoma Renal failure Iron-deficiency anemia Hyperthyroidism. Anxiety, stress and certain personality traits should be treated concurrently as these may contribute as causative factor. Pruritus ani may be a manifestation of: Depression or Psychological disturbance.

Pathology
Rarely nonspecific histological abnormalities are observed in skin biopsy samples. Commonly observed abnormalities are: Hydrops of the epidermis Irregular proliferation of the stratum mucosum Edema of the dermis.

Clinical Features
Women are not as commomly affected as men. Starting as a pleasent slight itch, it may progress to severe pruritus extending over the entire perineum. Symptoms may be the sole focus of attention, and are usually worse at night. Because of excessive sweating the condition is worse during the summer.

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Scratching the perineum, produces short lived relief and relieves the patient of the itch. But continued scratching causes damaging excoriations, which may bleed. This vicious circle of itching and scratching is difficult to break and may induce a state of nervous exhaustion. Examination of the perineum discloses a wide range of appearances. Some patients with severe pruritus ani have: A completely normal looking perineum and anus Others have: Pronounced perianal skin creases and folds. The skin may have a sodden white appearance or There can be various shades of red with excoriations from scratching. The perineum is red raw and bleeding (In its most severe form).

Diagnosis
History
Even though the patients may not relate perianal itch to skin symptoms elsewhere, specific questions for coexisting skin disease, atopy, urticaria and other allergies should be asked for. Considered safe, devoid of side effects and not as a medicine a good number of over-the-counter topical therapies may have been the causative factor for the symptoms or altered skin morphology. History of previous patch testing, illness, diarrhea and treatments such as antibiotics and steroids may guide to the diagnosis. Intermittent or seasonal itch is very typical of recurrent anorectal pathology, different clothes or laundry detergents.

Examination
The patient should be examined for evidence of other dermatological disorders. Complete and general examination may reveal other sites of localized or generalized skin disease or infection. Tinea, psoriasis or neoplasia have a distinct boundary.

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However the extent of neoplasia extends beyond this sharp border. If the reddened skin has a clearly demarcated margin fungal infection should be strongly suspected. The diagnosis is further confirmed by microscopic examination of skin scrapings: Erythema is seen with chronic topical steroid use Bright erythema suggests yeast infection Hyperpigmentation is evidently present in any chronic inflammation, in these cases infection and chronic discharge should be looked for The labia or perineum are always involved in lichen sclerosus Herpes is associated with severe itch and multiple lesions Severe cases have the following characteristic symptoms: The skin becomes lichenified Thickened Leathery Exaggerated skin folds Fissures Erosions. Palpable groin nodes are present in: Neoplasia Sexually transmitted infections Idiopathic inflammation is nonspecific visually and is identified by indistinct borders Chronic trauma results in lichen simplex chronicus Threadworms appear as thin white threads about 6 mm in length and may be seen around the anal orifice, they can also be identified in the effluent of a diagnostic saline enema A thorough anorectal examination is performed to identify potentially treatable causes of pruritus ani.

Investigations
Because microbiological investigations are frequently incorrectly performed, false negatives occur, even though the concurrent rate of infection is significant; this is the reason for treatment failure in these type of patients.

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Special instructions for media and preservation of specimens: Fungal and bacterial specimens should be placed in bacterial transport medium and refrigerated Anaerobic samples can be stored at room temperature but need specific anaerobic medium Exudates from vesicles should be placed on a slide or viral culture medium, after vesicles have been unroofed. Look for: 1. Streptococcus spp. 2. Staphylococcus spp. 3. C. Minutissimum 4. Fungus In all specimens: Swabs should be taken before internal examination, because water-soluble lubricants have bactericidal activity. Fungal culture and microscopy should be performed on all skin scarping. Apart from the affected skin, neighboring normal skin should be included in all biopsies. Skin-patch testing should be carried out, in all refractory and persistent cases.

Management Treat the Cause is the Thumb Rule


However, most patients will not have an identifiable lesion to treat, and many of the patients who undergo surgery for potentially implicated anorectal conditions continue to have symptoms. Patients tend to make repeated visits to outpatient clinics with little improvement, seeing a different doctor at each visit. There is a danger that they will become disillusioned. At any stage, if the response is poor, one must reconsider the diagnosis. Yet the aim of surgical treatment of anorectal lesions such as hemorrhoids and tags should be to:

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Guidelines for patients with pruritus ani Keep the anal area clean by washing after defecation Avoid medicated soaps which may cause sensitization Dry the anal area by gentle dabbing rather than rigorous rubbing. Do not use lavatoryuse moist tissues normally used be helpful, but scented powders should be avoided as they may be allergenic Use only specifically prescribed ointments as some keep the skin moist and may be allergenic Avoid impervious underwear such as acrylic and nylon garments which trap sweat Maintain a regular bowel habit and avoid highly seasoned and spiced foods Wear cotton gloves at night to reduce the damage from subconscious scratching

Management of pruritus ani Identify and treat secondary causes Give advice about personal hygiene Maintain the patients confidence Avoid frequent unproductive clinic visits

Achieve a smooth anus that can be easily wiped Where feces cannot accumulate. Guidelines on how to minimize the symptoms need to be provide to these patients with refractory disease. As a matter of fact strict adherence to such advice undoubtedly helps and the regimen may be relaxed as symptoms ease. Management has three components which function in parallel: Elimination of irritants and scratching General control measures Active treatment measures.

Elimination Step
Eliminate irritants such as: Creams Soaps Bubble baths Toilet paper Scratching

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Certain foods Drinks. The perineum should be rinsed free of residue with a shower head, if a shampoo or any other cleanser is used whilst in the bath. Patient should be provided with a list of foods that have been found to be associated with itching. An elimination diet may be attempted and symptom diary kept. Clothes should be washed in nonperfumed detergent. If itch worsens after the use of wet wipes, patients must be warned against their use and they must be stopped immediately in case of sensitization.

General Control Measures


The perineum needs to be washed with a shower head without soap, and dried with a hair dryer. To assure that the anal canal is washed of retained feces. Perineal cleansing should ideally be done in the squatting positions. Instead of soap aqueous cream or emollients should be used. Barrier creams, such as zinc oxide or petroleum ointment can be applied after washing. Before underwear is worn. The perineum should be absolutely dry and the underwear should be changed daily. Especially for nocturnal itch, acute itch is suggestive of fecal seepage and immediate cleansing is the most effective remedy. Patients should be given advice on how to cleanse when outside their homes. Small containers of oil-based preparations or aqueous cream tubes take up little space and the contents can be squeezed onto cotton wool to clean the perineum. In those who sweat excessively, cotton tissue can be placed perianally to absorb moisture. To reduce trauma from inadvertent nocturnal scratching, short finger nails have been advocated.

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Active Treatment
If threadworms are discovered: Patients and their families are treated with a course of mebendazole To prevent reinfection, strict measures of hygiene need to be adopted. Pediculosis pubis and scabies are treated with topical lindane or malathion. If the diagnosis is confirmed as fungal infection, treatment with a topical antifungal agent is given. All dermatophyte infections should be treated in all with a topical imidazole or terbinafine. Treat Candida infection with nystatin ointment. Many may become obsessional about their bowel habit and perineum because they continue to suffer. The vicious circle of itching and scratching can be broken by local applications. Calamine lotion and carbolic lotion are the most popular topical preparations used to soothe the perineum. Topical corticosteroids may also help in short courses. Though the relief may be short lived, these treatments often interrupt the cycle and allow damaged skin to heal. To prevent skin atrophy which is counter productive, prolonged treatment with topical steroids should be avoided. There are some doctors who have advocated the use of topical immune modulators, which avoid skin atrophy and have antifungal activity, but no studies have yet investigated this. Though some doctors advocate injecting alcohol or phenol into the perianal skin in order to destroy the subcutaneous nerves and ease the itching, the results, however, are almost invariably disappointing. Dermatological conditions should be treated by an appropriate specialist as for example in chronic cases a skin condition such as psoriasis should not be missed and a dermatological opinion is valuable. -Hemolytic streptococci, S. aureus and C. Minutissimum should be eliminated with topical antibiotics such as fusidic acid or mupirocin, and oral antibiotics may be necessary especially if:

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The itch has a long history There are skin changes present or Other sites may also need to be treated. All anorectal conditions should be sought and treated if need be surgically, because even small skin tags: May hide fecal residue or Trap moisture perpetuating the condition. If not constipated, seepage may be reduced by adding fiber to the diet and loperamide. Nocturnal scratching which is probably a marker of anal seepage can be reduced by systemic antihistamines and, the patient should be advised to wash the area immediately and apply a barrier cream. Topical antihistamines are not potent enough and sensitize the skin. The short, intense, burning sensation produced by topical capsaicin produces an inhibitory feedback which may eliminate to need to scratch. Anal tattooing should be considered: In those who have failed other treatment measures Become steroid dependent or In whom symptoms severely impact on quality of life. Topical use of anesthetics have little or no role as: They do not alter the disease Provide relief for only a few hours Sensitize the skin. Hypnosis has been used, but there is insufficient evidence available for its recommendation. An honest approach is best: The patient should be informed about the chronic nature of the condition Not only to reduce the expectation of immediate cure But also to improve compliance with advice given. Warn the patient that a precise cause for their condition may not be found but that By paying attention to personal hygiene their symptoms can be minimized.

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Solitary Rectal Ulcer Syndrome


Solitary rectal ulcer syndrome (SRUS) and stercoral ulceration, are two conditions that are related to local tissue ischemia and often seen in the elderly population though it can affect all ages. Solitary rectal ulcer syndrome is the final clinical outcome of different pathologic settings associated with compromised perfusion to the rectal mucosa. Solitary rectal ulcer syndrome, as the name implies, consists of several different clinical pathologic processes, which ultimately end in a mutual common pathway that is associated with reduced blood perfusion of the rectal mucosa, leading to local ischemia and ulceration. Solitary rectal ulcer syndrome is a benign uncommon disorder of evacuation frequently associated with rectal prolapse, but most of the times it is a disabling condition in which excessive straining at defecation results in focal mucosal changes with pain, bleeding, and mucous discharge. Typical characteristics of solitary rectal ulcer syndrome include: Rectal ulceration Rectal bleeding Copious mucous discharge Anorectal pain Erythema or mass associated with straining at defecation Rectal prolapse A feeling of incomplete evacuation Typical histologic features.

Due to lack of awareness of the disorder, the diagnosis often is delayed. In the early nineteenth century, by the French anatomist J. Cruvilhier, in his report on chronic rectal ulcer described the SRUS. In 1969, by Madigan and Morson, the distinctive histopathologic characteristics were defined. With a prevalence of less than 1 in 100,000 per year, SRUS is a rare syndrome.

Functional Anorectal Disorders 271

Clinical Presentation
Solitary rectal ulcer syndrome (SRUS) diagnosis is delayed in many cases due to: Its rarity Nonspecific signs, and symptoms Various causes However major complaints encountered by physicians are: Chronic constipation Strenuous defecation Bloody and mucous secretions per rectum Nonspecific pelvic pain.

Diagnosis
Endoscopy typically discloses a raised erythematous patch with or without frank ulceration, a solitary ulcer on the anterior rectal wall and biopsy confirms a solitary rectal ulcer or colitis cystica profunda. Biopsies should always be taken to rule out a malignant disease. The microscopic changes are analogous, and comprise of: Fibromuscular obliteration Disorientation of the muscularis mucosa Characteristic fibrosis of the lamina propria.

Etiopathology
Chronic local ischemia of the colonic wall is the underlying cause for this type of ulceration. The pathogenesis of SRUS is uncertain. There is history of any or all of the following in a large subgroup of patients: Excessive straining during defecation. A behavioral disorder. Although the gradual sequence of this pathology may originate for various reasons, SRUS has been related to several independent clinical settings: Occult or overt rectal prolapse with paradoxical contraction of the pelvic floor

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Straining during defecation results in prolapse and high fecal voiding pressures which in turn reduce local blood flow causing ischemia and ulceration The pressure of prolapsed mucosa against a closed anal canal can result into mucosal trauma.

Rectal Prolapse and Intussusception


Rectal intussusceptions leads to: Full-thickness rectal prolapse Which in turn leads to localized vascular trauma and ischemia Initiates solitary local ulceration.

Paradoxic Contraction of the Pelvic Floor Muscles


Uncoordinated sequence of muscle contraction and relaxation that is required for the defecation process, and also known as puborectalis syndrome or pelvic outlet obstruction. It typically causes increased pressure inside the rectum and anal canal, generating ischemia and ulceration: Evidence of inappropriate pelvic floor contraction is seen in electromyographic and video proctographic studies.

Trauma
History of digitation or self-instrumentation leading to localized rectal trauma, has been proposed as one of the causes of SRUS one of the most common in our setups. Though not well documented there is supportive evidence for anal intercourse as a basis for rectal ulceration. Chronic constipation and hard stool leading to extraneous defecation basically cause high pressure similar to pathogenesis of outlet obstruction and lead to: Chronically reduced mucosal blood flow in the rectum Local mechanical-induced tears.

Radiotherapy and Ergotamine Suppositories


The use of ergotamine suppositories has been shown to have a substantial role in the pathogenesis of SRUS.

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Again, ergotamine suppositories have been shown to effect the mucosal perfusion and results in ischemia. These strong vasoconstrictors, indicated for treating severe migraine, have been shown to induce local ischemia and ulceration. Radiotherapy, which in the long-term affects permanently small blood vessels, has been cited as potentially antecedent to SRUS as well. The mucosa of the anterior wall of the rectum, 7 to 10 cm above the anal verge, is the most common area of prolapse into the anal canal, and this corresponds to the usual location of ulceration in SRUS. SRUS has been associated with use of ergotamine suppositories and after radiation therapy, further supporting a pathogenic role for ischemia. Moreover, the successful treatment of SRUS using biofeedback has been associated with an increase in local blood flow, additionally suggesting that SRUS may be associated with reduced rectal blood flow from impaired extrinsic autonomic cholinergic nerve activity.

Treatment
The therapeutic approach is variable, because the etiology of SRUS is diverse. The therapeutic outcomes varies depending on the underlying cause and the chosen treatment. Usually by direct endoscopy and pathology results from biopsies that ruled out malignancy the diagnosis is arrived at, detecting the underlying pathologic basis of disease is the next diagnostic step. Thorough history-taking: To rule out: Local trauma or Behavioral patterns and How to avoid these may be the initial treatment. The following imaging and physiologic studies are usually indicated and help diagnose muscle relaxation-related pathologies as well as other mechanical disorders: Rectal ultrasound

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Cinedefecography Contrast enema. Conservative measures such as: Stool softeners Adequate daily water intake Keeping away from digitation Avoiding the use of relevant suppositories. Symptomatic relief may be achieved by optimizing bowel consistency and regularity with daily evacuation, as well as by correcting pelvic floor disorders, have helped patients suffering from some underlying pathologies, relief from the clinical signs and symptoms. The therapeutic aspects should focus on biofeedback training sessions, educating the patient to control the proper muscle contraction and muscle relaxation sequence, when the source of local ischemia is pelvic outlet obstruction. Surgical intervention is indicated, in some cases when rectal prolapse is diagnosed. Equally important is the decision on choosing the correct surgery, which may vary from a resection using the perineal approach to abdominal operation or even a permanent colostomy, should be made independently for each patient. Exclusion of malignancy is essential. Local treatments with steroid or sulfasalazine enemas are not effective in all patients, whereas using a fibrin sealant achieved good results in some patients. Identifying the correct foundation allows proper treatment with optimal results.

Anorectal Malformations

chapter

13

The surgical correction of anorectal malformations remains a serious and unresolved problem, despite its relatively frequent occurrence. It is important to consider the importance of the sphincter complex, in understanding the spectrum of anorectal anomalies. This complex is the combination of the: Puborectalis Levator ani External and internal sphincters The superficial external sphincter muscles all meeting at the rectum. Anorectal malformations are defined by the relationship of the rectum to this complex and include varying degrees of stenosis to complete atresia. Division of the abnormalities into high (rectal) malformations and into low (anal) malformations has proved to have both therapeutic and prognostic significance. The incidence is 1/4,000 live births. Significant long-term concerns focus on bowel control and urinary and sexual functions. During the last several decades, signicant advances have been made in the understanding and treatment as well as in the correction of anorectal malformations. Despite these advances, the primary goal of the surgeon remains a very evasive one. The main aim of the surgical treatment for these patients is to achieve a repair and to create a reconstructed anatomy which provides a nearly normal anal outlet for the patient, in an attempt to provide these children with a good quality of life.

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Imperforate Anus
The rst description of imperforate anus was by Aristotle, who described the condition of an imperforate anus with a rectourethral stula in a cow. Paul of Aegina, a Byzantine physician, successfully incised the perineum of an infant born without an anus, in the seventh century. In 1835, Jean Zulema Amussat described the dissection of the perineum with mobilization of the end of the rectum to the skin, emphasizing the necessity of mucosal continuity with the skin.

Prevalance
The incidence of occurence of imperforate anus is 1 out of every 4000 to 5000 live births, most commonly with: A rectourethral stula in boys A rectovestibular stula in girls. Imperforate anus with a rectovaginal stula was considered as a relatively common defect in earlier times, later retrospective studies have shown that these malformations were likely either: A misdiagnosed rectovestibular stula A persistent cloacal malformation, where the urinary tract, vagina, and rectum form a common channel. As a matter of fact, a true rectovaginal stula is quite rare, occurring in less than 1% of all diagnosed cases. Imperforate anus occurring without a stula occurs in only about 5% of patients. The incidence of a subsequent sibling also having an anorectal malformation is approximately 1%. Imperforate anus in good number of cases is a misnomer, because the great majority of cases have some opening even though it be displaced and small. The majority of abnormalities found clinically can be explained by these two concepts: Failure of migration so that an orifice or its remnant will remain at the site of a more primitive anus.

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The concept of excessive fusion of the lateral genital folds covering the anus and usually leaving an opening somewhere anterior to the usual anal site. Clinically imperforate anus can be divided into: Low lesions where the rectum has descended through the sphincter complex High lesions where it has not. Most patients with imperforate anus have a fistula. In both males and females there is a spectrum of malformation.

Manifestation and Diagnosis


Low Lesions (Fig. 13.1A)
As a protocol examination of a newborn includes the inspection of the perineum. Further evaluation is needed in the absence of an anal orifice in the correct position. Many patients have no symptoms, although the primary symptoms and constipation, have been attributed to anterior ectopic anus. Commonly known as anal stenosis or anterior ectopic anus, mild forms of imperforate anus are probably imperforate anus with a perineal fistula. The normal position of the anus on the perineum is approximately halfway between the coccyx and the scrotum or introitus. There may be a low lesion or covered anus, even if no anus or fistula is visible. In these cases: The buttocks are well formed Often presence of a thickened raphe or bucket handle (also called black ribbon.) Meconium bulging may be seen after 24 hour, due to accumulation and presents as a blue or black bulge. An immediate perineal procedure can often be performed in these cases, and then followed by a dilation program.

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Figs 13.1A to D: Imperforate anus in females

In a male patient: The perineal cutaneous fistula may track anteriorly along: The median raphe across the scrotum Sometimes down the penile shaft. In males, low lesions usually present with: Meconium staining somewhere on the perineum along the median raphe. In most cases the perineal fistula is a thin track, and the normal rectum lies just a few mm from the skin. Some of these patients have accompanying extraintestinal anomalies.

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Figs 13.2A to C: Imperforate anus in males

Girls with low lesions also present as a spectrum: From an anus that is only slightly anterior on the perineal body To a fourchette fistula that opens on the moist mucosa of the introitus distal to the hymen. In the latter instance the rectum descends through the sphincter complex. The primary treatment of children with a low lesion is perineal procedure and dilation. It is very important to visualize these fistulas for proper evaluation and treatment to the extent that is advised not to pass a nasogastric tube for the 1st 24 hours, in order to allow the

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abdomen and bowel to distend, in turn pushing meconium down into the distal rectum.

High Lesions (Figs 13.1B and 13.2A to C)


A high imperforate anus in a male has no apparent cutaneous opening or fistula but usually has a fistula to the urinary tract, either the urethra or the bladder. The perineum appears flat in a boy with a high imperforate anus. High imperforate anus is usually accompanied by a fistula, the features of different fistula are as follows: When the fistula is high, entering: The bulbar or prostatic urethra or the bladder air or meconium may be passed via the penile urethra. Most commonly in males a rectourethral fistula features: A satisfactory sphincter mechanism Usually an underdeveloped sacrum Presence of an anal dimple.

Rectoprostatic Fistulas
The sacrum is poorly developed The scrotum may be bifid The anal dimple is near the scrotum.

Retrovesicular Fistulas
The sphincter mechanism is poorly developed The sacrum is hypoplastic or absent. The stulas associated with imperforate anus can also extend to the perineum (i.e. cutaneous stula) or to the bladder neck.

In Patients with a Rectoperineal Fistula


Rectum is located within most of the sphincter mechanism Only the most distal portion of the rectum is anteriorly misplaced.

In Boys with Trisomy


Apart from all the features of a high lesion: There is an absence of a fistula

Anorectal Malformations 281

The sacrum and sphincter mechanisms are well developed The prognosis is good. Imperforate anus with a rectovestibular stula is the most common anorectal malformation in girls. Previously, many of these patients were misdiagnosed as having a rectovaginal stula. Diagnostic finding in these type of girls is: A normal urethral opening and vagina The stula entering just below into the vestibule. High lesions in girls are usually cloacal anomalies in which the rectum, vagina, and urethra all empty into a common channel or cloacal stem of varying length. Though a true rectovaginal fistula is rare, there may be appearance of the same in girls with high imperforate anus. Fistula opens to the vestibule outside the hymen orifice A normal sacrum is present An anal dimple is present Sphincter function is intact Prognosis is good. A stula opening in the posterior wall of the vagina, within the hymenal ring is confirmatory of a true rectovaginal stula.Only one percent of all girls with anorectal malformations, suffer from this malformation. The surgical approach and the prognosis in girls with: Rectal atresia Those with imperforate anus A rectoperineal stula Those with imperforate anus Without a stula is similar to boys.

Cloacal Anomalies (Figs 13.1C and D)


Occuring one in 50,000 births a persistent cloaca includes a spectrum of malformations with a combination of the urinary, genital, and gastrointestinal tracts.

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This is usually a form of cloaca wherein the rectum, urethra, and vagina communicate with the cloaca. Cloacal anomalies are different from other anomalies in that: They have a much broader range of anatomic anomalies than any other congenital malformation Require a complex reconstruction. A persistent cloaca is characterized by a common channel that empties the rectum, the vagina, and the urinary tract. The patient might have: a persistent urogenital sinus, draining the vagina and bladder, with an anteriorly displaced anus adjacent to this sinus at the mild end of the spectrum. On the other side of spectrum are more severe malformations wherein, the three tracts join in the pelvis, with varying lengths of the common channel. Low cloacal malformations are typically less complex with shorter channels, i.e. < 3 cm, contrary to this higher malformations with longer channels are frequently associated with a more complex defect and require a more complicated surgical repair. The children with these anomalies might appear to have imperforate anus and small genitalia. However on careful inspection, a single perineal orice is usually found. The infant may become distended, in case the colon is obstructed. In around half of the patients, the urine ows retrograde into the vagina, after it lls the common channel, resulting in distention of the vagina and displacement of the bladder forward. Furthermore, this can lead to bladder outlet obstruction and hydronephrosis. It is important to realize this anomaly, as the repair will often require repositioning of the urethra and vagina as well as the rectum. Children of both sexes with a high lesion require a colostomy before repair.

Cloacal Exstrophy
Cloacal exstrophy is a different anatomic problem than a persistent cloaca.

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The incidence of this malformation is approximately 1 in every 300,000 live births. The classic description of cloacal exstrophy includes: An omphalocele Imperforate anus Exstrophy of two small hemibladders surrounding a lateral cecal ssure Ambiguous genitalia. There are instances when the terminal ileum prolapses through the cecal ssure, where as the colon usually connects with the cecum and blindly ends in the pelvis.

Rectal Atresia
Rectal atresia is a rare defect occurring in 1% of all patients with an anorectal malformation. The characteristic features are same in both sexes. It is unique anorectal anomaly in the sense that affected patients have a normal anal canal and a normal anus. Though the anal canal is normally located, it is very small and the upper rectum is dilated. The separation of the rectum and anal canal can vary from a thin membrane to a dense brous tissue. Usually, the defect is discovered while taking the rectal temperature. About 2 cm above the skin level, an obstruction is present. A protective colostomy is needed in these type of patients and the functional prognosis is excellent because they have a normal sphincteric mechanism which resides in the anal canal, apart from the normal sensation.

Associated Anomalies
Many different anomalies are associated with anorectal malformations. Of these, the most common are anomalies of the kidneys and urinary tract in conjunction with abnormalities of the sacrum, commonly known as the caudal regression syndrome. Next in the list are cardiac anomalies and esophageal atresia with or without tracheoesophageal fistula.

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Other anomalies related to spinal column also occur though very rare.

Management
The first and foremost step in management of neonate with anorectal malformations is to exclude associated malformations such as: Vertebral anomalies Cardiac malformations Esophageal atresia Urinary defects. To rule out these associated defects following investigations are a part of the work-up: An echocardiogram Spine radiographs A spinal ultrasound An abdominal ultrasound. Not to be missed out is the most vital, a thorough examination of the perineum. To determine the presence or absence of a perineal stula, observation over the rst 24 hours of life may be required. During this period: The intraluminal pressure of the bowel increases Forcing the meconium through the stula Allowing it to be seen on clinical examination. A descending colostomy should be considered, if evaluation is pointing to the diagnosis of a rectovesicular stula in a male: With the presence of meconium in the urine An abnormal sacrum A at bottom. A colostomy is also indicated, if a persistent cloaca is identied. A formal reconstruction can then be performed later, in both cases. A posterior sagittal approach is advocated by most pediatric surgeons to repair anorectal malformations. Similarly, more stress is being laid on a primary reconstruction of an anorectal malformation without a protective colostomy.

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Procedure
All pediatric surgeries are best performed under general anesthesia. To demonstrate muscle contraction and keep the incision in the midline, an electrical stimulator is used. This identification guides the surgeon to divide the bers of the muscle complex in the midline, following this, the rectum is separated from the urogenital structures. By using the electrical stimulator, the limits of the anal canal are identified anteriorly and posteriorly. The rectum and anus are then placed within the muscle complex. The perineal body is repaired and the muscle complex is reapproximated to avoid rectal prolapse the rectal wall is incorporated in the muscle repair at the anterior and posterior edges. In patients with a persistent cloaca, a decompressive colostomy is usually required. A right transverse colostomy is mostly advocated, as a more distal colostomy could compromise: A subsequent pull-through procedure A subsequent vaginal reconstruction. In patients with hydrocolpos and resulting bladder outlet obs truction, intermittent catheterization of the urogenital sinus might be needed to drain the vagina of urine and mucus. The anatomy of the cloaca and distal limb of the colostomy should be defined using contrast studies, before attempting a denitive reconstruction. As the level of the conuence can have a substantial implication for surgical repair, the length of the channel should be ascertained by endoscopic examination of the common channel. In patients with cloacal anomalies and cloacal exstrophy, magnetic resonance imaging of the spinal cord is essential to evaluate the presence of a cord, which is present in one-third of persistent cloacal patients and in nearly all cloacal exstrophy patients. Between 6 and 24 months of age is the most appropriate time for denitive repair of the persistent cloaca.

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In case, the common channel of the confluence of the urinary, genital, and gastrointestinal tracts occurs low, i.e. common channel is less than 3 cm, a posterior sagittal approach is good for most surgical reconstructions. In patients suffering from higher anorectal malformations, an abdominal approach and a vaginal reconstruction must be added to the posterior sagittal incision for management, because the rectum of these patients is unreachable through a posterior sagittal incision. Though earlier repairs of a persistent cloaca involved complete separation and individual mobilization of the rectum, vagina and urinary tract, newer techniques however, describe the technique of a total urogenital mobilization in patients with a low malformation and a short common channel. This technique involves: Separating the rectum from the vagina Mobilizing the vagina and urethra as a single unit. Thus, allowing: A shorter operative time Avoiding some of the complications of a urethrovaginal stula or a vaginal stricture. It is usually advocated that to avoid the tedious task of a separate procedure, the surgeon should perform: A pull through procedure Take care of the genitourinary tract at the same operation. A cloacal exstrophy as previously mentioned, is anatomically different from a persistent cloaca, and requires different surgical management. The procedure involves the following steps: The gastrointestinal tract and the urinary tract should be separated Making it convenient for the two hemibladders to be joined and closed The divergent pubis approximated once the omphalocele should be closed

Anorectal Malformations 287

Keeping the hindgut in continuity with the gastrointestinal tract, the cecum should be separated from the bladder and closed. This rudimentary colon ultimately provides satisfactory colonic absorptive function, as it has the capacity to enlarge and lengthen. Especially in children with: Sacral agenesis A lack of perineal muscle. An end colostomy can be performed. A pull-through procedure could be performed either immediately or as a second stage later in the course of management. In either case, one should consider as a protective ileostomy. Further reconstruction later in life is usually required in these children, in the form of: Bladder augmentation Continent diversion Vaginal reconstruction.

Laparoscopic Assisted Pull-Through


A new technique of a laparoscopically assisted anorectal pullthrough for the repair of a high imperforate anus has been advocated recently.

Steps
Rectum is dissected laparoscopically and the stula to the genitourinary tract is divided. In the next step bowel is extracted out of the pelvis to allow clear visualization of the pelvic musculature. The limits of the proposed anal opening are determined after the external perineum is evaluated using transcutaneous electrostimulation.

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The intrasphincteric plane is bluntly dissected toward the light emanating from the laparoscopic light source, through a small external perineal incision at this site. Under direct laparoscopic visualization, a Veress needle is passed into the middle of the pelvic musculature. The rectum is pulled through the path created by dilatation of the tract through which the Veress needle is introduced, and an anorectal anastomosis is performed.

chapter

Fissure in Ano

14

Although fissure in ano is an extremely common condition, it is surprisingly difficult to know exactly how widespread it is. In day-to-day practice, all anorectal problems encountered in practice, anal fissure represents one of the most common, if not the single most common. An anal fissure is a painful tear or split in the epithelial lining of the distal anal canal. Because many fissures will resolve without surgical or medical intervention, many people avoid seeking treatment. Nevertheless, the combination of anal pain and bleeding is sufficiently worrisome that patients often seek medical attention. Patients typically complain of severe anal pain lasting minutes to hours, during and after defecation. Bleeding is commonly seen either on the toilet tissue or streaking the stool surface, in the form of bright red blood. Anal fissures may be classified: Acute fissure in ano Chronic fissure in ano. According to: Length of symptoms Typical morphologic appearances. The majority of acute fissures heal spontaneously but a proportion becomes chronic. Chronicity is justified by: Persistence of symptoms beyond 6 weeks By the presence of visible transverse internal anal sphincter (IAS) fibers at the base of a fissure. Associated features include (Figs 14.1 to 14.3): Indurated edges A sentinel pile A hypertrophied anal papilla.

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Fig. 14.1: Fissure in ano

Another mode of classification is: Typical Atypical. Because of the absence of accepted definitions for chronic fissures, there is a wide and differing consensus on healing rates with various interventions reported in the literature. Therefore, the fraternity should work out a precise classification for fissure in ano. Lindsey and colleagues have described a chronic anal fissure as the presence of visible transverse internal anal sphincter fibers at the base of an anal fissure of duration not less than six weeks. Location: Anal fissures are most commonly seen in the posterior midline, although 10 to 20% in women and 1 to 10% in men are located in the anterior midline. It is a common finding that fissures located off the midline suggest the presence of underlying pathology, such as: Crohn disease Syphilis Anal cancer and generally require further evaluation: Like an examination under anesthesia

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Biopsy to establish a diagnosis. Because the chronic fissures are associated with: IAS spasm Ischemia, the relief of these issues is primary for achieving healing, whether a surgical or medical approach is taken.

Pathogenesis
Though one of the most common anorectal disorders and despite the common nature of this longstanding problem. The exact mechanism surrounding the pathophysiology of anal fissures has not been clearly established and the exact cause remains uncertain. Many patients relate the occurrence of a fissure to the passage of a hard stool or anal trauma. Anal sphincter tonicity and blood flow are the basis of the current hypotheses. Trauma to the anal canal is the primary initiating factor, possibly due to the passage of hard stool. Surprisingly constipation is not always reported and some patients describe repeated episodes of diarrhea.

Perpetuating Factors
Constipation is likely to play a role in perpetuating an anal fissure, by repeated aggravation of the anal canal. The common finding of sphincter hypertonicity has been described in early reports of the disease and documented by manometry in multiple studies and it is the leading hypothesis behind the pathogenesis. In patients with fissures, increased resting pressures within the IAS, has been described as another perpetuating factor. In fissure patients anorectal manometry has consistently demonstrated that internal anal sphincter (IAS) tone as measured by the resting pressure is elevated, when compared to normal controls.

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IAS alone seems to be responsible for the hypertonicity. Maximal voluntary contraction of the external anal sphincter remains similar between the two groups. Relative ischemia is another perpetuating factor: In posterior midline of the anal canal, there is a relative ischemia and this is exacerbated by increased tone. Key factor in preventing fissures from healing. Secondary to the anorectal angle, there may be mechanical factors in the posterior midline that creates the greatest stress at that location.

Internal Anal Sphincter Physiology


The rationale for current nonsurgical treatment is the significantly improved and the clear understanding of the physiology of the IAS in recent years. The resting tone of the IAS depends on: Intracellular calcium concentration Contraction of the smooth muscle cells within the IAS. Which in turn are mediated by: Influx of calcium through calcium channels By stimulation of a1-adrenoreceptors at the smooth muscle cells. Nonadrenergic, noncholinergic (NANC) relaxation is inhibited by activation of 2-adrenoreceptors in the myenteric inhibitory neurons presynaptically. Relaxation of these cells is mediated directly through: Decreasing intracellular calcium concentration Increasing cyclic guanosine monophosphate Increasing cyclic adenosine monophosphate. Potassium influx hyperpolarizes the cell membrane and decreases calcium entry. Inhibitory neurotransmitters, such as nitric oxide and vaso-active intestinal peptide, in addition mediate NANC relaxation. Nitric oxide is the major neurotransmitter mediating NANC relaxation of the IAS.

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By increasing substrate for nitric oxide synthase, the enzyme involved in nitric oxide synthesis, L-arginine, a precursor of nitric oxide, has been found to relax IAS smooth muscle. A preliminary study has shown that compared with controls, there is reduced nitric oxide synthase in the IAS of patients with anal fissures. The reduced production of nitric oxide provides a possible explanation for the high IAS pressures seen in the most fissure patients. Similarly, it also explains why pressures return to pretreatment values in patients whose fissures have healed with medical treatment. The chemical sphincteromy lasts only as long as the treatment is continued.

Acute Fissure in Ano


Acute fissures cause: Bright red bleeding with bowel movements Anal pain or spasm that can last for hours after the bowel movement. A linear separation of the anoderm is the most common physical findings, at times visible with just separation of the buttocks (Fig. 14.2). On digital rectal examination, often, elevated anal resting pressures are revealed. After using an anesthetic lubricant and if tolerated by the patient, the suspected diagnosis can be confirmed by visualizing the break in the anoderm with office anoscopy. If only one area can be examined, the posterior midline should be evaluated first which is the site of up to 90% of typical anal fissures. The remaining minority of typical fissures are found in the anterior midline. Acute fissures generally resolve within 4 to 6 weeks of appropriate management.

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Fig. 14.2: Acute fissure in ano

Chronic Fissure in Ano


Those fissures which produce symptoms beyond 6 to 8 weeks are usually labeled as chronic fissures. Another important feature of a chronic fissure in ano is the presence of visible transverse internal anal sphincter (IAS) fibers at the base of a fissure. Chronic fissures have additional physical findings of: A sentinel tag at the external apex Indurated edges A hypertrophied anal papilla at the internal apex.

Typical Fissures
Typical fissures are usually: In the posterior or anterior midline Have the characteristic findings described Not associated with other diseases.

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Fig. 14.3: Typical anal fissure with sentineal tag

Atypical Fissures
As against typical fissure atypical fissure: Can occur anywhere in the anal canal Can have a wide variety of findings Tend to be associated with other diseases, including: i. Crohns disease ii. Human immunodeficiency virus (HIV) infection iii. Cancer iv. Syphilis v. Tuberculosis.

Treatment
Conservative Management
Practice parameters from the American Society of Colon and Rectal Surgeons state that conservative therapy is safe, has few side effects, and should usually be the first step in therapy for all fissure types.

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Breaking the cycle of a hard stool, pain, and spasm is the primary aim of treatment of an acute fissure. This can be accomplished by adequate fluid, fiber, and, if necessary, stool softeners. Up to 90% of patients diagnosed with acute fissures heal with these measures alone but chronic fissures usually require medical or surgical therapy. A more frequent problem for the surgeon is the patient, who presents with symptoms for several weeks and has failed in initial approach. In these patients with more chronic fissures, spontaneous healing is, unfortunately likely to be seen in minority of cases only. Therefore, these patients are felt to benefit from a more aggressive technique that may involve a stepwise approach with initial topical or local therapies. The benefits of conservative management have been repeatedly demonstrated in the control groups of trials testing various interventions for fissure treatment. Suggested conservative treatment protocol includes: High fiber in diet or supplemented A warm Sitz bath for 15 minutes twice daily and after bowel movements, if possible.

Medical Therapy
There is an increasing enthusiasm for pharmacologic treatments for chronic anal fissure, the factors responsible for the same are: Increased understanding of anal sphincter physiology Concerns regarding long-term impaired continence as a consequence of surgery. There is a widely held belief that internal anal sphincter hypertonicity is a determining factor in the development and continued presence of an anal fissure. Therefore, initial nonoperative treatment strategies are targeted at alleviating this internal anal sphincter smooth muscle activity.

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Creating a reversible reduction in the abnormally high resting sphincter pressure until the fissure has healed is the primary intention with which the medical agents have been developed. Mainly two topical agents, nitrates and calcium channel blockers, and one injectable agent, botulinum toxin A are used in regular medical management of fissure in ano.

Glyceryl Trinitrate
Chemical Sphincterotomy is the term used for medical management of fissure in ano with GTN, the first pharmacologic treatment used for the same. Nitric oxide was reported to be the neurotransmitter mediating relaxation of the internal anal sphincter muscle Nitrates are metabolized by smooth muscle cells to release nitric oxide, the principle nonadrenergic, noncholinergic neurotransmitter in the IAS. Its release results in IAS relaxation and increased anodermal blood flow. The usual course is 0.2% GTN, applied topically two or three times daily, for 8 weeks. In most studies, healing rates are significantly higher in the GTN than in the placebo group. A very important observation in most studies is that even in patients who do not heal, the treatment significantly reduces pain on defecation after 2 weeks. Repeated applications are safe and may be necessary. Higher dosing does not improve the outcome but, interestingly, does not appear to worsen side effects. The most common side effects of GTN are headache (27%) and hypotension (6%). A second potential drawback is tachyphylaxis, which eventually does not respond to escalations in dose or frequency. Late recurrence is common in the range of 50% of those initially cured. The reduction in mean anal resting pressure usually lasts for about 2 hours only and this is probably the reason for high rates of failure.

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The high rates of failure mean that the question of how to treat GTN-resistant fissures is significant. Despite this, GTN is safe, readily available, and has the modest but significant effect compared with placebo. It remains first-line treatment used in an escalating or stepwise plan of care.

Calcium Channel Blockers


Calcium channel blockers prevent influx of calcium into smooth muscle cells, decreasing intracellular calcium and preventing smooth muscle contraction with a consequent reduction in resting IAS pressure. Oral agents appear to have poorer healing rates and higher rates of side effects than topical preparations. Diltiazem 2% and nifedipine 0.3%, in either oral or topical form, have been described as causing relaxation of the smooth muscle of the internal anal sphincter. Topical calcium channel blockers achieve fissure healing to a degree similar to that reported for topical nitrates but with fewer side effects and better compliance. Recurrence rates after long-term follow-up appear to be no better than treatment with GTN. Oral and topical nifedipine have also been shown to lower mean resting anal pressure. With diltiazem, the effect to lower mean resting anal pressure is greater with the topical rather than oral formulations. Though very rare and almost unknown in topical forms as both are also used as blood pressure agents, there is a small chance of postural dizziness or an unanticipated drop in blood pressure, although this happens in less than 5% of patients and is almost unheard of in the topical forms.

Botulinum A Toxin Injection


Botulinum A toxin is a potent neurotoxin, and is derived from exotoxin produced by the bacterium Clostridium botulinum.

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It has well documented effects on smooth muscle. When injected into the IAS, it produces a chemical denervation of motor end plates with a subsequent decrease in resting anal pressure and improved perfusion. Though the treatment is more invasive than the topical ointments, yet it can be performed in an outpatient setting and apart from it does not have the same problems with compliance. It provides a reversible chemical sphincterotomy and represents a novel nonoperative treatment in the management of chronic anal fissure. Side effects, appear to be infrequent and reversible. The most common known are temporary minor incontinence and urgency. Though the major disadvantage is its cost, this has to be set against the cost of surgery. And the major issue is recurrence after botulin toxin injection and it definitely remains to be addressed. Another concern with Botulinum A toxin is that there is a still debate regarding the ideal location of injection and optimal dose. The common locations used for injection are: Into the IAS External anal sphincter The intersphincteric groove. Commonly used recommended dose is 20 U divided in one to four injections, though higher doses have shown to give better results. Comparing both modalities botulin toxin and nitrates botulin toxin was found to be no better or worse than topical nitrates, yet botulin toxin is effective in healing 50 to 70% of patients with fissures resistant to topical nitrates, and it may have a role either alone or in combination with topical nitrates in the treatment of refractory fissures. Medical treatment should be used in individuals wanting to avoid surgery, and the option for surgical management should be reserved for treatment failures.

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Other Nonsurgical Treatment


A variety of other medical agents have been tested and used in the treatment of anal fissures. Some of these are: The nitrous oxide precursor L-arginine Alpha-1 receptor antagonists Angiotensin-converting enzyme inhibitors Hyperbaric oxygen. As a matter of fact, none of these have demonstrated advantages over currently available therapy and data is limited at present.

Surgical Management
Surgery in its original form represents traditional management of chronic anal fissure. To create a permanent reduction in resting anal pressure, manual dilatation and internal sphincterotomy have been employed.

Manual Dilatation of the Anus


Once, the first-line treatment for chronic anal fissure, manual dilatation in its original form is found to cause variable degrees of tear of sphincter muscle. The aim of the procedure is to reduce sphincter tone by controlled manual stretching of the internal sphincter. A variable number of fingers are inserted into the anal canal and lateral distraction exerted on the sphincter and sustained for a period. This procedure is gradually being abandoned because it frequently produced an uncontrolled tearing of the sphincter muscles which results in incontinence, with characteristic findings on anal endosonography. Incontinence to flatus ranges from 0 to 27%. Compared with internal sphincterotomy, anal stretch, in its classical form, carries a higher risk of fissure persistence or recurrence and of impaired continence.

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In the modern management of anal fissure, there is no role for its continued use. However, the concept of anal stretch has been revisited more recently and a more standardized, controlled, and objective method of anal stretch, pneumatic balloon dilation, has been reported that uses controlled balloon dilatation with a standardized protocol that overcomes the problem of reproducibility. Although manual dilation is now rarely indicated for anal fissure, balloon dilation may be a preferable alternative, though formal recommendations await increased experience and longer follow-up. Limited available data suggest results comparable to those for lateral internal sphincterotomy. In a prospective randomized trial comparing ballon dilatation and internal sphincterotomy the results were really appreciable. A 40 mm balloon insufflated to 1.4 atmospheres for 6 minutes was used. Healing rates were high and no different in both groups (overall 94%). However, after 24 months of follow-up, compared with 16% in the lateral internal sphincterotomy group, no patients in the balloon dilatation group developed incontinence.

Lateral Internal Sphincterotomy


The references of internal sphinceterotomy in various forms dates back to early 1800s. Internal sphincterotomy was first described by Eisenhammer in 1951. He was the first person to advocate and effectively describe the anatomy and physiology behind isolated division of the internal anal sphincter muscle (sphincterotomy) for anal fissure. Although successful at healing the fissure, regrettably, his original posterior internal sphincterotomy method of dividing internal anal sphincter muscle in the posterior midline fissure bed often led to a keyhole or gutter deformity with associated impaired continence.

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Lateral Internal Sphincterotomy (Fig. 14.4)


Notaras then described a simple modification: performing the sphincterotomy laterally, which eliminated this problem and providing similar success rates. The procedure remains the surgical intervention of choice for management of anal fissures not responding to nonsurgical therapy and may be offered as the first line of management even without a trial of pharmacologic treatment. Under direct vision as an open procedure or blindly through a stab incision, the internal anal sphincter fibers are divided laterally. The length of IAS divided varies: Some surgeons divide muscle from the distal end of the fissure to the dentate line Others take muscle equal in length to the fissure [This approach attempts to diminish the risk of impaired continence]. Because it encourages deformity, the fissure itself does not require excision or fissurectomy.

Fig. 14.4: Fissure in anoSuitable for lateral internal sphincterotomy

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Lateral internal sphincterotomy (LIS) may be done with the patient under local, regional, or general anesthesia. It can be clubbed with other procedures for concomitant anorectal pathology. The variations currently include: Open technique Closed technique Conservative sphincterotomy Traditional sphincterotomy. The closed technique is performed by inserting the scalpel blade in the intersphincteric groove or submucosa and then turning it to divide the distal fibers of the internal sphincter. The open technique is done through a radial incision just outside the intersphincteric groove, allowing dissection and visualization of the internal anal sphincter before division. Lateral internal sphincterotomy (LIS) effectively heals anal fissures with rates of 90 to 100% and low recurrence rates ranging from 1 to 3%. Unfortunately the price to be paid for the same in the form of risk of incontinence, has been variably reported from 0 to 50%. Though incontinence sufficient to cause any measurable impairment in quality of life making it miserable is in the range of 3 to 5% only. But unlike the damage caused to continence mechanism on medical therapy with LIS, it may be permanent. Similar to the manual dilatation procedure, there seems some problem with standardization and reproducibility because the procedure appears to be well controlled with careful division of muscle under vision. Sultan and colleagues used anal ultrasonography to evaluate the extent of sphincterotomy and demonstrated a high incidence of inadvertent full-length division of the IAS. This problem appears to be more common in women as a result of overestimation of the length of the shorter female IAS.

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On the other hand, a few investigators evaluated patients, who had undergone LIS and had persistent fissures. On anal ultrasonography they concluded that over 70% of these patients had no internal sphincter defect, whereas several had incurred an external sphincter defect. Above mentioned studies support the conclusion that the wide range of continence impairment after LIS vary due to a function of different surgical techniques among units and individual surgeons. Similarly, patient selection plays a very vital role because there are studies which have documented unexpected obstetric injuries after LIS, on anorectal physiology and ultrasound.

Relative Contraindications to Lateral Internal Sphincterotomy


Patients with preoperative incontinence problems Irritable bowel syndrome Diabetes Elderly or postpartum women. Special care should be excercised in women with a prior obstetric injury and a nonhealing fissure and it is advisable to have a satisfactory preoperative anal manometry and endoanal ultrasound and then proceed with lateral internal sphincterotomy (LIS) in such patients. In patients with a fissure and normal or subnormal IAS tone. There is no rationale for LIS, as hypertonicity is not an issue in this subgroup. An anal advancement flap is recommended in patients with lowpressure fissures and those with significant birth injuries.

Summary
The choice of treatment remains difficult. Surgery is very effective but high healing rates come with the risk of continence impairment. Publications on treatment and outcome for incontinence after sphincterotomy for fissure are absent and so the duration and magnitude of this problem are uncertain.

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Medical therapy with GTN is safe and represents a good first line of treatment. Thirty to fifty percent of patients with chronic fissures and resistant to GTN can subsequently be offered second-line treatment with topical diltiazem or botulinum toxin injection and in some cases, lateral internal sphincterotomy. Patients at high risk of continence disturbance should be identified and evaluated by anorectal manometry and ultrasound before surgery is offered. All patients considered for surgery should be fully cognizant of the potential risks and benefits before giving informed consent as some may wish to persist with an alternative medical therapy.

chapter

Hemorrhoids (Piles)

15

Awards are like hemorrhoids. Sooner or later every asshole gets one. Sarah Morton Hemorrhoids are like Awards. Sooner or later every asshole wants one. Ajit Naniksingh Kukreja Ardene (13071390), a surgeon from Newark, England, was reputed to have said: The common people call them piles, the aristocracy call them hemorrhoids, the French call them figs What does it matter so long as you can cure them? Hemorrhoids may be the butt of jokes and a social stigma in Indian scenario, yet misunderstood anorectal problem for both physicians and patients. In clinical practice, for a layman the term hemorrhoid means any anorectal problem, from pruritus ani to malignancy and form a significant part of a colorectal surgeons workload. Hemorrhoids is a condition that has been known and treated for at least 4000 years but has only recently come to be partially understood. The first descriptions of problems associated with hemorrhoids are found in the Bible, and the occupation of proctology apparently was established then as well. History mentions it in 1815 the battle of Waterloo marked the defeat of Napoleons army and presumptions say Napoleon suffered from hemorrhoids at the time of his defeat. Hemorrhoidal disease continues to afflict modern humans. Both sexes are affected, and an increased frequency has been documented among those of high socioeconomic status. Hemorrhoids are a normal part of anatomy and not varicose veins, the hemorrhoidal disease presents by itching, bleeding and prolapse when the muscularis submucosa weakens and the anal cushions are displaced distally. They also appear to have a role in the maintenance of continence, contributing to resting anal pressure.

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The word hemorrhoid is derived from the Greek adjective haimorrhoides, which means bleeding (haima = blood; rhoos = flowing). Whereas: The word pile is derived from the Latin word pila, meaning a ball. Hemorrhoids are defined as dilated vascular channels usually located in three constant locations: (1) left lateral, (2) right posterior, and (3) right anterior. Those that originate above the dentate line and are covered with columnar or transitional mucosa are called Internal hemorrhoids. Those located closer to the anal verge and covered with squamous epithelium are called External hemorrhoids.

Epidemiology
The exact incidence of this common anorectal condition is really difficult to estimate as most patients are reluctant to seek medical advice for various personal, cultural, and socioeconomic reasons and embarrassment or the fear, discomfort, and pain associated with the treatment. Different studies show variable prevalence ranging from 4.4% in adults in the United States to over 36% in general practice in London, of which one-third presented for medical advice. Yet a sizable 10 to 25% of the adult population is thought to be affected. Symptoms seem to be more common in older individuals, with a peak in prevalence at 45 to 65 years. Against the presumption that men seek medical help more often than women, there does not appears to be a major difference in distribution of hemorrhoidal disease between the sexes. Development of hemorrhoids before the age of 20 is unusual, and Caucasians are affected more frequently than are African and Americans.

Principles of Disease
The cause of hemorrhoids is not clearly understood and very much controversial.

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The most widely accepted theory is the anal vascular cushion theory. Instead of forming a continuous ring around the anal canal, the submucosa forms three distinct cushions of tissue that are supplied richly with small blood vessels and muscle fibers. The superior rectal artery provides the main blood supply to these cushions, with some contribution from the middle and inferior hemorrhoidal arteries, the reason for bright red color of hemorrhoidal bleeding (Fig. 15.1). Venous distention, prolapse, bleeding, and thrombosis occur after the supportive tissue deteriorates, usually around the third decade of life. Factors that contribute are: Constipation, and straining (by producing venous back-flow when intra-abdominal pressure increases) Inadequate fiber and water intake Prolonged sitting in lavatory

Fig. 15.1: Cross-sectional view of nonprolapsing and prolapsing hemorrhoid complexes

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Diarrhea Conditions like pregnancy (direct pressure on a hemorrhoidal vein can produce symptomatic hemorrhoids), ascites, and space-occupying lesions in pelvis. The common factor appears to be the association with elevated intra-abdominal pressure. Hemorrhoids and Varicose veins are common during pregnancy. The following factors probably contribute to their cause: The inferior vena cava and the inferior mesenteric vein are compressed by the pressure of the gravid uterus resulting into impaired venous return. Increased progesterone levels in the blood, results into relaxation of the smooth muscle in the walls of the veins and venous dilatation. Some familial predisposition is recognized and a family history of hemorrhoidal disease has also been suggested to be relevant, but whether this is a result of genetics or acquired factors such as diet is unknown. Against common belief portal hypertension does not cause hemorrhoids. The occurance of symptomatic hemorrhoids in patients with and in those without portal hypertension is similar. The cause of rectal bleeding in patients with portal hypertension may be rectal varices, which are vascular communications between the superior and middle hemorrhoidal veins. But a major exception to this observation is in the pediatric age group; children with portal hypertension are susceptible to hemorrhoidal exacerbations.

Anatomical Considerations
The mucosa and submucosa in the anal canal are arranged into thickened cushions at the following positions: The right anterior The right posterior The left posterior (Variable and secondary cushions are equally common).

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The longitudinal clefts between them form the columns of Morgagni. The cushions comprise of the following: Venous plexus Arterial supply (Both Embedded in a stroma) Connective tissue and smooth muscle Richly supplied by nerves. Arterial supply to anal canal as shown by Thomson is extremly variable, in the way that the terminal vessels of the superior rectal artery branch to supply the anal canal, and none of his 50 dissections matched the classic pattern. He also confirmed the presence of multiple small arteriovenous anastomoses between the arterial supply and the venous plexus. In 1853, Treitz first described the muscle, which probably corresponds in part to Parks suspensory ligament at the level of the dentate line. These fibers appear to act as a supportive network to the venous plexus and the rest of the anal submucosal and mucosal tissue, with age fibrous tissue gradually replaces this smooth muscle along with some loss of the connective tissue organization.

Classification
The simplest classification of hemorrhoidal disease is based on the dentate line (see Fig. 15.1): Hemorrhoids that originate distal to the dentate line and are lined with sensate modified squamous epithelium are called external hemorrhoids (Figs 15.2 and 15.3). [Thrombosis in these vessels often is called perianal hematoma, although. Thomson sensibly suggested that they be known as subpectineal thromboses.] (Fig. 15.2) Hemorrhoids that originate proximal to the dentate line and are covered with mucosa are called internal hemorrhoids. In some patients the two types coexist. Gollighers classification: (For Internal Hemorrhoids) Factor taken into consideration amount of prolapse and not the symptoms of the patient.

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Fig. 15.2: Internal and external hemorrhoids

Fig. 15.3: Schematic representation of all types of hemorrhoids

First degree hemorrhoids: There is bleeding but no prolapse and can be seen only on proctoscopy. Findings: Hemorrhoids bulge into the lumen of the anal canal and there may or may not be painless bleeding.

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Symptoms: Painless bleeding. Signs: Bleeding which is bright red and occurs at end of defecation, blood usually trickles into toilet, or bleeding may be occult. Additional features: None, with exception of some pain occasionally. Second degree hemorrhoids may prolapse beyond the external sphincter and be visible during evacuation but reduce spontaneously. Findings: Hemorrhoids bulge out of the anal canal during defecation but reduce all by themselves. Symptoms: Bleeding is painless, something coming out during defecation, pruritus ani Signs: Bleeding which is bright red and prolapse during defecation which reduces spontaneously. Additional features: Anal itching (pruritus ani), and sometimes skin tags Third degree hemorrhoids protrude outside the anal canal and require manual reduction. Findings: Hemorrhoids bulge out of anus spontaneously or with defecation and requires manual reduction. Symptoms: Painless bleeding, something coming out per rectum, perianal itching, mucus discharge. Signs: Bleeding which is bright red, blood trickles into the toilet, perianal stool or mucus, prolapsed hemorrhoids that need manual reduction, rarely anemia. Additional features: Anal itching (pruritus ani), discomfort, skin tags Fourth degree hemorrhoids are irreducible and are constantly prolapsed. Findings: Hemorrhoids are irreducible and permanently prolapsed. Symptoms: Painless or painful bleeding, irreducible swelling, mucus discharge, feeling of inadequate defecation, difficulty in maintaining perianal hygiene, pruritus ani.

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Signs: Bleeding which is bright red, blood trickles into the toilet, perianal stool or mucus, prolapsed hemorrhoids that can not be reduced, rarely anemia. Additional features: Severe pain, anal itching, severe discomfort, soilings, skin tags.

Clinical Features and Presentation


Though the exact pathogenesis is not known clearly. It is presumed that internal hemorrhoids become symptomatic when their supporting structures become disrupted and the vascular anal cushions start prolapsing. Because most patients use this term to refer to any perianal condition, a careful history is essential to confirm the diagnosis of hemorrhoids. Detailed history regarding following aids in diagnosis: 1. Recent stool patterns, such as diarrhea or constipation 2. Chronic medical problems, such as portal hypertension or bleeding disorders 3. A dietary and family history.

Painless Bleeding
The most common symptom associated with hemorrhoids is painless bleeding: Which is bright red Noticed while wiping or seen dripping into the toilet bowl Occurs most of the times with defecation Occasionally the bleeding can be more substantial, and the blood gets collected in the rectum, and is passed later as dark blood or clots Reduction of the prolapsed hemorrhoid reduces the bleeding significantly.

Prolapse
Complain of something coming out of anus and irritated tissue in the perianal region is seen commonly in patients with third or fourth degree hemorrhoids.

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Incomplete Evacuation
The prolapsed tissue in third and fourth degree hemorrhoids may also cause a feeling of incomplete evacuation by giving a sense of fullness and a continuing sense of the need to evacuate.

Soiling
Because of an impairment of the fine control of continence in third and fourth degree hemorrhoids, soiling in the form of mucus discharge is seen in some patients.

Irritation and Itching


With prolapsed hemorrhoids, constant exposure of the perianal skin to mucus may be associated with irritation and itching resulting into a feeling of discomfort or the presence of a moist perianal area.

Pain
Though intolerable pain is rare. An acutely thrombosed, prolapsed internal or external hemorrhoid can be very painful. Usually the pain is associated with a perianal mass, which is immediately evident on physical examination.

Differential Diagnosis
It is important to rule out other causes of symptomatology of hemorrhoids, because most patients that come with complain of hemorrhoids have varied anorectal symptoms. The differential diagnosis is all dependent on the symptoms of the patient. In case the main complaint of the patient is anal pain, the causes of pain are almost invariably found in pathology distal to the dentate line, i.e. fissure, abscess, fistula, external hemorrhoid thrombosis, or prolapsed thrombosed internal hemorrhoids.

Acute Pain
Anorectal abscess Acute anal fissure

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Anorectal fistula Impaction Rectal trauma Thrombosed hemorrhoid. Anorectal abscess Anal fissure Anorectal fistula Anal stenosis Crohns disease affecting the anal canal Thrombosed hemorrhoid.

Chronic Pain

Bleeding Per Rectum


Fissure in ano Inflammatory bowel disease Internal hemorrhoids Malignancy Polyps Proctitis Ruptured thrombosed hemorrhoids. Anogenital warts (condyloma acuminata) Anal incontinence Eczema Fistula Fungal infection Infections (sexually transmitted diseasesSTDs) Prolapsed hemorrhoids Rectal prolapse.

Pruritus Ani

Swelling or Lump
Abscess Anal tumor Rectal tumor

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Rectal polyp Rectal prolapse Thrombosed hemorrhoids.

Examination and Work-up


Examination of patients with symptoms of hemorrhoids include: A general patient assessment: After clearly explaining what you are going to do and reassuring the patient. Anal inspection: Spread the buttocks gently to fecilitate careful inspection of the: Squamous portion of the anal canal The perianal Genital Perineal Sacrococcygeal regions. Look carefully for presence of any of the following: External hemorrhoids Fissure in ano Fistulas Infection Mucosal prolapse. [If the patient is asked to strain, the degree of prolapse of mucosa can be ascertained.] Perianal rashes Prolapsed hemorrhoids Rectal prolapse Skin lesions Skin tags Thrombosis Tumors. Palpation: To localize pain, tenderness, induration, swelling, lump or a growth palpation is the key to diagnosis. Digital rectal examination: Digital rectal examination is the basic evaluation for any patient with anorectal pathology. It can:

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Localize pain Identify masses Identify Abscesses Evaluate sphincter tone.

Anoscopy/Proctoscopy
Simplest tool to visualize the anoderm and internal hemorrhoidal cushions. When symptoms point to and need arises to assess the rectum and lower colon for neoplasms and inflammatory bowel disease, proctoscopy or flexible sigmoidoscopy must be performed. Though all patients with anorectal symptoms should be subjected to anoscopy, rigid proctosigmoidoscopy and/or flexible sigmoidoscopy. Depending on the findings at physical examination, patient age, and history further evaluation and work-up may be planned. Colonoscopy or barium enema to examine the colon is indicated in following situations: Anorectal examination is inconclusive The bleeding is not pointing to hemorrhoids Presence of anemia or positive occult blood in stool is present Presence of significant risk factors for colonic neoplasia (family history, personal joint pathology, pulmonary disease, significant abdominal symptoms, weight loss, change in bowel habits, age older than 50 years, or other risk factors for colonic malignancy.) Describe the location of all anal pathology anatomically (anterior, posterior, left lateral, right lateral, etc.) or by the clockwise numbers on the face of a clock.

Laboratory Studies
A CBC may be useful as a marker for infection. Anemia due to hemorrhoidal bleeding is possible, and rarely its presence should raise suspicion of an alternate diagnosis.

Imaging Studies
Defecogram may be indicated in rectal prolapse.

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Treatment
Ranging from reassurance to surgical hemorrhoidectomy to newer minimally invasive modalities the management of hemorrhoids has had a facelift with better and safer modalities with lesser postoperative complains available for different grades of hemorrhoids. Broadly classified into three categories: 1. Dietary and lifestyle modification 2. Nonoperative medical management/daycare procedures 3. Operative hemorrhoidectomy/stappled hemorrhoidectomy/ Doppler guided hemorrhoidal artery ligation with recto anal repair. To summarize hemorrhoids that cause only minor bleeding, can be treated conservatively with simple measures such as: Dietary and lifestyle modification Modifications in defecatory habits Office procedures. Third or fourth degree hemorrhoids that cause more severe symptoms and bleeding require surgical intervention.

Dietary and Lifestyle Modifications


Lifestyle modifications are an integral part of the treatment of hemorrhoidal disease. Patients suffering from all grades of hemorrhoids are benefited from these. These modifications include: Improving anal hygiene Increasing the intake of dietary fiber and fluids in the diet Avoidance of certain food and drinks such as nuts, coffee, spicy foods, and alcohol Avoid straining during defecation Avoid postponing the urge to defecate Avoid prolonged sitting on the toilet bowl Avoiding constipation or diarrhea.

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Therapeutic and preventive effects have been demonstrated with some of these lifestyle and dietary modifications; like Increasing the amount of fiber in the diet may relieve pain, bleeding, and prolapse Sitz baths are useful for relieving anal pain. (Recommended at temperatures not more than 40C for fifteen minute durations, at least two times a day) A useful and helpful habit to learn would be, local skin care by cleansing the anorectal area after defecation with mild unscented soap and water The use of ice packs often provides some relief, by decreasing the edema In quiet some cases just a change in defecatory habits like asking the patient to avoid reading on the commode relieves the symptoms. One of the mainstays of therapy for patients with hemorrhoidal disease is dietary modification with fiber supplementation (psyllium husk, methylcellulose).

Oral Medication
Though there is lacking evidence for the effect of medicinal products yet some medicinal products apart from sitz bath and ice packs have been widely used in the medical management of hemorrhoids. Oral vasotopic drugs are used commonly in Europe and Asia, for treating hemorrhoids. These treatments were first described in the treatment of varicose veins, venous ulcers, and edema.

Purified Flavonoid Fraction (Natural Phlebotonic)


Purified flavonoid fraction is a botanical extract from citrus. The effect of micronized puried avonoid fractions (MPFFs) is a reduction in capillary hyperpermeability, which results in the inhibition of the inammatory process and helps reduce the edema.

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It is effective on both diseased and intact vasculature, and it acts by: Increasing vascular tone Increasing lymphatic drainage Increasing capillary resistance. It is also assumed to have: Anti-inflammatory effects Promote wound healing. Safety prole and efcacy in symptom alleviation in pregnant women is an added benet for use of purified flavonoid fraction. The Food and Drug Administration (FDA) does not approve the use of micronized, purified flavonoid fraction in the United States. Other natural phlebotonics used are: Rutosides (troxerutin, buckwheat herb extract, ruscus aculeatus), diosmin, hidrosmin, ginkgo biloba, saponosides; escin (horse chestnut seed extract).

Calcium Dobesilate (Synthetic Phlebotonic)


Calcium dobesilate is the most widely used synthetic phlebotonic product. Previously demonstrated effective in the treatment of diabetic retinopathy and chronic venous insufficiency, calcium dobesilate (calcium 2,5-dihydroxybenzene sulfonate) is a synthetic phlebotonic. These beneficial effects of the drug are related to its ability to: Decrease capillary permeability Decrease platelet aggregation Decrease blood viscosity Increases lymphatic transport. Other synthetic phlebotonics used are: Naftazone, aminaftone, chromocarbe, iquinosa, flunarizine, sulfo-mucopolysaccharide.

Topical Treatment
Astringents (ingredients that cause coagulation, such as witch hazel), protectants (such as mineral oils, cocoa butter), vasoconstrictors,

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keratolytics, antipruritics, local anesthetics, antiseptics, and other ingredients are some of the common commercial topical preparations used and prescribed. It is a well-known fact that the patient with hemorrhoids suffer in silence for a long time and uses all sort of over-the-counter medications which includes pads, topical ointments, creams, gels, lotions, and suppositories. Long-term use of high-potency corticosteroid creams should be avoided, even though topical application of corticosteroids may ameliorate local perianal inflammation, because it can cause permanent damage and thinning of the perianal skin. Most of these products help the patient maintain personal hygiene, and may alleviate symptoms of pruritus and discomfort. There are no prospective randomized trials suggesting that they reduce bleeding or prolapse.

Internal Hemorrhoids: Nonsurgical Treatment


Nonsurgical management of hemorrhoids is offered in the early stages of hemorrhoids or to those who are medically compromised patients. These modalities include rubber-band ligation, sclerotherapy, infrared coagulation, bipolar diathermy and direct-current electrotherapy, cryotherapy, laser therapy, radiofrequency and more. These procedures are usually office-based or day care procedures done during the patients first visit. The need for anesthesia or preparation of the patient is not essential for treatment of hemorrhoidal disease with these interventions. Bowel preparation though not essential, some physicians advocate a mild bowel preparation (such as an enema or a mild oral cathartic) before these procedures. The presence of fecal material in the rectum is not considered a contraindication to these procedures. On the contrary it has been observed that liquid stool might make the procedure technically more difficult.

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It is important to remember that mixed hemorrhoids, have a component of the anoderm, richly innervated with pain fibers, so, some form of anesthesia is required in these cases.

Sclerotherapy
Described about two centuries ago, in 1869 as treatment for hemorrhoidal disease, iron persulfate was used as the sclerosant. The ultimate aim of the procedure is to cause brosis of the vascular cushions, thereby obliterating them. With passage of time, several other sclerosants have been used, including phenol (5%) in vegetable oil, quinine, urea hydrochloride, sodium morrhuate, hypertonic saline solution and sodium tetradecyl sulfate. How it works: Edema, inflammatory reaction with proliferation of fibroblasts, and intravascular thrombosis are produced by the injection of an irritant sclerosant. This results into submucosal fibrosis and scarring. Which ultimately prevents or minimizes the extent of the mucosal prolapse and potentially reduces the hemorrhoidal tissue itself. Indications: Injection sclerotherapy is usually recommended as a treatment option for patients with symptomatic nonprolapsing rst and second degree hemorrhoids. Occasionally, a large hemorrhoid can be successfully treated with sclerotherapy. Contraindications: It is contraindicated in the management of thrombosed external hemorrhoids, as this might result in scarring and stricture if applied to external hemorrhoids. Advanced-grade internal hemorrhoids preferably should not be treated with sclerotherapy specifically those with evidence of inflammation, infection, or ulceration. Another contraindication to the use of sclerotherapy as a treatment option is, concomitant anal diseases such as fistulas, tumors, anal fissures, and skin tags. Equipment: No special equipment is needed except a syringe and a needle the surgeon should be comfortable with.

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Special syringe and needle sets as shown in the image are available for better grip during the procedure (Fig. 15.4). Procedure: Sclerotherapy is frequently done without anesthesia, but with topical local anesthetic sprays being available apprehension of the patient can be reduced by their usage (Fig. 15.4). Can be easily performed in left lateral position, with patient in lithotomy or prone jack knife position depending on the surgeons preference. Pass the anoscope or proctoscope through the anal canal into the rectal ampulla and then withdrawn it gradually until the mucosa prolapses over the opening of the scope. Identify the hemorrhoidal tissue, inject the submucosa at the base of the hemorrhoid with 5 ml of preferred sclerosant of choice like 5% phenol oil, vegetable oil, quinine, and urea hydrochloride or hypertonic salt solution. Because it can cause immediate transient precordial and upper abdominal pain, injection of the sclerosant solution directly into the hemorrhoidal vein should be avoided. Postoperative care: After the procedure, the patient can be allowed home immediately. Appropriate dietary education should be provided and patient should be advised to take stool softeners, bulking agents, sitz baths, and mild analgesics. Because of the possibility of bacteremia after sclerotherapy, antibiotic prophylaxis is indicated for patients with predisposing valvular disease or patients with compromised immunity. A follow-up visit is not required, if the patient is asymptomatic after sclerotherapy. Although sclerotherapy can be done safely within a few minutes, because of the proximity of the rectum to the periprostatic parasympathetic nerves, special caution needs to be observed when injecting in this area. Erectile dysfunction can result in male patients if the periprostatic parasympathetic nerves are accidently injured during the procedure of sclerotherapy.

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Fig. 15.4: Special hemorrhoid injection syringe and needle

Complications: Despite the simplicity of the technique, potential complications are known. Pain can occur in 12 to 70% of patients. Patients undergoing multiple injections may complain of burning sensation and discomfort. Rarely in few cases, local infection, abscess formation and impotence may occur.

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Hepatic complications after sclerotherapy for hemorrhoidal disease are mentioned in literature. Results: Symptom improvement has been described in up to 90% of patients with rst and second degree hemorrhoids. However, some studies have shown no difference in bleeding rates when compared to bulk laxatives alone. In up to 30% of patients, recurrence rates after initial success have been described after four years. Rubber-band ligation: The rubber band ligation was rst described by Barron in 1963. This is one procedure that has evolved into an easy ofce-based procedure, in any colorectal surgeons practice. Since somatic sensory nerve afferents are only present distal to the anal transition zone, no anesthetic is required. One disadvantage this procedure has as an office based procedure is that it usually requires two experts (operator and assistant) to perform the procedure; one needs to maintain the anoscope/proctoscope in position while the other holds the ligator and the grasping forceps. Numerous devices have been developed to eliminate the need of an assistant for performing this procedure. The more modern equipment utilizes a suction device to draw redundant tissue into the applicator. How it works: Ligation of the hemorrhoidal tissue with a rubber band causes ischemic necrosis, ulceration, fibrosis and scarring, which results in fixation of the connective tissue to the rectal wall thereby reducing the prolapse. Indications: Rubber band ligation is commonly advocated for use in managing rst to third degree hemorrhoids. Contraindications: One must bear in mind that this method addresses only the internal component of hemorrhoids and not external hemorrhoids. Because of the increased risk of delayed hemorrhage band ligation is contraindicated in patients who are taking anticoagulants.

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Fig. 15.5: Band ligator and slotted proctoscope

Equipment
Band applicator, band loader, grasper, bands, slotted proctoscope [Preferred] (Fig. 15.5).

Procedure
Procedure can be performed best with the patient typically placed in the left lateral decubitus position. For the procedure to be performed properly, adequate lighting and appropriate equipment are essential.

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Few experts advocate placement of the band on the redundant mucosa above the hemorrhoid. Thus providing the advantages of preserving the anal cushions and ensuring that the ligations are well above the dentate line, thereby minimizing the risk of postligation pain. Some experts advocate applying two bands to the same column at the same sitting. Though ligation of up to three columns at one sitting has been described, the best recommendation is one to two columns ligated each time, to avoid the unfortunate experience of excessive discomfort and pain for the patient. Associated with significant incidence of prolonged postligation pain, three-column ligation has been proven effective. High patient satisfaction has been reported in the range of 80 to 90% range. Triple rubber-band ligation has been found to be more cost effective. Postoperative care: Appropriate dietary modification, stool softeners, bulking agents, sitz baths, and mild analgesics are indicated. Complications: Described in a wide range from 5 to 60% of patients. Pain is the most predominant complaint following ligation. This is usually relieved with warm sitz baths and oral analgesics. The patient might feel discomfort, when the rubber band is applied close to the dentate line. It is very important to carefully place the rubber band on the base of the internal hemorrhoid, which usually lies 1.5 to 2 cm proximally to the dentate line. The rubber band can be removed, if the patient experiences severe pain. Severe pain during or immediately after the procedure is rare, and can result from: Strangulation of the anoderm (specially in mixed hemorrhoids, when the rubber band is placed close or distal to the dentate line) Inflammation Edema of the area.

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Closely inspect the area for exclusion of any other local causes. Consider sedation or general anesthesia. If the patient has severe pain and anxiety, to allow a more thorough examination of the area. If no gross evidence of infection or other cause of pain is found, after the rubber band is removed, a second attempt for ligation at a more proximal sight away from the dentate line may be considered. Abscess formation and urine retention can also occur. Thrombosis of adjacent hemorrhoids is also known in small number of patients. Postligation bleeding, pelvic sepsis, ulceration, slippage of the rubber band, are rare with a described incidence of as low as 0.5%. Though extremely rare Fourniers gangrene has also been reported. Look for the triad of severe pain, fever, and urine retention in patients with pelvic sepsis. Of late exible video endoscopic elastic band ligation (VEEBL) has been described by surgeons, to overcome the limited maneuverability and the narrower eld of vision with the anoscope. Found relatively easy to perform has a good safety factor also. Clubbing of injection sclerotherapy and rubber band ligation has also been tried but to no extra advantage.

Cryotherapy
Cryotherapy uses cold coagulation (nitrous oxide or liquid nitrogen) to destroy hemorrhoid tissue. Initially introduced as a painless and effective method of treating, both internal and external hemorrhoids is not used freely these days, as better options are available and this treatment does not offer the patient any advantages over other available treatment modalities. The procedure consists of using a probe of liquid nitrogen or nitrous oxide to cause rapid freezing and cellular destruction in the tissues, which results in necrosis of the vascular cushions. However, the results reported in the literature have been disappointing.

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A common side effect of the procedure is that it results in prolonged profuse, foul-smelling discharge and pain due to necrosis. Damage to the internal anal sphincter which in turn may result in anal stenosis or fecal incontinence, if used inappropriately. Recovery is prolonged and cryotherapy is no longer recommended for the treatment of hemorrhoids.

Electrocoagulation
Bipolar diathermy and direct-current electrotherapy cause coagulation and fibrosis after local application of heat. The success rates of these methods in treating grade I and II hemorrhoids are similar to those of infrared coagulation, with relatively low complication rates. Bipolar electrocoagulation works by the local application of heat through a specialized probe. Because of the ease of use it can be performed by a single operator without the need for assistance. The result are comparable to photocoagulation and unipolar diathermy. Unipolar electrocoagulation or galvanic generator uses a lowvoltage current of maximally tolerable amplitude passing through a probe to an earthed patient. Its use in a busy outpatient setting is restricted because it requires around 10 minutes per hemorrhoid for effective treatment.

Infrared Coagulation
Among the best available modalities that are noninvasive for treatment of hemorrhoids is the infrared coagulator. The basic principle lies in coagulation of the hemorrhoidal vessels with the help of infrared rays with tissue destruction limited to a depth of 3 mm. It is smokefree and odorfree, in contrast to diathermy, can be performed by surgeon alone without the help of an assistant. The main use of photocoagulation is for grade 1 and 2 hemorrhoids.

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Fig. 15.6: Infrared coagulator

Equipment
The equipment consists of a base unit, a hand applicator with lamp assembly which consists of a 15 volt tungsten-halogen lamp with a 24 K gold plated reflector surrounding the bulb to focus the light to a long solid quartz glass, light guide which transmits the rays to the teflon tip (Fig. 15.6). There is an option to set the time for application ranging from 0.5 to 3 secs and the depth of coagulation corresponds in mm with the time, i.e. 1 sec application coagulates to the depth of 1 mm.

Procedure
The procedure is easy to learn and easier to perform, the patient can be treated on an outpatient basis without any anesthesia, but if the patient is very apprehensive and non-cooperative short general anesthesia may be used. The patient is to be given a left lateral position or a lithotomy if in GA. If no anesthesia is used, 10% lignocaine spray suffices.

Hemorrhoids (Piles) 331

B
Figs 15.7A and B: Infrared coagulation being applied and status after application

Gently introduce the proctoscope and identify each pile mass, by default it is recommended that the timer be set to 1.5 sec, touch the tip of the IRC on the pile mass and apply the switch, do

332 Anorectal Surgery

not leave the switch till the light goes off by itself, there will be a white spot created at the site of coagulation, similarly coagulate the pile mass in semilunar position taking care not to overlap two applications, the other piles may also be dealt with in the same way (Figs 15.7A and B) Postoperative care: Usually no dressing is required The patient may go home immediately and resume the duties the next morning No medications are required, except for the symptomatic cure of pain and control of constipation.

Complications
Except for tolerable pain the postoperative convalescence is excellent An occasional patient may complain of severe pain if the coagulation is done at the muco cutaneous junction Some patients may bleed in the first week, needs no treatment except reassurance There have been no reported incidents of sepsis or stricture.

Advantages
State-of-the-art, user-friendly technology Easy to learn and useno extensive training required Takes only seconds to perform Instantaneous coagulation without smoke or odoreven in a wet field Less pain, fewer complications than rubber band ligation No disinfection requiredeliminates cross-contamination.

Summary
In more than 20 years clinical experience, a majority of patients chose infrared coagulation over other hemorrhoid treatments. This non-surgical procedure can significantly shorten recovery time, allowing patients to return to normal activities almost immediately.

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Radiofrequency Coagulation and Excision


The Basics
The principle of radiosurgery involves using radio waves at 5.0 to 6.0 MHz, delivered at low temperature through radiofrequency electrode.

Equipment
The unit comprises of a transformer that converts the main voltage of 220 to 240 VAC to the output of 125 to 700 W on 200 ohm load for monopolar and 50 to 350 W on 200 ohm load in bipolar mode (Fig. 15.8). The output current is used for both coagulation and cutting. The timer selection varies from 1/8 th of a second to 1 second and continuous. There are handles long and short to which different tungsten tipped electrodes are attached, which in turn are used for coagulation and cutting.

Fig. 15.8: Radiofrequency equipment

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Fig. 15.9: Radiofrequency coagulation being applied

Procedure
First and second degree early hemorrhoids coagulate mucosa without resection, after setting timer for 1 second and output to 5 to 6 MHz, electodes use straight or bended semiball (Fig. 15.9). Second or third degree early hemorrhoids inside coagulation of mucosa with insulated bipolar electrode coagulate around hemorrhoidal plexus (Fig. 15.10). Third or fourth degree hemorrhoids, strangulated hemorrhoids, mixed hemorrhoids incision, hemostasis and excision of hemorrhoidal plexus using different electodes.

Advantages of the Procedure


It can be done under local anesthesia, regional anesthesia or short general anesthesia

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Fig. 15.10: Radiofrequency application inside the hemorrhoid mass

No postoperative stay required Easy learning curve Patient can resume work the next morning It can be performed as an outpatient procedure.

Complications
Apparently there are no complications of the procedure, but due care should be taken while handling the equipment and positioning the patient plate.

Doppler Guided Hemorrhoidal Artery Ligation


In 1995, a Japanese surgeon, Kazumasa Morinaga, conceived of a novel way to treat hemorrhoids.

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Fig. 15.11: HAL-RAR equipment Courtesy: AMI GmbH (Austria)

He identified the hemorrhoidal arteries by means of a Doppler (ultrasound) technique. He designed a special instrument, which contained a Doppler transducer and a window, which permitted the surgeon to identify and ligate the hemorrhoidal arteries by placing a suture (stitch) around them. This is a simple maneuver, which produced prompt resolution of most of the hemorrhoidal symptoms of bleeding and protrusion.

The Equipment Set Consists of the following Items (Fig. 15.11)


Modified Proctoscope with built-in ultrasound transducer Light and special window (Figs 15.12C, E and F) Echo sounder (Fig. 15.11) A strong atraumatic needle and 2/0 suture (Fig. 15.12D) Forceps Scissors (Fig. 15.12B) Knot pusher (Fig. 15.12A) Xylocaine jelly.

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Figs 15.12A to D: (A) Knot pusher; (B) Special needle holder; (C) Modified proctoscope; (D) Special suture for hemorrhoidal artery ligation Courtesy (Figs 15.12A to C): AMI GmbH (Austria)

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F
Figs 15.12E and F: (E) Ligation window and Doppler transducer; (F) Hemorrhoid tissue as seen from ligation window during procedure Courtesy: AMI GmbH (Austria)

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Fig. 15.13: Branch of superior hemorrhoidal artery identified Courtesy: AMI GmbH (Austria)

Procedure
Can be very well-performed under local anesthesia, but saddle block is preferred and depending on surgeon on anesthetist preference general or regional anesthesia may be used Before proceeding to the Doppler guided hemorrhoidal artery ligation, accurately locate the terminal of all different branches of the superior rectal artery considering the vessels depth. Firstly the xylocaine jelly is applied to the tip of the instrument and to the anus. The HAL II is slowly inserted into the anus and rotated to locate the artery to be ligated. The arterial sound is clearly audible when the Doppler transducer is directly over the hemorrhoidal artery (Fig. 15.13).

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Fig. 15.14: Vessel being ligated Courtesy: AMI GmbH (Austria)

Fig. 15.15: Knot being pushed Courtesy: AMI GmbH (Austria)

The special needle and 2/0 PNW 602 AK suture is inserted into the HAL II (Fig. 15.14). A knot is tied externally, which is then pushed down into the mucosa with the knot pusher, thus ligating the artery. The Doppler sound disappears as soon as the ligation is successfully performed (Figs 15.15 and 15.16).

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Fig. 15.16: Schematic representation of superior hemorrhoidal artery ligation Courtesy: AMI GmbH (Austria)

A
Before DG-HAL surgery

B
3 months after DG-HAL surgery

Figs 15.17A and B: Preoperative and 3 months postoperative images of surgery performed with hemorrhoidal artery ligation

The suture is cut with scissors inside of the instrument. All the six branches identified one by one and ligated.

Advantages of this Procedure Include


Optimized for adjunctive use in hemorrhoidal artery ligation (HAL) Precise, rapid localization of hemorrhoidal arteries for ligation Probe designed for easy insertion and brightly lit for maximum visualization Suitable for use during outpatient surgery for Goligher Degree I to IV (Figs 15.17A and B)

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Prevents prolapse by anchoring the mucosa to the muscularis Especially good for bleeding hemorrhoids No medication or anesthesia required [We do it under short GA] Back to work on same day or next day Simple, easy procedure
Complications 1 2 Severe secondary (delayed) hemorrhage Infection Cellulitis Abscess/Fistula Septicemia 3 4 Anal fissures Perianal thrombosis No (%) 8 [0.56] 7 [0.49] 2 4 1 14 [0.98] 7 [0.49]

Complications
Dr Dennis of Australia reports following complications in his study of 1415 patients As against common belief after pelvic surgery there was no case of urinary retention The operation is best carried under left lateral position. Doppler ultrasonic anoscope is placed into the rectum, with the Doppler ultrasonic probe located 2 to 3 cm above the dentate line. Rotate the whole instrument along with the rectum to look for the artery needed. The 2-0 absorbable sutures and the firm 5/8 curved needles should be used to carry 8 like suture above the Doppler ultrasonic probe where the Doppler ultrasonic signals are received. Run a test circle by placing the probe 1 to 2 cm distally. Any strong arterial signal should be ligated as well. There is no need to achieve a totally quiet result. Minor arteries will still deliver some arterial sound but this should not disturb a surgeon.

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Always try best to leave at least 1 cm of distance from the dentate line. After the tissue chunk inside the anoscope is reduced, the Doppler ultrasonic anoscope should be gradually exited, and the location of the suture be examined using finger. Generally, the observation should be that the volume of the external hemorrhoids shrinks significantly, and the internal hemorrhoids has retracted into the anus. All the major symptoms of patients are usually ameliorated after the operation.

Postoperative Care
Oral antibiotic was routinely used for 5 days. Usually no analgesics are required, in patients with low tolerance oral NSAIDs may be prescribed for five to seven days. Dietary modifications, control of constipation, etc. are advised accordingly. No side effect (for example, fever, urine retention, and nausea) was found in any of the patient.

Rectoanal Repair
The purpose of this technique is to obliterate the branches of superior hemorrhoidal artery and do a mucopexy for the prolapsing mucosa in one sitting under spinal anesthesia. Specially considered for the treatment of prolapsing hemorrhoids allows ligation of artery and lifting of mucosa in one session (Figs 15.22A to C).

Easy Handling
Sterile single probe to be used in conjuction with reusable sleve can be performed as a day care procedure under spinal anesthesia or saddle block, or short general anesthesia Small pieces of mucosa might get trapped between the probe and the metal sleeve, especially if the patient is not relaxed enough (under local anesthesia) and squeezes the pelvic floor muscles! Care must be taken when rotating the handle or removing the probe

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Fig. 15.18: Flexiprobe the new modified proctoscope for rectoanal repair Courtesy: AMI GmbH (Austria)

Procedure
Position the metal RAR sleeve at the start pexy and insert into the rectum (Figs 15.18 and 15.21). Place the pexy window on the prolapsed part of the mucosa Turn the sleeve in clockwise direction (Figs 15.19A and B) The ligation window will then open and allow the mucosa to gradually prolapse into the probe The running suture can be taken now The window is totally open when the metal RAR sleeve is placed at the end position The running suture can be tied with knot pusher and mucosa be lifted and secured in the anal canal (Fig. 15.20).

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B
Figs 15.19A and B: Modified proctoscope for rectoanal repair Courtesy: AMI GmbH (Austria)

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Fig. 15.20: Steps of hemorrhoidal artery ligation and rectoanal repair Courtesy: AMI GmbH (Austria)

Fig. 15.21: Rectoanal repair performed Courtesy: AMI GmbH (Austria)

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Before surgery

Immediate post RAR

Three months post RAR


Figs 15.22A to C: Rectoanal repair results

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Stapled Hemorrhoidectomy
Stapled hemorrhoidectomy, later termed stapled hemorrhoidopexy (PPH), was rst described in 1995. Stapled hemorrhoidectomy is one of the newer surgical technique for treating hemorrhoids, and along with Doppler guided hemorrhoidal artery ligation it has rapidly become the treatment of choice for third and fourth degree hemorrhoids. Though the learning curve is steep, since the introduction by Longo in 1995, it has allowed colorectal surgeons to offer patients a new treatment for symptomatic prolapsing internal hemorrhoids. Since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward, stapled hemorrhoidectomy is a misnomer. The associated advantages of this procedure are: Improved short-term outcomes Less postoperative pain Shorter operating times Earlier return to work Greater patient satisfaction. Along with decreasing their blood supply, stapled PPH theoretically, aims to return prolapsing hemorrhoids to their original anatomic position and which in turn allows potential involution of the external component. Keeping aside these possible advantages of stapled PPH, some patients have had unsatisfactory results, and one of the most frequent complains is the postoperative pain. This can be justified considering the relative proximity of the staple line to the sensitive anoderm. Local inflammation plays an important role as a possible etiology for postoperative pain, complications, and suboptimal results, in addition to the sensitive anoderm as a source of pain. Indications: Third and fourth degree hemorrhoids, prolapsing hemorrhoids are the prime indications for use of PPH.

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Contraindications: Thrombosed and strangulated hemorrhoids are a contraindication to PPH. Anal abscess or gangrene.

Procedure
Best performed under spinal anesthesia, can also be performed under general anesthesia. Patient positioned in a lithotomy position. The first step is reduction of the prolapsed of the anal mucosa and anal skin by introduction of the Circular Anal Dilator (Fig. 15.23). The prolapsed mucous membrane falls into the lumen of the dilator, once the obturator is removed. The purse-string suture anoscope is then introduced through the dilator. This anoscope will push the mucous prolapse back against the rectal wall along a 270 circumference, while the mucous membrane that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. It will be possible to complete a purse-string suture around the entire anal circumference, by rotating the anoscope. Open the hemorrhoidal circular stapler to its maximum position. Before the purse-string is closed with a closing knot, the staplers head is introduced and positioned proximal to the purse-string (Fig. 15.24). The ends of the suture are knotted externally. The entire casing of the stapling device is then introduced into the anal canal (Fig. 15.25). It is advisable to partially tighten the stapler, during the introduction. By a simple maneuver and with moderate traction on the pursestring, draw the prolapsed mucous membrane into the casing of the circular stapling device (Fig. 15.26). Tighten the instrument and fire the stapler to the prolapse. The stapling device is kept in the closed position for approximately 30 seconds before firing and approximately 20

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Fig. 15.23: Dilatation being performed

Fig. 15.24: Taking purse string suture

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Fig. 15.25: Head introduced beyond the purse string

Fig. 15.26: Knot tied externally

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Fig. 15.27: Complete stapler casing introduced inside

seconds after firing acts as a tamponade, which may help promote hemostasis (Fig. 15.27). Firing the stapler releases a double staggered row of titanium staples through the tissue (Fig. 15.28). A circular knife excises the redundant tissue. A circumferential column of mucosa is removed from the upper anal canal. Finally, examine the staple line using the anoscope. In case of any bleeding from the staple line, additional absorbable sutures may be placed.

Advantages
1. Less pain as compared to conventional techniques. 2. Quicker return to work. 3. Lower inpatient stay.

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Fig. 15.28: Stapled line after stapler is fired

Risks and Complications


Although rare, there are risks that accompany PPH: 1. It can result in damage to the rectal wall, if too much muscle tissue is drawn into the device. 2. Too much stretching of the internal muscles may, result in shortterm or long-term dysfunction. 3. Pelvic sepsis cases though rare have been reported following stapled hemorrhoidectomy. 4. As gaining access to the anal canal can be difficult and the tissue may be too bulky to be incorporated into the housing of the stapling device PPH may be unsuccessful in patients with large confluent hemorrhoids. 5. Persistent pain and fecal urgency has been reported, after stapled hemorrhoidectomy, although rare.

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6. Stapling of hemorrhoids is associated with a higher risk of recurrence and prolapse than conventional hemorrhoid removal surgery.

Early Complications
Hemorrhage Severe pain Urinary problems Suppuration

Late Complications
Chronic pain Suture dehiscence Anal stricture Anal fissure External hemorrhoidal thrombosis Intramural fistulization and abscess formation Anal incontinence Persistent symptoms or reccurrence The arterial blood vessels that travel within the expanded hemorrhoidal tissue and feed the hemorrhoidal vessels are cut, during stapled hemorrhoidectomy. This results in reduction of the blood flow to the hemorrhoidal vessels and reduction in the size of the hemorrhoids. Scar tissue forms around the staples, during the healing of the cut tissues, and this scar tissue anchors the hemorrhoidal cushions in their normal position higher in the anal canal. The staples are not needed after the tissue heals. They then fall off and pass in the stool unnoticed after several weeks. Designed primarily to treat internal hemorrhoids, stapled hemorrhoidectomy can reduce external hemorrhoids also if they are present.

Surgical Hemorrhoidectomy
Hemorrhoidectomy is one of the most commonly performed anorectal operations.

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Two well-established methods, the open Milligan-Morgan excision and the closed Ferguson technique (Figs 15.29A to D) are prevalent among most colorectal surgeons. Both procedures carry risks of postoperative bleeding, urinary retention, and late anal stenosis. The convalescence also is similarly long and difficult after both operations. Therefore, the search for an improved technique of radical excision of hemorrhoids is always justified.

Fergusons (Closed) Hemorrhoidectomy (Figs 15.29A to D)


Considered as a gold standard for management of hemorrhoids in United States, this procedure was developed in 1952, Ferguson.

Figs 15.29A to D: Modified ferguson hemorrhoidectomy

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These days, like most other surgical treatments for hemorrhoids, it is usually done as a daycare procedure. Indications: All grades of hemorrhoids can be treated with surgical hemorrhoidectomy. Hemorrhoidectomy is indicated for patients with symptomatic combined internal and external hemorrhoids, who have failed and/or are not candidates for nonoperative treatments. This would include patients with extensive disease, patients with concomitant conditions such as fissure or fistula, and patients with a preference for operative therapy. Contraindications: Except for patients with acute thrombosed external hemorrhoids (Relative Contraindication), or patients with bleeding disorders and anesthesia risk there is no apparent contraindication to this procedure. Equipment: No specific equipment is required. Conventional scalpel, scissors, electrocautery, proctoscope, retractor and sutures are essential. Though the conventional Fergusons hemorrhoidectomy is performed with a scalpel, scissors, or electrocautery, excision of the hemorrhoidal tissue can be achieved with any (electronic or other) cutting instrument.

Procedure
Hemorrhoidectomy can be performed using a variety of techniques or instruments, however, most are variants of either a closed or open technique. Mostly performed under spinal or saddle block, depending on surgeon, anesthesiologist, and patient preference, anesthesia can be general, caudal, or spinal. Local anesthesia, in which the anal submucosa is infiltrated with a local anesthetic or in expert hands a pudendal block can also be used. A retractor is used to expose the hemorrhoids. An absorbable suture is usually placed at the pedicle site, after the hemorrhoidal pedicle has been mobilized. At this stage, the hemorrhoidal bundle, is excised, with any internal or external components of the disease.

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Following excisional of the hemorrhoidal bundle the mucosal wound and skin are closed completely with a continuous suture. Clean the wound and check for any active oozing or a bleeder, after adequate hemostasis has been obtained, an antiseptic ointment and a small dressing are often applied, though packing is not necessary.

Postoperative Care
Patients are advised prolonged sitz baths (approximately 20 minutes or more) several times a day, preferably after each motion. Topical creams especially local anesthetic ones or lotions may be applied, but ointments should be avoided. Mild non-narcotic analgesics and nonsteroidal anti-inflammatory agent are usually recommended to avoid constipation. Strongly recommended are diet modifications rich with fiber and high fluid intake, bulking agents, and/or stool softeners. Usually patient needs to be discharged only after he/she has passed urine and a strict instruction should be passed to the patient to report any complaints of urinary retention. It is equally important to inform the patient that the sutures may often loosen after the first bowel movement. If no complications develop the patient is called for a follow-up visit usually after 3 weeks of the procedure.

Milligan-Morgan (Open) Hemorrhoidectomy


This method is indicated in specific situations like: Location Technical difficulties Extensive disease with gangrenous hemorrhoidal tissue More useful for avoiding subsequent anal stenosis. Described around two hundred years ago, the technique is widely used as on today in the United Kingdom. This was made popular in 1937 in United Kingdom by Milligan and Morgan, thus the name given to it.

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Figs 15.30A to F: Steps of milligan-morgan open hemorrhoidectomy

Hemorrhoidal tissue and vessels involved are excised in this procedure, in the same manner as in Fergusons procedure. A suture is also placed at the hemorrhoid pedicle, but the incisions are left open (Figs 15.30A to F). To achieve hemostasis, electrocautery or radiofrequency is often used.

Hemorrhoids (Piles) 359

To avoid stricture and anal stenosis using the open technique, it is important to maintain adequate bridges of normal anoderm because primary wound healing can also result in stricture and stenosis.

Postoperative Care
Postoperative management is apparently same as recommended for closed hemorrhoidectomy. There are instances depending on surgeon preferences some of the sites will be left open and others will be primarily closed, thus the technique used in these instances is a combination of open and closed hemorrhoidectomy.

Complications
Possible complications of both open and closed hemorrhoidectomy include postoperative pain: Urinary retention Secondary hemorrhage Anal fissure Abscess Fistula Formation of skin tags Anal stenosis Pseudopolyps Fecal incontinence. Postoperative pain resulting either because of manipulation of the skin distally to the dentate line or spasm of the anal sphincter after the procedure is a major concern after hemorrhoidectomy. The reason being none of the techniques offer the patient a painfree postoperative course. Urinary retention can be attributed to: Pain Narcotics and anticholinergic drugs Fluid overload High ligation of the hemorrhoidal pedicle Operative trauma.

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Management and Prevention of Urinary Retention


Minimal intravenous fluids to be administered before operation. In case the patient is given anesthesia, the patient should be encouraged to void after the procedure. Worst come worst if urinary retention occurs, most patients will require temporary urinary catheterization.

Secondary Hemorrhage
Occurs usually after 7 to 10 days of surgery and is easily diagnosed by rectal examination. It is relatively a common complication, and occurs from the vascular pedicle or from the edges of the wounds. An examination under anesthesia should be performed, if the patient is hemodynamically unstable or the patient does not allow adequate rectal examination due to severe pain. Pruritus ani is caused by inadequate hygiene secondary to painful skin tags in the initial postoperative period, in such cases a planned removal of the same should be offered. One of the most dreaded complications of hemorrhoidectomy is fecal incontinence. The patient usually regains normal control within a few weeks after the procedure and the anal leakage which is common in the early postoperative period is relieved. To prevent Frank incontinence demand for preoperative physiologic studies and anal ultrasonography are advised for patients with history of imperfect continence. If adequate mucosal bridges are retained after closed or open hemorrhoidectomy, anal stenosis which occurs because of anal narrowing secondary to fibrosis, can be minimized. Anal stenosis should send a warning signal to the surgeon of an extensive underlying damage to the anal sphincter mechanism. Physiologic studies and anorectal ultrasonography need to be performed in these patients before surgical correction.

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The Harmonic Scalpel and Ligasure


Excision of the hemorrhoidal tissue can be achieved with numerous techniques. With harmonic scalpel and ligasure surgeon can minimize the damage to adjacent tissues, causing less discomfort and faster healing. These methods can be used either with open or closed hemorrhoidectomy. The harmonic scalpel uses ultrasonic waves that allow cutting and coagulation of hemorrhoidal tissue at lower temperatures in a specific point, with reduced lateral thermal effect. Compared with lasers and other electrosurgical instruments, the harmonic scalpel generates less smoke. In available studies harmonic scalpel hemorrhoidectomy did not show any advantage in: Postoperative pain Fecal incontinence Operative time Quality of life Other complications compared with traditional closed hemorrhoidectomy. Ligasure vessel sealing system for sutureless hemorrhoidectomy is a relatively new technique that uses a bipolar electrothermal device. The advantages of this procedure are it offers surgical treatment with shorter operative time and less postoperative pain. These instruments by their inherent quality of sealing the vessels, provide a dry operating field and allow the procedure to be performed more rapidly. These methods have the obvious disadvantage of increased costs.

Laser Surgery for Hemorrhoids


The laser is a newer modality for management of hemorrhoids, because of its inherent therapeutic property, it seals off nerves and tiny blood vessels with an invisible light.

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This results in less discomfort, less medication, and faster healing. The procedure can be performed as a day care procedure. Skilled and experienced surgeons can use laser light with pinpoint accuracy. The unwanted hemorrhoid is simply vaporized or excised. The infinitely small laser beam allows for: Unequaled precision Unequaled accuracy Rapid and unimpaired healing. Patients have a minimum of postoperative discomfort as the superficial nerve endings are sealed, and the sealing of tiny blood vessels, offers a relatively dry field and the surgeon can operate in a controlled and bloodless environment. Procedures can often be completed more quickly and with less difficulty for both patient and physician. Laser can be use alone or in combination with other modalities. Most studies with laser hemorrhoidectomy show a high patient satisfaction ratio of up to 90%+ The only inhibitory factor is the basic cost of the equipment.

Atomizer Wand
Among the newer techniques which need long-term evaluation, used in management of remove hemorrhoids is atomizing. The Atomizer is a medical device that was developed specifically to atomize tissue. The term atomizing hemorrhoids has been perfectly matched with the procedure because the hemorrhoids after atomizing are actually reduced to minute particles into a fine mist or spray, which can be immediately vacuumed away. An innovative waveform of electrical current and a specialized electrical probe, the Atomizer Wand (Patent Pending) are used for this purpose. The hemorrhoids are simply excised or vaporized one or more cell layers at a time, with a wave of the Atomizer Wand, this results into disintegration of the hemorrhoids into an aerosol of carbon and water molecules.

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The tissue is sculpted into a desired shape and smoothness, using the Atomizer. The advantage to the surgeon is that he/she gets a field with minimal bleeding to operate, and gets better homeostasis than with traditional electrosurgical techniques. The advantages to the patient is that he/she gets better postoperative results, and fewer anal tags with Atomizer Wand than with traditional operative techniques. A clinical study comparing the traditional Ferguson hemorrhoidectomy with the CO2 laser hemorrhoidectomy, and the Atomizer hemorrhoidectomy, in a small volume of patients shows the following:
Atomizer Bleeding (perioperative) Healing time Pain Complications (i.e. skin tags) Costs Less Same Less Less More CO2 laser Less Same Less Less More

Though the results of closed hemorrhoidectomy with laser and Atomizer Wand are apparently same, the Atomizer Wand scores over the laser in following aspects: There is less bleeding using the Atomizer The Atomizer costs less. Following positive aspects of both procedures are noted: Less discomfort Less medication Less constipation Less urinary retention A hospital stay is generally not required. Complications using the Atomizer are rare, and excellent results are typical. Atomizing hemorrhoids is not available for use outside the USA.

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Thrombosed Internal Hemorrhoids


Special management is needed in case internal hemorrhoids prolapse and cause stasis and resulting into thrombosis. Though this complication is less common than thrombosed external hemorrhoids and is less painful, but operative intervention is more complicated and is rarely indicated, because of the location of the internal hemorrhoids. Sitz baths, analgesics, topical anesthetics, and stool softeners are part of the conservative management. If surgery is indicated, excisional hemorrhoidectomy is the best choice.

Thrombosed External Hemorrhoids


Thrombosis often manifests as acute discomfort and the presence of a painful mass. This condition represents one of a few instances when hemorrhoidal disease manifests with symptoms of pain. In patients who have recurrent episodes of thrombosis: Avoidance of straining Avoidance of constipation Increase in the amount of dietary fiber Increased fluid intake may serve as a prophylactic measure. Predisposing factors involve the increased pelvic oor pressure seen in diarrhea, constipation, straining at defecation, pregnancy, prolonged sitting, childbirth, and lifting heavy weights. Conservative treatment to reduce pain and regress the swelling includes sitz baths, mild analgesics, and stool softeners to relieve the symptoms. The thrombus usually gets absorbed during the course of several weeks, the pain usually subsides after 2 or 3 days, and the mass resolves within 7 to 10 days. The extent of the hemorrhoidal disease should be assessed, and other anal pathology should be excluded, especially thrombosed internal hemorrhoids. Before surgical intervention is planned for thrombosed external hemorrhoids.

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Best and rapid relief from symptoms is obtained if excision is performed within 48 to 72 hours of onset of symptoms. The universal fact that the discomfort of surgical excision often exceeds the pain of the thrombosed hemorrhoid after 72 hours of onset of the symptoms and this should be clearly passed on to the patient. Strong Indications for excision are as follows: Patients with severe pain Ulceration Rupture. Both occuring within 72 hours of onset of symptoms. Although it causes the pain to subside. It is always advisable to avoid incision and simple removal of the clot, because it often results in clot reorganization by recurrent hemorrhage into the subcutaneous tissue.

Procedure
Simple excision under local anesthesia is the recommended treatment and is associated with a low incidence of complications. Preferably radial to the sphincter, an elliptical incision is made into the skin overlying the thrombosed hemorrhoid. The incision usually bleeds and may be controlled with pressure or electrocautery. The wound can be left open or primarily closed. General anesthesia is recommended in patients with: Bulky hemorrhoidal disease Severe pain with hypersensitivity Anxiety. Histopathology is advised if a mass or an unusual tissue is encountered during the procedure.

Postoperative Care
Postoperative care is very important and should include pressure to control bleeding by a pressure dressing kept in place for a few hours postoperatively.

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As with most hemorrhoid procedures sitz baths, topical anesthetic cream, and mild analgesics are recommended for the first 7 to 10 days after the procedure. Complications are usually minor: Bleeding Local infections Skin tags Scarring Most of the patients have no further complaints and will remain symptom-free at follow-up. Recurrence rates up to 22% of the following excision have been reported.

Hemorrhoids in Special Situations


Crohns Disease and Hemorrhoids
Symptomatic hemorrhoids are known to occur in patients with Crohns disease, although probably it is presumed that the occurance is not as a result of the inflammatory process. Any form of intervention that causes tissue damage should be avoided because of the prohibitively high complication rate incurred. If the proximal disease is quiescent and perianal sepsis is controlled the risks of intervention can be minimized. Though no data exist to support the fact. The role of metronidazole and ciprofloxacin in controlling perianal Crohns disease is evidently proved, it would be very sensible to cover any procedure with antibiotics.

Pregnancy and Hemorrhoids


Even though all pregnant women do not suffer from hemorrhoids, hemorrhoidal symptoms are common in pregnancy. Factors known to account for hemorrhoidal symptoms during pregnancy include: Hormonal changes Connective tissue laxity Constipation

Hemorrhoids (Piles) 367

Pelvic pressure and congestion Increased circulating blood volume. Treatment usually consists of dietary control, laxatives, and rest. Injection sclerotherapy has been proved to be safe during pregnancy, suggesting other conservative modalities be safe as well. There is no evidence suggesting an increase in fetal abnormalities following surgery for hemorrhoids during pregnancy, but there is enough evidence to document that surgery leads to an increased rate of preterm labor. When possible, surgical intervention should be delayed until the fetus is viable but on the grounds of pregnancy alone intervention should not be withheld. Understanding of hemorrhoidal etiopathology, management and treatment has come a long way. The theory of a sliding anal canal lining The documented evidence suggesting hemorrhoidal cushions to be a normal part of the anal anatomy and it is importance in maintaining continence should encourage symptom control rather than radical removal of tissue. Techniques that fix the cushions back in position and can be performed in outpatients with reasonable success rates would be the golden standard. Surgery should be aimed at symptomatic hemorrhoids, when indicated and when situations warrant. It is expected that newer developments like Doppler guided hemorrhoidal artery ligation with recto-anal repair and better pain management will promote increased day surgery, better pain control, and early return to work for patients.

chapter

Anorectal Abscess

16

Anorectal abscess is one of the most common anorectal problem. Although anorectal suppuration may have several causes, by far the most common is a nonspecific infection of cryptoglandular origin. Other causes are rare, except for Crohns disease and hidradenitis suppurativa. In order to achieve a satisfactory response to treatment and successful eradication and to avoid devastating consequences such as fecal incontinence: Indepth understanding of the anorectal anatomy Adequate knowledge of the pathophysiology of anorectal abscess Identication of possible colorectal pathologies that may contribute to the presence of an abscess Identication of potential complex cases that may require drainage under anesthesia are crucial. It is presumed that anorectal abscess is an acute presentation of a stula. These abscesses can be incised and drained as daycare surgery, in an otherwise healthy nontoxic patient.

Clinical Anatomy
A clear understanding of the existence of potential anorectal spaces is essential (Figs 16.1A and B): The perianal space The intersphincteric space The ischioanal space The supralevator space The superficial postanal space The deep postanal space The retrorectal space

Anorectal Abscess 369

Figs 16.1A and B: Anorectal spaces. (A) Coronal section; (B) Sagittal section

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The perianal space is located in the area of the anal verge. Laterally the perianal space becomes continuous with the ischioanal fat Medially it extends into the lower portion of the anal canal. It is continuous with the intersphincteric space. Extending from the levator ani to the perineum, the ischioanal space is bounded anteriorly by: The transverse perineal muscles The lower border of the gluteus maximus. The Posterior border is formed by the sacrotuberous ligament. The medial border is formed by: The levator ani. External sphincter muscles. The lateral border is formed by the obturator internus muscle. The intersphincteric space lies between the internal and external sphincters and is continuous: With the perianal space inferiorly With the rectal wall superiorly. The supralevator space is bounded: Superiorly by peritoneum Laterally by the pelvic wall Medially by the rectal wall Inferiorly by the levator ani muscle. The deep postanal space is located between: The tip of the coccyx posteriorly and lies Below the levator ani and Above the anococcygeal ligament. The ducts of the anal glands empty into the anal crypts, at the level of the dentate line. They are scattered in all planes with the distribution as follows: More than three-fourth of the anal glands are submucosal in extent Some extend to the internal sphincter Some to the conjoined longitudinal muscle Few to the intersphincteric space Very few penetrate the internal sphincter.

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This might be the pathologic explanation of transphincteric stula and the various locations of anorectal abscess.

Pathogenesis
Various type of epithelium and glands that form the lining of anal canal take part in the pathologic process of abscess formation. Five to twenty millimeter above the dentate line the proximal end of the anal canal is a transitional zone. Here there is change of the columnar epithelium to a transitional epithelium. The mucosa is presumed to be important for discrimination between gas and stool in the transitional zone because of its cuboidal cell type. At the mucocutaneous junction, i.e. at the dentate line, this epithelium changes into stratied squamous epithelium. The epithelium of the anal canal: Proximal to the dentate line is mucosa Distal to the dentate line it is stratied non-keratinized squamous epithelium. At the level of the dentate line the anal glands lie within the intersphincteric plane. They secrete mucus that empties into the anal crypts (into the lumen of the anal canal) through the anal ducts. At the dentate line the anal crypts macroscopically appear as small pits along the anal valve. Most anorectal infections arise from: An obstructed crypt An infected gland. Though it is unclear which comes rst, the infection within the gland or the stasis, it has been observed that as the intramuscular anal glands become infected, the ducts become obstructed by debris resulting in stasis of the glandular secretions which in turn interferes with the bodys defense mechanisms. Another theory is that obstruction or infection of the duct itself may result in an abscess and subsequently stula formation.

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The pathogenesis of abscesses and fistulas is usually the same, with the abscess representing the acute phase and the fistula the chronic sequel. The anal verge is the point where the stratied squamous epithelium becomes skin it is here that the anal canal ends. Anal verge is futher marked by the presence of hair follicles and sweat glands, apart from apocrine glands that may be associated with hidradenitis suppurativa. Hidradenitis suppurativa is an inammatory process that involves the apocrine glands which are located in different areas of the body such as the axilla, scalp, and perineum. However the disease does not present prior to puberty and may well result in abscesses and stulas in various locations, including the anorectal region. Infection originates most likely in one of the anal glands in the intersphincteric plane. Resulting in a simple intersphincteric abscess, or it may extend in all directions of the potential anatomical spaces, vertically either upward or downward, horizontally, or circumferentially, resulting in a number of clinical presentations. Rarely an abscess in the anorectal tissues may originate from any of the below mentioned causes:
Inflammatory Crohns disease Ulcerative colitis Infection Tuberculosis Actinomycosis Extension of a pilonidal abscess Traumatic Impalement Foreign body Surgery Episiotomy Hemorrhoidectomy Hard stool Malignant Carcinoma Leukemia Lymphoma Radiation Immunocompromised: AIDS Postradiation AIDS
Contd...

Hidradenitis suppurativa Prostatectomy

Anorectal Abscess 373


Contd...

Inflammatory Tuberculosis Actinomycosis Lymphogranuloma venereum Nontyphoidal Salmonella Cryptococcal infection Rectal schistosomiasis Amebiasis

Traumatic Diarrhea

Malignant

Clinical Presentation
The infection can be manifested as a superficial perianal or ischiorectal abscess, because of obvious erythema and a tender, fluctuant mass. Both these conditions are usually easy to diagnose. The symptoms include: Pain, swelling, and fever are the characteristic symptoms associated with an abscess. If the patient complain of gluteal pain it should point the diagnosis to a supralevator abscess. In some cases rectal bleeding has been reported. An intersphincteric or supralevator abscess is characterized by: Severe rectal pain accompanied By urinary symptoms such as: i. Dysuria ii. Retention iii. Inability to void.

Physical Examination
Erythema, swelling, and possible fluctuation are typically found on inspection.

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In patients suffering from the intersphincteric or suprale vator abscesses despite the patients complaint of excruciating pain, no visible external manifestations are present. Because of extreme tenderness digital rectal examination may not be possible. However palpation, if possible demonstrates tenderness and a swelling. A tender mass may be palpated on rectal or vaginal, in patients suffering from a supralevator abscess. Anoscopy and sigmoidoscopy are not advocated in patients with acute symptoms.

Types of Abscesses
Common type of anorectal abscesses found are classified into (Fig. 16.2): An intersphincteric abscess A perianal abscess A supralevator abscess An ischiorectal abscess.

Intersphincteric Abscess
Usually limited to the primary site of origin an intersphincteric abscess may present as two extremes: It may be asymptomatic or present with severe, throbbing pain that mimics the pain of a fissure. In a patient diagnosed of fissure in ano if there is persistent pain even after adequate treatment of the fissure should point to an underlying, unrecognized intersphincteric abscess.

Perianal Abscess
Vertical downward spread of the intersphincteric infection to the anal margin results in perianal abscess. Usually presents as a tender swelling, which can be misinter preted as a thrombosed external hemorrhoid.

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Fig. 16.2: Location of common anorectal abscesses

Supralevator Abscess
In case the infection spreads vertically upward from an intersphincteric abscess, an intermuscular abscess within the rectal wall or a supralevator abscess may develop. Because of atypical symptoms and signs these abscesses are difficult to diagnose: Complain of vague discomfort External manifestations are absent The presence of rectal induration and swelling not evident and may be clearly established only with the aid of an examination under anesthesia.

Ischiorectal Abscess
Horizontal spread of infection may track across: The internal sphincter into the anal canal or In the opposite direction across the external sphincter into the ischiorectal fossa to form an ischiorectal abscess.

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If neglected or treated only with antibiotics the ischiorectal abscess may grow large and expand to the roof of the fossa or even through it into the supralevator space after traversing the levator ani muscle and downward to the perianal skin. The primary complain of the patient is pain and fever even before an erythematous mass is identified. However in short duration, an obvious red, fluctuant mass is visible. If not treated in time the infectious process may spread cir cumferentially from one side to the other of the intersphincteric space, the supralevator space, or the ischiorectal fossa, ultimately resulting into the complex, horseshoe abscess.

Treatment
In patients with acute anal pain an anorectal abscess should always be considered because a delay in diagnosis can lead to necrotizing infections, particularly in an immunocompromised host. In otherwise healthy individuals the abscess can be drained under local anesthesia if the abscess is simple and superficial. Hospitalization and drainage under anesthesia is advocated in patients who: Manifest systemic symptoms: Those who are immunocompromised for any reason, including: Acquired immunodeficiency syndrome (AIDS) Diabetes Cancer therapies Chronic medical immunosuppression. Those with complex, complicated abscesses. The internal sphincter may be divided at the level of the abscess, to drain the abscess in case of an intersphincteric abscess. A simple skin incision is all that is necessary for a perianal abscess. So long as it is not an ischiorectal abscess extension. An intermuscular abscess and a supralevator abscess need to be drained into the lower rectum and upper anal canal. Wide local drainage through an appropriate cruciform incision, through the skin and subcutaneous tissue overlying the infected

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space, is the surgical procedure of choice for an ischiorectal abscess (Figs 16.3A to D). Abscesses in: The intersphincteric Intermuscular Postanal Supralevator spaces are more difficult to diagnose and these abscesses commonly require drainage under anesthesia (Fig. 16.4). At times, these abscesses are sufficiently deep that needle localization of the purulent material may be required to guide the surgeon for optimizing the skin incision site. To break down all loculations it is essential for the cavity to be gently digitalized. If neglected abscesses can lead to devastating, necrotizing infections of the perineum that can spread and become lethal. Failure of response to local treatment or recurrent abscesses is suggestive of: Inadequate drainage with residual pus, The presence of a fistula, or Immunoscompromised state. In these type of failures the line of management should include: Preliminary evaluation of the pelvis and perineum by computed tomography (CT)/MRI. Examination under anesthesia. Antibiotics as per the culture report also are of great help.

Horseshoe Abscess
For horseshoe abscess, the deep postanal space should be drained through (Fig. 16.5): A posterior midline incision extending from The subcutaneous portion of the external sphincter, over the abscess To the tip of the coccyx.

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Figs 16.3A to D: Drainage of abscess. (A) Local anesthetic injected; (B) Cruciate incision applied; (C) Deroofing the cavity; (D) Cavity drained

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Fig. 16.4: Drainage of a supralevator abscess

Separating the superficial external sphincter and thus: Unroofing the postanal space, and Its ischioanal extension. To drain the anterior extensions of a horseshoe abscess: Para-anal incisions can be made and setons placed.

Antibiotics
The role of antibiotics is limited in the primary management of anorectal abscesses. Its only active role is in recurrent abscess or as an adjunct in patients with: Valvular heart disease or prosthetic valves Extensive soft tissue cellulitis Prosthetic devices

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Fig. 16.5: Drainage of horseshoe abscess

Diabetes, Immunosuppression, or Systemic sepsis.

Postoperative Care
Patients are allowed on a regular diet and are advised to take a bulkforming agent, non-codeine-containing analgesic and sitz baths. Daily dressing is equally essential. Except for intersphincteric or supralevator abscesses where the patients are called for a follow-up after 2 weeks, all other patients are generally seen in follow-up in 2 to 4 weeks postoperatively. All patients are observed regularly until complete healing has occurred.

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Complications Recurrence
Recurrent abscesses and fistula to the extent of 85% plus have been observed after incision and drainage, ischioanal and intersphincteric abscesses. The primary reasons for recurrence of anorectal infections include: Missed infection in nearby anatomic spaces An undiagnosed fistula or abscess present at initial abscess drainage Inadequate drainage of the abscess.

Incontinence
Incontinence may result either: From iatrogenic damage to the sphincter Inappropriate wound care after incision and drainage of an abscess. During drainage of a perianal or deep postanal abscess if the superficial external sphincter is inadvertently divided, continence may be compromised in a patient with preoperative borderline continence. If the puborectalis is inappropriately divided. Drainage of a supralevator abscess may lead to incontinence. Prolonged packing of a drained abscess may impair continence by: Preventing the development of granulation tissue Promoting the formation of excess scar tissue.

Special Consideration
Necrotizing Anorectal Infection
Anorectal abscesses if not provided with timely attention, rarely may result in necrotizing infection and death if associated with any of the factors thought to be responsible: Delay in diagnosis and management

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Virulence of the organism involved Bacteremia and metastatic infections Underlying disorders such as diabetes, blood dyscrasias, heart disease, chronic renal failure, hemorrhoids, and previous abscess or fistula.

Hidradenitis Suppurativa

chapter

17

Hidradenitis suppurativa (HS) is an annoying chronic condition of the skin. It is a chronic acneiform infection of the cutaneous apocrine glands and it can also involve adjacent subcutaneous tissue and fascia. Primarily affecting young individuals, it has a chronic clinical course with frequent flare-ups followed by quiescent periods. The typical characteristics include: Swollen Painful Inflammed lesions in the parts of the body that contain apocrine glands. The areas of skin most frequently affected are the axilla, inframammary region, groin and inguinal areas, and the perineal and perianal skin. The severity of HS is variable: The mild type is at one end of the spectrum, where the disease may involve a small area of the skin causing minimal problems. Whereas at the other end HS may be a devastating disease causing serious disability. Because of the recalcitrant, painful lesions with malodorous discharge, the quality of life of those affected by HS may be significantly diminished. As against the fact that HS is located in areas with a high concentration of apocrine glands, the theory of its initiation is something different. It is presumed that the hair follicles get occluded and subsequently dilated, which ultimately rupture with spillage of keratin and bacteria into the dermis and lead to the typical clinical presentation of HS. The final outcome of the disease is sinus tracts in the apocrine gland body areas, which in turn can become draining fistulas.

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The term acne inversa has been coined after the theory of causation of HS changed to involvement of the hair follicles, from the conventional belief of causation from the apocrine glands.

Prevalence
The prevalence of HS has been estimated to be between 1 to 4% in different studies. More prevalent in women than men at a ratio of 2:5, except for perianal HS which is twice more common in men than women. Because the apocrine glands are inactive until triggered by a surge in sex hormones, HS does not present prior to puberty. The second and third decades of life is the most common age of presentation though the condition may be observed in patients of any age after puberty. HS is a chronic disease. HS is characterized by periods of quiescence and activity, but not relentlessly progressive. It is observed that the disease becomes less active as patients become older.

Etiology
The exact etiology for underlying factor predisposing to occlusion of the hair follicles in areas affected by HS is not very clear. In around one-fourth of patients, a positive family history is present. Endocrine factors as etiology for HS have also been suggested. The fact that HS is associated with: Acne vulgaris Premenstrual flare-ups The use of birth control pills. Supports the possible promoting role of sex hormones in HS. HS is more frequent in patients with history of smoking. In patients with HS, associated obesity may be an aggravating rather than a causative factor.

Hidradenitis Suppurativa 385

Bacterial contamination and infection are secondary to follicular occlusion, is suggested by bacteriological studies and Staphylococcus aureus and coagulase negative staphylococci were the organisms most frequently isolated.

Pathogenesis
As determined by the study of pathologic specimens, the initial step in the pathogenesis of HS, is occlusion of the hair follicles. Dilatation and rupture of hair follicles into the dermis leads to: Dermal infiltration by: Inflammatory cells Giant cells Formation of sinus tracts and fibrosis. Commonly found in the axilla, genitofemoral, perineal and perianal areas, periareolar, inframammary, and periumbilical areas, apocrine glands are compound sweat glands. Again it seems that inflammation and destruction of apocrine glands is incidental rather than a causative factor of HS.

Clinical Presentation and Diagnosis


Pain and malodorous discharge originating in the area of affected skin, are the chief complains of patients with HS. Typical findings on physical examination are: Indurated subcutaneous nodules Subcutaneous abscesses Draining skin sinuses, that may form a network of subcutaneous cavities and tracts with extensive fibrosis. The axillary, inguinal, and perineal regions are the regions most frequently affected. The diagnosis is exclusively based on clinical findings and diagnostic biopsies are rarely necessary. Biopsies should be obtained to establish a definitive diagnosis, if the differential diagnosis includes perianal Crohns disease or malignancy.

386 Anorectal Surgery

Differential Diagnoses
Skin carbuncle Dermoid cysts Furuncles Granuloma inguinale Pilonidal cysts Skin tuberculosis Perianal cryptoglandular fistulas Perianal Crohns disease. Because the clinical presentation of HS encompasses a wide spectrum of severity, and the chronic and relapsing nature of the disease, it becomes essential to formulate custom made individual treatment plans for individual patients to be delivered by a multidisciplinary team.

Treatment
The management of HS is tailormade to individual pathology, many different forms of treatment ranging from simple local measures of hygiene to wide surgical excision of affected areas, have been advocated. As mentioned earlier the treatment should be tailored to each individual patient and patients with HS are better served by a multidisciplinary approach involving: Dermatologists Surgeons A wound clinic Physical therapists Psychologists. An assessment of its severity and location, once the diagnosis of HS is made, allows different treatment modalities to be used according to the individual situation. A single patient may need and can be offered, one or multiple forms of treatment.

Hidradenitis Suppurativa 387

Nonsurgical Treatment
Patients education is the primary step in management of this disorder: The patients should be educated about the chronic and relapsing nature of HS. They should also know that: The disease is not contagious or due to poor hygiene. General measures common for all patients: Avoiding skin irritants (shaving, depilation, and deodorants), Avoid tight clothing Avoid prolonged heat exposure Lose weight Stop smoking. Though these suggestions appear practical, their efficacy has not been documented and is only anecdotal.

Antibiotic Treatment
To control local inflammation in areas affected by HS: Topical clindamycin Oral administration of tetracycline are effective. The natural history of HS, however is not altered with shortterm antibiotic therapy and it usually relapses after discontinuation of treatment. In the treatment of severe recurrent disease, long-term sup pressive antibiotic therapy has been suggested. However, the mechanism of action of long-term antibiotic therapy is not clear, doubts exists if it: Prevents progression or Changes the natural history of HS.

Hormonal Therapy
Though the role of sex hormones has not been clearly established in HS, presumptions of the indirect evidence of hormones promoting

388 Anorectal Surgery

HS, has led to lot of attempts to define the effectiveness of antihormonal therapy. Decreased disease activity has been found in patients treated with the antiandrogen, cyproterone acetate. In few patients finasteride, used in the treatment of benign prostatic hypertrophy, has been found to improve HS. A derivative of vitamin A isoretinoin, which has an established role in the treatment of acne has also been found to reduce epithelial differentiation and sebaceous secretions. Unfortunately, the results in the treatment of HS have been less favorable. Yet, isoretinoin may be used to decrease inflammation in areas of HS before surgical excision at a dose of 0.5 to 1.0 mg/kg daily. Similarly, at a dose of 25 mg twice daily, acitretin, used to treat psoriasis, may be effective for HS. Retinoids being teratogenic should be avoided during pregnancy. Immunosuppression: In severe HS, cyclosporine and infliximab may ameliorate inflammation. Immunosuppressive therapy cannot be recommended for routine use in HS considering the following facts: The toxicity Side effects Lack of clinical studies defining their therapeutic role.

Surgical Treatment
The surgical management of HS may be divided into two categories: Surgery to control local infection Surgery performed with curative intent.

Surgery to Control Local Infection


In case if patients with HS present with a subcutaneous abscess, these patients can be treated with incision and drainage of the abscess. Once local inflammatory changes subside, depending on the individual circumstances, the patient is subjected:

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To one of the different available forms of nonsurgical management or To pathology specific further surgery with curative role. There are instances when patients may present with: An infected sinus tract Surrounding cellulitis. The treatment option, these patients may be offered is: Unroofing and marsupialization of the tract Subsequently subjecting the patient to other forms of therapy if needed.

Surgery with Curative Intent


As a golden standard, the fact is to prevent recurrence, the entire affected area in HS must be removed. Complete excision is not advisable in some patients, as the area of skin involved is very large. Another factor which would prevent the surgeon from going for complete excision is the location of HS (perianal or perineal). Decreasing local inflammation with antibiotics or retinoids, preoperatively may improve postoperative healing and prevent complications. Depending on the size of raw area left, once the area with HS has been removed, the resulting wound may be approached in different ways. If the wound is small: It can be closed primarily without tension, with following advantages: Decreased morbidity Decreased length of hospitalization Decreased postoperative disability. If the wound is large: The defect may be left open to close by secondary intention, and the patient be subjected to the wound specialsit for active participation. Large wounds may also be treated by immediate or delayed split thickness skin grafting. Negative pressure dressings my be used to support skin grafts.

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If dealing with patients, who have large contour wounds, negative pressure dressings are particularly attractive. The use of local or distant flaps is not routinely advocated in HS. However flaps may be used in: Cases of complex wounds or In the surgical treatment of skin contractures. To keep the wound clean and avoid infection, changing the dressing regularly is very important and valuable. To prevent disabling contractures early physiotherapy should be started in patients with wider excisions and large wounds. Perineal and perianal wounds are treated by allowing the wound to heal by secondary intention. A colostomy is rarely necessary after excision of perianal HS. Though some experts believe it to be the procedure of choice in most patients suffering from perianal or perineal HS and have been treated by complete excision followed by wound closure by secondary intention. In the care of these patients, the wound clinic plays the role of an active participant. The recurrence rate after wide surgical excision vary with the area of involvement lowest for perianal disease, low for axillary disease and relatively high more than one third patients having recurrance for inguinoperineal disease. Radiotherapy and laser treatment have been used to treat HS. Though the results have not been found to be comparable or favorable comparing with the results of wide surgical excision.

chapter

Fistula in Ano
History of Fistula in Ano

18

In the History of Surgery References to fistula in ano date back to antiquity. Way back in 400 BC Hippocrates made reference to surgical therapy for fistulous disease. Treatises of Fistula in Ano were written by The English Surgeon John Arderne in 14th Century (13071390). Clysters described the procedure for fistulotomy and use of seton way back in 1376. There are references in history mentioning that Louis IV was treated for an anal fistula in the 18th century. Prominent physician/surgeons, such as Goodsall and Miles, Milligan and Morgan, Thompson, and Lockhart- Mummery, made substantial contributions to the treatment of anal fistula in the late 19th and early 20th centuries. Theories on pathogenesis and classification systems for fistula in ano were offered by these physicians. Little has changed in the understanding of the disease process, since this early progress. The classification system that is still in widespread use, was refined by Parks in 1976. Many authors have presented new techniques and case series over the last 30 years, in an effort to minimize recurrence rates and incontinence complications. Fistula in ano remains a perplexing surgical disease, despite 2500 years of experience. Fistula in ano has been a troublesome pathology to both patient and physician throughout surgical history.

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Definition
A stula is an abnormal connection between two epithelial lined surfaces. The term stula is derived from the Latin word meaning of reed, pipe, or ute. A fistula in ano is a hollow tract that is lined with granulation tissue and connects a primary opening inside the anal canal to a secondary opening in the perianal skin. For all practical purposes, an anal stula is a tract which usually communicates an infected anal gland to a secondary opening in perianal skin, and is often lined with granulation tissue. Secondary tracts may be multiple and from the same primary opening.

Etiology and Prevalence


Cryptoglandular disease is responsible for 90% of fistula in ano. Cryptoglandular disease in its acute form presents as an Anorectal abscesses, while stulae are the chronic evolution of the same process. Considering the cryptoglandular pathogenesis an abscess will always have preceded a stula, there would be instances that at the time of presentation it may have been so long ago that the patient cannot recall. A previous cryptoglandular perirectal abscess that was either drained surgically or spontaneously discharged ends up into cryptoglandular fistulae in most cases. A remnant of that abscess cavity and tract from the drainage, consisting of granulation tissue, persists, giving rise to the stula. The tract connects: The primary opening in the rectum (which was the opening of the infected gland), to The secondary opening in the skin of the perianal area (which was the drainage site, be it spontaneous or surgical). It is a common observation that sepsis originating in the anal canal glands at the dentate line is the most common area that results into a fistula the reason for this is that anal canal glands

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situated at the dentate line afford a path for infecting organisms to reach the intramuscular spaces. Trauma, Crohn disease, anal fissures, carcinoma, radiation therapy, actinomycoses, tuberculosis, and chlamydial infections are some of the diseases which can give rise to secondary fistulas. 8.6 cases per 100,000 population is the prevalence rate. Prevelance of fistula in ano is higher in male population. The male -to- female ratio is 1.8:1. The prevalence in men is 12.3 cases per 100,000 population. In women, it is 5.6 cases per 100,000 population. It is more common in the middle age group of the general population. The mean age of patients is 38.3 years.

Pathogenesis
The most accepted hypothesis is the cryptoglandular hypothesis which states that an infection begins in the anal gland and progresses into the muscular wall of the anal sphincters to cause an anorectal abscess. Occasionally, a granulation tissue lined tract is left behind, after spontaneous or a surgical drainage in the perianal skin, and thus causing recurrent symptoms. Local anatomy plays an important role in determining the path of the fistula (Figs 18.1A and B). Most commonly, when they track in the fascial or fatty planes, especially the intersphincteric space between the internal and the external sphincter into the ischiorectal fascia, the track passes directly to the perineal skin. Circumferential spread may also occur in the ischiorectal fossa, in some cases, where in the track passes from one fossa to the contralateral one through the posterior rectum forming what is commonly known as the horseshoe fistula.

Clinical Presentation
Clinical presentation of patients with fistula in ano is very suggestive, most patients often provide a reliable history of previous pain,

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Figs 18.1A and B: Anorectal spaces

swelling, and spontaneous or planned surgical drainage of an anorectal abscess.

Signs and Symptoms


Perianal discharge and soiling of undergarments Pain: Pain is intermittent maximum when the track is filled with discharge and minimum when it ruptures Swelling: There is a typical history that the swelling intermittently ruptures and swells again Bleeding

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Diarrhea Skin excoriation External opening.

Past Medical History


Past history of any of the following along with a fistula in ano usually recurrent should raise an alarm of it being a complex fistula in ano: Inflammatory bowel disease Diverticulitis Previous radiation therapy for prostate or rectal cancer Tuberculosis Steroid therapy HIV infection.

Physical Examination
Physical examination findings are the key to arriving at a diagnosis in patients with fistula, even before any investigation is asked for the examiner look for an external opening in the entire perineum, this would usually appears as an open sinus or elevation of granulation tissue. Upon digital rectal examination, spontaneous discharge may be apparent or expressible via the external opening. Digital examination may reveal a palpable nodule in the wall of the anal canal, an indication of the primary opening digital rectal examination may also reveal a fibrous tract or cord beneath the skin. It also helps appreciate any further acute inflammation that is not yet drained. Lateral or posterior induration suggests deep postanal or ischiorectal extension. The relationship between the anorectal ring and the position of the tract is also very important before any surgical intervention. A malleable probe can be eased gently (not forcefully) from the external opening in the perineal skin to the internal, anal canal opening. To identify the internal opening, anoscopy is usually required.

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To decide whether preoperative manometry is indicated before any surgical intervention. The sphincter tone and voluntary squeeze pressures should be assessed.

Differential Diagnosis
Among the few situations that mimic a fistula but do not communicate with the anal canal are the following: Hidradenitis suppurativa Infected inclusion cysts Pilonidal disease Bartholin gland abscess in females.

Grouped Differential Diagnosis Nonspecic 90%


Cryptoglandular.

Specic 10%
Trauma Foreign body Obstetric Hemorrhoidectomy Radiation therapy Inammatory bowel disease Crohns disease Cancer Adenocarcinoma of the rectum Squamous cell carcinoma of the anus Lymphoma Infectious Tuberculosis Actinomycosis Lymphgranuloma venereum Abdominal Diverticulitis Pelvic inammatory disease Appendicitis

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Extra-anal sources Presacral cyst Bartholins cyst Pilonidal disease Hidradenitis suppurativa

Classification
An in depth understanding of the pelvic floor and sphincter anatomy is essential for clearly understanding the classification system for fistulous-in-ano. As described by Parks and colleagues in 1976, Fistulas usually fall under four main anatomic categories.

Intersphincteric (Fig. 18.2A)


Seventy percent of all fistula fall under this category. The common course of the track of fistula is via internal sphincter to the intersphincteric space and then to the perineum. Uncommon presentations of the track: No perineal opening; high blind tract; high tract to lower rectum or pelvis. An intersphincteric fistula can rarely originates in the pelvis from the colon.

Trans-sphincteric (Fig. 18.2A)


Approximately twenty-five percent of all fistula fall under this category. The common course of the track of fistula is: Low via internal and external sphincters into the ischiorectal fossa and then to the perineum. Uncommon presentations of the track: High tract with perineal opening; high blind tract: If a transphincteric tract penetrates the upper portion of the sphincter (high blind track), it constitutes a more difficult therapeutic situation.

Suprasphincteric (Fig. 18.2B)


About five percent of all fistula fall under this category.

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B
Figs 18.2A and B: Classification of Fistula in ano

The common course of the track of fistula is: Via intersphincteric space superiorly to above puborectalis muscle into ischiorectal fossa and then to perineum. Uncommon presentations of the track: High blind tract which is palpable through rectal wall above dentate line.

Extrasphincteric (Fig. 18.2B)


Hardly one percent of all fistula fall under this category.

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The common course of the track of fistula is: From perianal skin through levator ani muscles to the rectal wall completely outside sphincter mechanism.
Intersphincteric (the most common): The fistula track is confined to the intersphincteric plane. Trans-sphincteric: The fistula connects the intersphincteric plane with the ischiorectal fossa by perforating the external sphincter. Suprasphincteric: Similar to trans-sphincteric, but the track loops over the external sphincter and perforates the levator ani. Extrasphincteric:The track passes from the rectum to perineal skin, completely external to the sphincteric complex.

Current Procedural Terminology Codes Classification


Subcutaneous Submuscular (intersphincteric, low trans-sphincteric) Complex, recurrent (high trans-sphincteric, suprasphincteric and extrasphincteric, multiple tracts, recurrent) Second stage The Parks classification systemUnlike the current procedural terminology coding, does not include the subcutaneous fistula. These fistulae are usually caused by unhealed anal fissures or anorectal procedures, such as hemorrhoidectomy or sphincterotomy and are never of cryptoglandular origin. For all practical purposes, stulae are frequently classied as either: Simple or Complex. Intersphincteric or low trans-sphincteric stulae are considered to be simple fistulae. The sphincter compromise is below 30% in these instances. The best treatment for this kind of stula is fistulotomy, and is not expected to put a patients continence at risk.

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Trans-sphincteric, suprasphincteric, or extrasphincteric fistula with more than 30% of sphincter compromise are usually labeled as complex stulae. Fistulae in the following situations are also classified as complex stulae: Anterior stulae in women The presence of multiple tracts Recurrent stula Pre-existing incontinence Local irradiation Crohns disease. And need special consideration in evaluation and management. Alternative treatments to stulotomy have been developed specically for these patients.

Patient Work-up
Laboratory Studies
A complete blood count with erythrocyte sedimentation rate, montoux test in specific conditions and a preoperative culture and sensitivity test of the discharge if available from the external opening. Apart from this the normal preoperative studies performed based on age and comorbidities is all that is mostly required. No other specific laboratory studies are required.

Imaging Studies Radiologic Studies


These are not performed for routine fistula evaluation. They can be helpful: When the primary opening is difficult to identify In the case of recurrent or multiple fistulae to identify secondary tracts or missed primary openings. The Goodsall rule is useful for anticipating the anatomy of simple fistulas (Fig. 18.3).

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Fig. 18.3: Goodsall rule

The rule states that when an imaginary line is drawn transversely through the center of the anus: External openings anterior to this line follow a radial (straight) path toward the anal canal and the diseased crypt If the external opening is posterior to this line, the fistulous tract will curve and enter the anal canal in the posterior midline with an internal opening in the posterior commissure. Exceptions to the rule occur when an anterior opening curves around and is located in the posterior midline. In these cases, the external opening usually is several centimeters from the anal verge. Because of the nature of the spaces around the anus, the fistulous tract can curve around and have an additional external opening anywhere along the tract on the opposite side. This type of fistula is termed a horseshoe fistula because of its long, curved course. If the internal opening cannot be identified by direct probing, it should be identified by probing the external opening or by injecting a mixture of methylene blue and hydrogen peroxide into the track using a pediatric feeding tube.

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Fistulography
This involves injection of contrast via the external opening, which is followed by: Anteroposterior Lateral Oblique. X-ray images to outline the course of the fistula tract.

Image
The accuracy rate is 16 to 48%. The procedure apart from the sensitivity to the contrast media is well tolerated but requires the ability to visualize the internal opening. Except in the case of recurrent disease, fistulography may be slightly more useful than a careful examination under anesthesia.

Endoanal/Endorectal Ultrasound
These studies involve passage of a high resolution 7- or 10-MHz transducer into anal canal and help define muscular anatomy differentiating intersphincteric from trans-sphincteric lesions. A standard water filled balloon transducer can help evaluate the rectal wall, for any suprasphincteric extension. Studies show that the addition of hydrogen peroxide via the external opening can help outline the fistula tract course. This may be useful to help delineate missed internal openings. These studies are reported to be 50% better to help find an internal opening that is difficult to localize, than physical examination alone. This modality is being used widely for routine clinical fistula evaluation.

Magnetic Resonance Imaging (MRI)


Fistulae are intimately related to the anal sphincter complex, so that incision and drainage may damage these muscles to a variable degree with the risk of anal incontinence. The correct balance between eradication of infection and maintenance of continence depends upon accurate preoperative assessment of fistula geography, namely:

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The site and level of any internal opening The anatomy of the primary track The presence of any secondary ramifications. These questions are best answered by MRI, which is more accurate than all other preoperative investigations, including examination under anesthetic. When observing a primary tract course and secondary extensions, findings show 80 to 90% correlation with operative findings. Magnetic resonance imaging (MRI) is becoming the study of choice when evaluating complex fistulae and recurrent fistulae. Unknown extensions that are missed during primary evaluation and surgery can be minimized with the sensible use of MRI as a diagnostic aid in fistula as it has been shown to improve recurrence rates by providing information on otherwise unknown extensions.

CT Scan
A CT scan is better for delineating fluid pockets that require drainage than for small fistulae because it is more helpful in the setting of perirectal inflammatory disease than in the setting of small fistulae. Apart from the fact that CT scan requires administration of oral and rectal contrast the muscular anatomy is also not well delineated.

A Barium Enema/Small Bowel Series


To help rule out inflammatory bowel in disease patients with multiple fistulae or recurrent disease a barium enema is always of great help.

Other Tests
Anal Manometry
In certain situations it is always advisable to study the resting and squeeze pressures and evaluate the sphincter mechanism before operating a patient for fistula in ano: Decreased tone observed during preoperative evaluation: History of previous fistulotomy History of obstetrical trauma

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High trans-sphincteric or suprasphincteric fistula (if known) Very elderly patients If decreased, surgical division of any portion of the sphincter mechanism should be avoided.

Diagnostic Procedures
Examination Under Anesthesia
As a standard the following are performed after the anesthesia of choice is administered: An examination of the perineum Digital rectal examination Anoscopy. If outpatient evaluation causes discomfort or has not helped delineate the course of the fistulous process this examination is necessary before surgical intervention. Several different techniques have been described to help locate the course of the fistula and, more importantly, identify the internal opening. Injection of either hydrogen peroxide, milk, or dilute methylene blue into the external opening and watch for egress at the dentate line is the most commonly used method for identifying the internal opening. A good number of experienced surgeons are of the opinion that methylene blue often obscures the field more than it helps identify the opening. Traction (pulling or pushing) on the external opening may also cause a dimpling or protrusion of the involved crypt. Insertion of a blunt tipped crypt probe via the external opening may help outline the direction of the tract. A direct extension is presumed likely, if it approaches the dentate line within a few millimeters of insertion from the external opening. Care should be taken not to use excessive force and create false passages.

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Proctosigmoidoscopy/Colonoscopy
To help rule out any associated disease process in the rectum, rigid sigmoidoscopy can be performed at the initial evaluation. Further colonic evaluation is performed only as indicated.

Management
A fistula may first present as: An acute abscess Simply as a draining sinusThat may irritate the perineal skin. Subcutaneous induration may be traced from the external opening to the anal canal on examination. A palpable nodule, an indication of the primary opening, may be revealed in the wall of the anal canal on digital rectal examination. A probe can be eased gently (not forcefully) from the external skin opening to the internal, anal canal opening. Optimal management is aimed at: Eradicating the fistula Preserving the anal sphincter Preventing recurrence Allowing an early return to normal activity for the patient. Though achieving these aims, however, represents a real challenge to the surgeon. In modern times, advances in molecular biology and bioengineering have meant that we now have access to a number of new materials that may be used as adjuncts to stula closure. Correctly identifying the full extent of disease and its relationship to the sphincter complex is the key to successful management of fistula in ano. Particularly in patients with a fistula in ano having a supralevator extension, some fistulae recur because distant sepsis has gone unsuspected, resulting in incomplete treatment. If the primary track crosses the external sphincter high in the anal canal, management problems also arise in these situations.

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If a high internal opening is not suspected preoperatively, then fistula incision and drainage will risk subsequent incontinence because of substantial sphincter division. Particularly in the above mentioned situation a seton thread or sphincter-saving surgery would be more appropriate.

Treatment
To the colorectal surgeon, fistula in ano remains a challenging condition to manage despite the best of technologic advances. The treatment objective remains: The eradication of perianal sepsis Effective stula healing Alleviation of symptoms Prevention of recurrence Preservation of the anal sphincter Rapid patient recovery. Conventional stula surgery has its role, and although technologies such as brin glue have promised to improve results, the reported success in the literature has decreased with increasing lengths of patient follow-up evaluation. The advent of the anal stula plug and early evaluation seems superior to brin glue because it eradicates the problem of slippage of the material from the stula tract. Denitive evidence of the advantages of the new technologies compared with traditional interventions relies on future randomized control studies being conducted.

Medical Therapy
No definitive medical therapy is availableThough in patients with Crohns disease, long- term antibiotic prophylaxis and infliximab may have a role in recurrent fistulae. A standard management of fistula in ano should include the following steps: Palpation for induration, under anesthesia.

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Anoscopy for inspection Gentle probing along the dentate for internal openings. These steps of evaluation allow accurate definition of the abnormal anatomy. For anticipating the anatomy of simple fistulas, the Goodsalls rule plays an important role. If it becomes difficult identifying the internal opening, it should be identified by: Probing the external opening By injecting a mixture of methylene blue and peroxide into the track using a pediatric feeding tube. The key to perfect management is: Drainage of primary intersphincteric infection in all types of fistulas Drainage of the primary track across the external sphincter Drainage of secondary tracks within the anorectal fossa. Primary fistulotomy is simple and definitive, for superficial fistulas involving small quantities of sphincter muscle. Seton placement should be preferred over primary fistulotomy in the following situations: For anterior fistulas in women Fistulas involving greater than one-fourth to one-half the bulk of sphincter muscles. Close follow-up and careful nursing of the wound involve twice a day sitz baths. To ensure healing from the depth of the wound to the surface. Professional wound dressing is of prime importance. For a suprasphincteric fistula, different type of seton of various materials are tied loosely around the fistulous track, to drain the trans-sphincteric track traveling above the anal valves. The seton may be removed 2 to 3 months later, it is presumed that by this time the track would have healed spontaneously. In case the track has not healed spontaneously, the track may be divided because fibrosis may cause minimal separation of the cut ends.

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A cutting seton can be placed during surgery and tightened every 3 to 4 weeks under sedation or in outpatient department. For more straightforward trans-sphincteric fistulas. This divides the track gradually over a few weeks and minimizes the sphincter defect and the risk for significant fecal incontinence.

Fistulotomy
First described in the 14th century by John Arderne, fistulotomy is a procedure that is the basic management for simple fistula in ano. Fistulotomy is basically the laying open technique of the fistulous tract. This procedure is useful for 85 to 95% of primary fistulae, (i.e. submucosal, intersphincteric, low trans-sphincteric). It consists of the gentle passage of a probe preferably a malleable one from the external to the internal opening, after its identication. The sphincter muscle is palpated. Meticulously the overlying skin, subcutaneous tissue, and internal sphincter muscle are divided with a surgical blade or electrocautery, thereby opening the entire fibrous tract. The stulous tract is opened along its length. If the amount of muscle is deemed to be insufcient as to cause incontinence. The base of the tract is usually covered with granulation tissue. The presence of granulation tissue is a conrmatory sign for the correct identication of the stulous tract, absence of granulation tissue is interpreted as a false passage created by the operator. The granulation tissue can be removed with a curette or gauze to reveal the brous stula tract underneath. This fibrous fistulous tract should be investigated to identify any secondary, or daughter tracts of the main stula which could complicate healing. Removal of immediately adjacent skin and subcutaneous fat ensures against premature closure of the wound. Alternatively, marsupialization with approximation of the skin edges to the opened stula tract is also effective.

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Without affecting continence, the internal sphincter and subcutaneous external sphincter can be divided at right angles to the underlying fibers, at low levels in the anal canal. Do not attempt the above mentioned step if the fistulotomy is performed anteriorly in female patients. Seton placement should be performed and is recommended, if the fistula tract courses higher into the sphincter mechanism. Remove granulation tissue in the tract base, with careful curettage. Complete fistulectomy creates larger wounds that take longer to heal and yet offers no recurrence advantage over fistulotomy. Opening the wound out on the perianal skin for 1 to 2 cm adjacent to the external opening with local excision of skin promotes internal healing before external closure. Marsupialization of the edges to improve healing times has also been recommended. Not to miss out a biopsy should always be performed without fail, on any tissue removed with curette or excised as fistula tract.

Fistulectomy
Fistulectomy involves: Complete excision of the fistula A bigger deeper wound is created Yet no advantage shown over fistulotomy.

Seton Placement
Setons were rst described by Hippocrates. The term is derived from the Latin word seta, meaning bristle. Generally, they are used in more complex situations such as a high trans-sphincteric stula or complex stulous disease. High fistulas cannot be laid open as described above as this would lead to division of the sphincters and fecal incontinence. If the tract is at a higher level crossing the sphincter muscles, a seton can be a good option to use independently or in combination with the laying open technique (Fig. 18.4).

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Fig. 18.4: High trans-sphincteric fistulotomy with seton

In these situations seton is recommended. The material used for setons is always nonabsorbable. Setons are usually made from rubber slings, silk, monofilament nylon, glove rings, silastic vessel markers, rubber bands and various other materials. A seton can either be placed alone, but is usually combined with fistulotomy, or can be placed in a staged fashion. Seton placement technique is useful in patients with the following conditions: Complex fistulae (i.e. high trans-sphincteric, suprasphincteric, extrasphincteric) Multiple fistulae Recurrent fistulae after previous fistulotomy Anterior fistulae in female patients Poor preoperative sphincter pressures Patients with Crohns disease or patients who are immuno suppressed Two types of seton suture can be placed according to the purpose solved with their placement.

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Cutting Seton Slowly cheese-wires though the sphincter muscle This suture is progressively tightened every 2 weeks over 6 to 8 weeks Allows fibrosis to take place behind as it gradually cuts through. Draining Seton Facilitates draining of sepsis Left loose and allows fistula to heal by fibrosis.

Cutting Seton
The cutting seton was promoted by Hanley. The technique consists of division of the lower half of the internal anal sphincter, isolation of the bers of the external anal sphincter, and passage of a nonabsorbable suture, usually silk, around the remaining external anal sphincter. Silk is often used because it promotes brosis while the seton is gradually tightened over an eight-week period, and slowly divides the sphincter muscle. This allows healing and brosis proximally, thereby preventing separation of the muscle ends as they are divided. A cutting seton allows for the conversion of a high transsphincteric stula to a low trans-sphincteric stula, either to lay open the remaining stula or to allow passage of the seton all the way through. After opening the skin, subcutaneous tissue, internal sphincter muscle, and subcutaneous external sphincter muscle, the seton is passed through the fistula tract around the deep external sphincter. The seton is tightened down and secured not too tight, a double seton is always recommended to prevent slippage of the same while cleaning during dressing or after defecation. Fibrosis occurs above the seton with time, and it gradually cuts through the sphincter muscles and ultimately exteriorizes the tract.

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The seton is tightened on subsequent follow-up visits under sedation every two weeks, until it is pulled through over 6 to 8 weeks. A cutting seton can also be used without associated fistulotomy.

Draining Seton
A seton which is left loosely in the stula tract to provide prolonged drainage without dividing sphincter muscles is aptly described as a Draining Seton. To allow drainage and closure of any secondary tracts and to minimize reaction and facilitate drainage, materials such as silicone are used. It has a specic use for patients with Crohns stulae, complex AIDS, and those patients who are debilitated. The aims of loose setons are: 1. Long-term drainage of the stula in patients too inrm to undergo more invasive procedures or risk of recurrent sepsis. 2. To allow healing of secondary tracts in preparation for a second stage operation. Patients with any of the following situations may be best served with drainage alone: Immunodecient patients with neutropenia Hematologic malignancy Organ transplant Complex AIDS. If a more aggressive repair is attempted, these patients are susceptible to poor healing, and are at risk for uncontrolled local or systemic sepsis, thus antibiotic coverage is a must. Intervention in these patients should be tailored on a caseby-case basis; however, it is good to remember that conservative management with sitz baths, long-term antibiotics, and a draining seton may be the safest and most viable option. After opening the skin, subcutaneous tissue, internal sphincter muscle, and subcutaneous external sphincter muscle, the seton is passed around the deep portion of the external sphincter.

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Unlike the cutting seton, the seton here is not tightened and is left loose to drain the intersphincteric space and to promote fibrosis in the deep sphincter muscle. Usually the seton bound sphincter muscle is divided, once the superficial wound has healed completely usually around 2 to 3 months later. The seton is removed without division of the remaining encircled deep external sphincter muscle, once wound healing is complete.

Mucosal Advancement Flap


Firstly, described by Noble in 1902, endorectal advancement aps were specically designed for the treatment of rectovaginal stulae. This treatment modality consists of removal and patching of the internal opening with a muscularmucosal ap of rectal wall. Indicated for the same disease process as seton is indicated for. Mucosal advancement flap is reserved for use in patients with chronic high fistula or complex fistulous disease. It may also be used to close rectovaginal and rectourethral stulae. The basic and essential requirement for this procedure is that: The patient must have a mature single stula tract No active extensions No uncontrolled sepsis. To ensure the above mentioned conditions. A draining seton has been recommended to be kept in place for six weeks prior to scheduling the rectal advancement ap.

Advantages of Mucosal Advancement Flap


A single stage procedure with no additional sphincter damage. A reduction in duration of healing Reduced associated discomfort Lack of deformity to the anal canal Little potential additional damage to the sphincter muscles since no muscle is divided.

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A disadvantage is poor success in patients with Crohns disease or acute infection.

This Procedure Involves (Figs 18.5A and B)


Total fistulectomy Removal of the primary and secondary tracts Complete excision of the internal opening. A full mechanical and antibiotic bowel preparation is required for this procedure. The procedure is generally done with the patient in the prone jackknife position, although a lithotomy position may be preferred occasionally for a posterior internal opening. Usually performed under regional or general anesthesia. A Foleys catheter is introduced before any procedure is attempted. The stula tract is identied with a probe and the internal opening is either cored out or curetted. Following that, a broad-based, rectal muscular mucosal ap is raised. The base of this has to be wide to the extent of approx two times the apex width.

B
Figs 18.5A and B: Mucosal advancement flap

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The ap should be mobilized sufciently so that it can easily be advanced 1 cm below the level of internal opening. The remaining internal opening is then suture closed with an absorbable suture, so it is watertight. Finally, the ap is brought down over the previous internal opening taking all due care that it is covered without tension. The ap is then secured in place with absorbable material. To prevent recurrence of sepsis which can lead to flap failure, longer tracts should be drained with a catheter. Taking care that its suture line does not overlap the muscular repair. The internal muscle defect is closed with an absorbable suture, and the flap is sewndown over the internal opening.

Postoperative Care
Immediate postoperative period, the patient is placed on: A clear liquid diet Antidiarrheals. A so-called medical colostomy. There are studies which have led to this practice being abandoned as early oral intake showed no difference in morbidity or sepsis but increased cramps, nausea, and discomfort. Inadequate blood supply is the main cause of ap failure and this can be accessed by observation of color or capillary rell by gentle pressure to the perineal skin. All patients are not appropriate candidates for this treatment modality even though transanal rectal advancement aps are generally safe. Initially, the reported success of the procedure was in the range of 80%; however, more recent data suggests the effectiveness in the range of 60 to 70%. Functional results are good with minimal or no disturbance of continence.

Contraindications for Transanal Rectal Advancement Flap


Presence of proctitis, especially in patients with Crohns disease Undrained sepsis and/or persisting secondary tracks

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Severe perianal scarring from previous stula surgery Rectovaginal stula with a diameter >3 cm Malignant or radiation-related stula Fistula of < 4 weeks duration Stricture of the anorectum Severe sphincter defect.

Island Flap Anoplasty Dermal Island Advancement Flap


First introduced for the treatment of anal strictures and ectropion, anocutaneous advancement ap is being used for the management of fistula since the last decade. The added advantage being basically to avoid incontinence and mucosal ectropion after mucosal ap advancement. This procedure has been reported for: Trans-sphincteric stulae with or without suprasphincteric extension For complex or recurrent cases. In terms of: Healing Postoperative complications Pain Incontinence. There are appreciably good results

In complex multiple fistula: Colostomy may be fashioned Posterior sagittal anorectoplasty may be done for multiple fistulectomies.

Preoperative Preperation
On the morning of the operation, rectal irrigation with enemas should be performed. Choice of anesthesia varies with the choice of the operating surgeons can be saddle, spinal, general, local with intravenous sedation, or a regional block.

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Prophylactic preoperative antibiotics should be administered. Prone jackknife position with buttocks apart is the most advantageous position, though other positions like a left lateral and lithotomy are also advocated.

Intraoperative Care
To confirm the extent of the disease and to evaluate the fistula examine the patient under anesthesia. To prevent recurrence identifying the internal opening is imperative. A local anesthetic block at the end of the procedure provides postoperative analgesia.

Postoperative Care
Though most patients can be treated in an ambulatory setting with discharge instructions and close follow- up care, few important tips help in making the patient comfortable: 1. Regular dressing with a qualified surgeon or an experienced nurse. 2. Sitz bath just before dressings help in wound toileting and aid in faster wound recovery. 3. Postoperative antibiotics or disease specific medications as per the culture and biopsy report respectively. 4. Patient with draining seton should be shielded with impervious dressing to reduce their embrassement in general public. 5. Changing seton at 2 to 3 weeks interval without missing helps the complex fistulae heal faster.

Follow-up
Sitz baths, analgesics, and stool bulking agents (e.g. bran, psyllium products) are used in follow-up care. Frequent office visits within the first few weeks help ensure proper healing and wound care. Importantly, ensure that the internal wound does not close prematurely, causing a recurrent fistula. Digital examination findings can help distinguish early fibrosis.

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Complications
Early postoperative: Urinary retention Bleeding Fecal impaction Thrombosed hemorrhoids Delayed postoperative: Recurrence Incontinence (stool) Anal stenosis: The healing process of an operated fistula causes fibrosis of the anal canal. Bulking agents for stool help prevent narrowing. Delayed wound healing: Ideally complete healing occurs by 12 weeks unless an underlying disease process is present (i.e. recurrence, Crohns disease).

Outcome and Prognosis (Table 18.1)


The reported rate of recurrence is 0 to 18% following standard fistulotomy, and the rate of any stool incontinence is 3 to 7% following standard fistulotomy. The reported rate of recurrence is 0 to 17% following seton use, and the rate of any incontinence of stool is 0 to 17% following seton use. The reported rate of recurrence is 1 to 17% following mucosal advancement flap and the rate of any incontinence of stool is 6 to 8% following mucosal advancement flap.
Table 18.1: The rate of recurrence and rate of incontinence Rate of recurrence Fistulotomy Seton Mucosal advancement flap 018% 017% 117% Rate of incontinence 37% 017% 68%

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Future and Controversies


Future recent advances in biotechnology have led to the development of many new tissue adhesives and biomaterials formed as fistula plugs. These therapies lead to decreased postoperative morbidity and risk of incontinence, by their less invasive nature. But long-term data especially in complex fistulas which carry high recurrence rates are lacking for eradication of disease. High recurrence rates nearly up to 40 to 80% with one year follow-up have been reported in a series where fibrin glue was used as treatment of fistula in ano. The fistula plug has also had mixed long-term results in direct clinical trials. With newer materials, such as acellular dermal matrix and the bioabsorbable fistula plug, early success rates have been reported for low fistulas and good animal model data. Evidence regarding long-term success with plug techniques for complex disease awaits randomized trials.

Controversies
Careful surgical treatment is needed in Crohns disease of the perineum with multiple and often complex fistulae. Acute perianal abscess requires incision and drainage. The intra-abdominal disease control with medical therapy is required for a definitive repair of fistulae in these patients. If controlled, routine therapy, as outlined in treatment, is warranted. Panproctocolectomy is advocated in recurrent fistulous disease to the rectum and perineum with persistent anorectal sepsis. Medical therapy with infliximab, the monoclonal antibody to tumor necrosis factor has been shown in studies to have a 50 to 60% response rates for perianal fistulae in these situations.

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Special Situations and Considerations


Crohns Disease Fistulae
Fistulae from Crohns disease are resistant to many of the traditional management strategies offered and are a more perplexing problem to manage.

Pathogenesis
Pathogenesis of Crohns stulae is thought to be quite different from the common cryptoglandular stulae. Two different suggestions are available in literature: It is thought to originate as a deep penetrating ulcer in the anorectum, which then is plugged with fecal material. With time and the ensuing high pressure produced by the anorectum, the ulcer nds its way through the skin and transforms into a stula. Alternatively, it has been suggested that the stula originates from a cryptoglandular infection that heals poorly as a result of the inammatory nature of the primary pathology, nally leading to stula formation. In either case, a major contributory factor is the transmural involvement of rectum in Crohns disease. Several medical modalities for the conservative treatment of Crohns stulas have been described in the literature. 1. Antibiotic therapy alone has been documented by several series. Though there is a high incidence of recurrence after antibiotic therapy is discontinued. Closure rates of up to 50% have been reported in some studies. 2. Closure of stulae in up to 54% of cases along with control of active Crohns disease, has been described with the use of 6-mercaptopurine and azathioprine. The adverse effects of these chemotherapeutic agents are signicant drawbacks for patients, with the most common being: Leukopenia Hepatitis Pancreatitis

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Various allergic reactions Infections. 3. A murine and human chimeric monoclonal antibody to tumor necrosis factor. Iniximab has been used with successful closure of up to 62% of stulae. Adverse effects of iniximab include: Allergic reactions Delayed hypersensitivity reactions Drug-induced lupus. 4. Other therapies such as cyclosporine and tacrolimus also have been described, with initial response rates reported to be high. However, the recurrence rates tend to be higher when the therapies are discontinued. Surgery for Crohns stulae has to be customized individually: To the patients medical condition The degree of activity of proctocolitis The location and type of stula. The healing rate of stulotomy for simple low-lying stulas in Crohns patients vary with the presence of active proctocolitis: With no proctolcolitis the results are as high as 93%, in contrast With active proctocolitis the same fall to as low as 27%. The patients with active proctocolitis should have: A noncutting seton inserted, rather than A stulotomy performed. Because of the poor healing associated with the advanced form of the disease, which is not likely to allow closure of an open stulotomy. Along with it to inactivate the underlying disease, medical therapy should be instituted if possible. When the disease is in dormant state, a re-examination under anesthesia is advocated: To change the seton To lay open that stula. In patients with Crohns proctocolitis complex stulae consisting of:

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High trans-sphincteric Suprasphincteric Extrasphincteric stulae. It should be treated more conservatively to avoid the risk of incontinence. The use of permanent setons until the disease subsides in order to: Help the stula to heal To help preserve sphincter function Allows continued drainage without forming an abscess. Medical therapy has a role to play in conjunction with surgical intervention to help suppress the underlying disease as it has been observed that four out of five patients have complete closure of complex Crohns stulae using medical therapy together with surgical intervention. Nearly half of the patients have a recurrence when no adjunctive medical therapy is initiated with the surgical treatment.

Fibrin Glue
Because of its hazard in transmitting blood-borne viruses it was withdrawn from clinical use by the Federal Drugs Agency, but in the 1980s and 1990s, as the technology of virus elimination in blood plasma progressed, the Federal Drugs Agency reapproved the use of brin sealant for limited surgical procedures. Fibrin glue as a treatment of anal stulae was rst introduced in the early eighties, not exclusively for fistula in ano but all perineal stulae postoperatively (Fig. 18.6). Fibrin glue is a simple treatment strategy, preserves sphincter function with minimal adverse side effects. It is an activated mixture of solution containing brinogen, factor XIII, bronectin, and aprotinin. The mode of action is presumed to be by: Stimulating the migration, proliferation, and activation of broblasts Pluripotent endothelial cells into the stula tract to seal it off.

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Fig. 18.6: Fibrin glue

The bronectin and collagen present in the mixture is used as a matrix for the cells to integrate into and the fistula tract is sealed off. In the next stage of wound healing. These cells then lay collagen and extracellular matrix. Before application the primary opening is inspected to ensure: That it is not closed and That it does not lie in the high-pressure zone of the anorectum Because this results in the glue being pushed out of the stula tract. The operative technique involves identication and curettage of the internal and external openings. Fibrin glue is injected into the stula, thus lling the entire tract. A bead of glue can be seen extruding from both the internal and external openings. The reported healing rates were variable and ranged to both extremes with a mean of 50%. Long-term follow-up has often revealed that the healing reduces in the later follow-up. Because the shorter stulae do not hold the glue as strong as longer-tract stulae do, shorter stulae that are less than 3.5 cm

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tend to recur more often than longer stulae that are greater than 3.5 cm. Because there is no trauma to the sphincter musculature. Continence seems to be unaffected when the patient is treated with brin glue. Fibrin glue because of its safety profile should be considered treatment of choice in simple fistulae, however it is less likely to be successful in complex fistulae or those fistulae associated with inflammatory bowel disease. Secondary tracts and undrained infection will predictably lead to failure. Repeat gluing is unlikely to be successful. The complications of brin glue for treatment of stulae include formation of abscesses and new stulae tracts.

Anal Fistula Plug (Fig. 18.8)


Recently, a new technology, known as the anal fistula plug has become available (Fig. 18.7). It is a strong, advanced biomaterial, pliable tissue taken from lyophilized porcine small intestine that provides a scaffold for host cells to replace and repair damaged tissue. Small intestinal submucosa has the following inherent qualities which make it suitable as a biomaterial: It is naturally occurring Complex matrix that is Easy to handle, yet Strong enough to hold sutures and Provide support for weakened tissue. Through processing: It is denuded of cells and It is made biocompatible Sterile and pathogen free, Thus safe for human use.

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Fig. 18.7: Anal fistula plug being placed

This material after process has been documented to have an inherent resistance to infection in contaminated abdominal wounds. Its initial use was intended for bridging large tissue defects in: The abdominal or chest walls. It is designed to occlude the stula tract from the internal to the external opening. The technique of plug deployment is as follows: The tract is: Explored, Probed, and Irrigated gently with hydrogen peroxide. The next step is to tie the apex of the plug to the probe from the internal opening and the plug is dragged through to the external opening. Final step is to cut the plug to t and secure in the internal opening using a gure-of-eight suture incorporating it with the mucosa of the anorectum so as to close the internal opening.

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Fig. 18.8: Anal fistula plug

Advantages of this technique are the (Fig. 18.7): Mechanical stable conguration Minimal foreign body reaction Infection resistance There is also the added benet of the plug acting as a good bridging medium or matrix for human tissue regeneration. Comparing the results with fibrin glue, anal fistula plug has been found to offer better closure of the fistula. Recurrence rates are variable better success rates are reported in cryptoglandular stulae than in Crohns stulae management.

Ligation of Intersphincteric Fistula Tract (LIFT)


This is a new, simple, quick method for managing fistula in ano. Though it may take a little bit longer in terms of operative time, to get into the intersphincteric space, but it is a fairly simple procedure. If the surgeon is comfortable with the anatomy in that area, getting into the intersphincteric space is not terribly difficult. In LIFT procedure: The fistula tract is identified in the intersphincteric space, and then it is ligated. A cut is made and a plane is developed between the two anal sphincters and the fistula tract passing between the two sphincter muscles is isolated.

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This portion of fistula tract between the sphincters is ligated (tied) and excised (cut out). The internal opening of the tract is cauterized and the portion of the fistula tract outside the sphincters is curretted, cleaned and left open so that it can drain freely and get healed. The most important thing about the technique is that it is sphincter-sparing.

Video-Assisted Anal Fistula Treatment (VAAFT)


VAAFT: Video-Assisted Anal Fistula Treatment with closure of the internal fistula opening by staplerthe MEINERO technique. The VAAFT technique is performed for the surgical treatment of complex anal fistulas and their recurrences. Important steps include: The correct localization of the internal fistula opening under vision The fistula treatment from inside The meticulous closure of the internal opening.

Procedure
A fistuloscope is inserted through the external opening and the whole tract is visualized on screen. The internal opening is localized through the endoscope while visualizing the anorectum from outside. Next two stitches are taken through the internal opening so as to isolate the internal opening. Following this, the fistula tract is cauterized with a monopolar electrocautery so as to coagulate (burn) the fistula lining from internal opening to the external opening. The necrotic burnt tissue is taken out with the help of a brush and forceps. Finally, the internal opening is lifted with the help of two stitches taken earlier and closed with a linear cutting Stapler which closes the tract at the level of the internal opening.

chapter

Pilonidal Sinus

19

Even as pilonidal sinus continues to be a significant health issue today, the history of pilonidal disease dates back to the early 1800s. In 1833, Herbert Mayo described a disease that involved a hair filled cyst at the base of coccyx. Hodge coined the name pilonidal in 1880, from the Latin pilus that means hair and nidus that means nest. Over 80,000 soldiers in the United States Army were hospitalized with the condition, during World War II. Because a large number of soldiers who were being hospitalized for pilonidal disease rode in jeeps, it was termed Jeep riders disease. It was presumed that long journeys on rough terrain were responsible to cause the condition because of pressure on and irritation of the coccyx.

Definition
Derived from a set of Latin words pilus, meaning hair, and nidus, meaning nest. A pilonidal sinus is a short tract that extends from the skin surface and most likely represents a distended hair follicle. Also popularly known as Jeep Riders Disease. A pilonidal sinus is a subcutaneous sinus containing hair (see Fig. 19.1) Lined by granulation tissue rather than epithelium Usually occur in the natal cleft. It is most commonly found in the intergluteal fold of sacrococcygeal region, but it can also occur in: The interdigital area Umbilicus Chest wall Scalp.

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Fig. 19.1: Typical contents of an excised pilonidal tract

Pilonidal disease is a common condition, ranging from the routine cyst with abscess to extensive chronic infection and sinus formation. It can be associated with significant morbidity and prolonged wound healing after definitive surgery.

A Pilonidal Abscess can be Acute or Chronic


An acute pilonidal abscess usually results from rupture of an infected follicle into fat and always consists of pus and a wall of edematous fat. When an infected follicle ruptures directly into surrounding tissues. A chronic pilonidal abscess results; as against edematous fat in acute pilonidal abscess, the wall of a chronic pilonidal abscess consists of fibrous tissue. A chronic abscess of long duration after it gets lined by a thin and flat layer of epithelium which grows into the cavity from the skin surface, turns into a pilonidal cyst (Fig. 19.2).

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Fig. 19.2: Pilonidal sinus with midline pits

Epidemiology and Demographics


Currently, pilonidal disease is a fairly common condition that affects many patients worldwide.

Incidence
Twenty-six cases per 100,000 persons.

Predominant Sex
It affects men more frequently than women in a ratio of 34:1.

Average Age of Presentation


Twenty-one years. Pilonidal disease is most frequently seen in young adults. It is rarely seen after the age of 45 years.

Risk Factors
Although not found to be directly causative, risk factors for the development of pilonidal disease are as follows: Male sex Caucasian race Family predisposition

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Obesity Sedentary lifestyle Occupation requiring prolonged sitting Local hirsutism Poor hygiene Increased sweat activity Trauma or irritation to the gluteal cleft skin. Lifestyle changes can be implemented if risk factors are identified.

Etiology
There is a change in thought of the origin of pilonidal sinus originally thought to be congenital in origin, pilonidal disease is now thought to be an acquired condition. The presence of hair in the natal cleft is considered primary reason for pathogenesis. Drilling of hair shed from the perineum into the natal cleft. Drilling is facilitated by the friction of the natal cleft. This loose hair causes a foreign body reaction that leads to midline pit formation. In as many as Ninety-three percent instances pilonidal sinus run cephalad, they may be single or multiple, and they can be short or long leading to a variety of clinical presentations. If the pilonidal sinus runs caudad as in the remaining seven percent instances, the secondary opening may resemble the opening of a fistula in ano. Pilonidal sinuses are lined with granulation tissue and contain foreign matter such as hair and epithelial debris.

Physical Findings and Clinical Presentation


Its clinical presentation ranges from a simple intergluteal skin pit with minimal symptoms to a complex infection in the subcutaneous tissues of the sacral area with multiple sinuses and a secondary opening.

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Pilonidal disease can present as: A simple cyst May manifest as asymptomatic pits or pores in the natal cleft Tenderness after physical activity or prolonged sitting An acute pilonidal abscess with or without cellulitis in 20% of patients with pilonidal disease A chronic draining sinus. Presents as a hot, tender, fluctuant swelling just lateral to the midline over the sacrum that may exude pus through the midline pit. Chronic pilonidal abscess in 80% of patients with pilonidal disease Acute suppuration, tenderness, swelling, and heat Infrequently, systemic reaction: occasionally fever, leukocytosis, and malaise Subsequent infection by skin organisms leads to pilonidal abscess.

Diagnosis
The diagnosis is confirmed by a physical examination and the findings of different clinical forms can be listed as follows:

Acute Pilonidal Abscess


The onset of symptoms is usually rapid and intensity of pain may be severe. Characterized by: A tender fluctuant subcutaneous mass Surrounding cellulitis located off the midline of the natal cleft in the sacrococcygeal region. Primary openings are frequently seen on the midline natal cleft.

Chronic Pilonidal Sinus


There is a primary opening on the midline of the natal cleft in these cases (Fig. 19.2). Sometimes located 4 to 5 cm cephalad to the anus there could be extruding hair.

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Fig. 19.3: Pilonidal sinus with midline pits

Fig. 19.4: Pilonidal sinus with pits

A secondary opening located off the midline may also be found in some cases (Fig. 19.3). The secondary opening is usually cephalad to the primary opening and at a variable distance from it (Fig. 19.4).

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Complicated Pilonidal Sinuses


Multiple skin pits on the midline of the natal cleft leading to multiple sinuses is a common findings. A secondary opening at variable distances from the midline. Partially drained abscesses may also be present.

Recurrent Pilonidal Disease


Previous surgical scar with different degrees of surrounding fibrosis is a usual finding, although findings in this situation are variable. The primary opening may or may not be visible and one or multiple secondary openings may be present.

Differential Diagnosis
Perianal abscess arising from the posterior midline crypt Hidradenitis suppurativa Carbuncle Furuncle Osteomyelitis Anal fistula Coccygeal sinus Skin Furuncles Actinomycosis Syphilitic granulomas, or Tuberculous granulomas.

Work-up
In general, the diagnosis of pilonidal disease is straightforward on clinical grounds. Symptoms may vary from pain in the sacrococcygeal region to chronic drainage of purulent fluid from the same area. Diagnosis is based on history and physical examination. Midline pits present behind the anus overlying the sacrum and coccyx.

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Broken hairs are often seen extruding from the midline pits. Insert probe in pilonidal sinus in path away from the anus. Complicated anal fistula may be angulating posteriorly before passing into a retrorectal abscess, but thorough examination of the anal cavity usually discloses point of origin. Anorectal examination should be performed to rule out other disease processes.

Laboratory Tests
Complete blood count.

Imaging Studies
Ultrasonography and CT scan in advanced, recurrent cases.

Treatment
Nonpharmacologic Therapy
Prevention of exacerbations: 1. Local hygiene 2. Avoidance of prolonged sitting position 3. Weight reduction. Because hair follicle in growth and subsequent foreign body reaction have been attributed as the cause of pilonidal sinus disease, whether by shaving or laser epilation, local hair control and strict hygiene of the natal cleft has been used as a primary treatment and as an adjunctive strategy. An additional nonoperative adjunct to treatment is phenol or fibrin glue injection into the pilonidal sinus. After all hair and debris have been removed or curetted from the sinus, either of the medicated substance is injected into the cavity and they help to eliminate granulation tissue and further debris formation. In both these modalities the injection is followed by hair control and strict hygiene.

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Injection of phenol into the sinus tract has been described in literature but is not very prevalent as a modality for management of pilonidal disease. Phenol causes an intense inflammatory reaction which destroys the epithelial lining. In one study patient were treated with 1 to 2 ml of 80% phenol. The injection was performed under local anesthesia. Only 60% of patients healed in an average of 6 weeks, and 11% of patients developed abscesses. Due care should be taken to protect surrounding skin.

Pain is intense and may require inpatient admission for pain control. In treatment of chronic or recurrent sinuses and following various interventions. Fibrin glue has been used similarly as an adjunctive treatment. In small series, morbidity is low, and success rates are high (90 100%). Though primarily of historical value, cleansing and curettage of the midline pilonidal pits is recommended as an alternative treatment to excision. A thin bottle brush is used to brush the sinus and cleanse the sinus of hair and debris. This treatment is labor intensive and must be accompanied by continued strict hair removal and hygiene.

Acute General Rx
This is the procedure of choice for first-episode acute abscess: simple incision and drainage in an outpatient setting Documented cure rate of 76% after 18 months Antibiotics: Generally not indicated unless the patient has a medical condition such as rheumatic heart disease or is immunosuppressed.

Role of Antibiotics
Antibiotic use in pilonidal disease has a limited role.

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Aerobes are the most common organisms isolated in chronic pilonidal sinus Whereas in associated abscesses anaerobes such as bacteroides predominate. Antibiotic therapy has been recommended in the perioperative prophylactic, postoperative treatment, and topical roles. Wound complications, healing, or recurrence, have not been shown to be affected by either preoperative, single-dose, intravenous antibiotic before excision of a chronic sinus or varying courses of postoperative therapy. The use of antibiotics in this role has eventually shown little or no benefit in reducing wound infection rates. Topical therapy in the setting of pilonidal disease primarily involves: Antibiotic or abrasive solution-soaked sponge Dressing being packed into an abscess cavity or excised sinus. Apparently there is no conclusive evidence to support this practice of topical therapy, the reason being there has been no demonstrable benefit, as with most outcomes of antibiotic use in the pilonidal disease process. Although expert opinion has suggested a role of antibiotics and topical therapy in: The setting of cellulitis Underlying immunosuppression Concurrent systemic illness. Strong data to support antibiotic use in acute or chronic pilonidal disease is lacking. A rare presentation of this disease is the asymptomatic subclinically inflamed, incidentally discovered pilonidal sinus, where in most cases presence of hair and inflammation is found. Because, prophylactic surgery in asymptomatic accidentally detected pilonidal sinus has not demonstrated extra benefit over surgical intervention for symptomatic disease, nonoperative strategies, such as hygiene, hair control, and observation, are recommended in this group.

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Operative Treatment
Because none have proved to be full proof, there are many options for the surgical management of chronic pilonidal disease. Options range widely and encompass: Simple excision with or without primary closure, to Complex flap reconstruction. All standard procedures advocate adjunctive hair removal and strict hygiene. None of the recommended operative interventions has been proven superior to another in: Overall healing Time away from work Recurrence. Pilonidal disease can present acutely as an abscess with or without associated cellulitis. The appropriate therapy in the acute setting, is simple incision and drainage. The majority (approximately 60%) of those presenting with abscess at initial episode and treated in this way will heal without further intervention.

Incision with Marsupialization (Fig. 19.5)


The entire sinus tract is opened from the primary to the secondary openings in this technique. The tracts are identified and unroofed in marsupialization. As an option excision of the tracts and pits can be done as against unroofing. The wound is curettaged. Skin edges are sewn to the fibrotic base of the wound to: Decrease the size of the wound In turn accelerate wound healing. After the hair is removed, the granulation tissue is thoroughly curetted. The wound surface is reduced by 50 to 60% by leaving the fibrous tract which is left in place and sutured to the edges of the skin.

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Fig. 19.5: Incision and marsupialization

This procedure is simple and can be performed under local anesthesia and sedation in the outpatient setting. Though the length of follow-up is not clear, the recurrence rates are found relatively as low as 6% and with an average of 4 weeks, the time to healing is found to be between 3 and 20 weeks.

Lateral Incision and Excision of Midline Pits (Figs 19.6A and B)


The midline pit or pits are excised, in this technique. The sinus tract is then cleaned and curetted. Through a longitudinal incision off the midline of the natal cleft, as against the conventional approach to the sinus tract for the procedure. At a mean follow-up of 3.5 years, the cure rate was 84%.

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B
Figs 19.6A and B: Lateral incision and excision of midline pits

Chronic Treatment
Apart from those with acute abscess needing either of the above procedures, the remainder of patients will need a more definitive excision to address hypertrophic granulation tissue before closure. Atleast 10 to 15% of patients, even after complete healing, will need evaluation and management of pilonidal disease recurrence. The role of curettage of the cavity at time of incision and drainage is controversial, hardly any difference has been demonstrated in regards of greater complete healing and lower incidence of recurrence as compared with no curettage. Even with the theoretical benefit of the elimination of future disease excision of the midline pits at time of incision and drainage, has always been an issue. Not to forget the fact that the practice of excision of the midline pits, however, has not been shown to: Increase rate of healing Decrease hospital stay Decrease rate of recurrence. Pilonidal sinus excision can be performed in many different ways and can be accompanied with or without primary closure. Complete sinus excision can be approached through a midline or lateral incision, and this involves removal of the pilonidal sinus while sparing normal tissue.

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The options for managing the wound for sinus removal through a midline approach are as follows: The wound can be primarily closed Marsupialized Left open and allowed to heal by secondary intention. Although it has been demonstrated that with primary closure there are faster median healing rates and more rapid return to work, the same have also been shown to have higher recurrence rates as compared with healing by secondary intention. Marsupialization is a procedure in which the skin edges are sutured to the wound base after debridement and this procedure acts to decrease the overall wound volume and prevent premature epithelialization. In case this repair break down, the wound can continue to heal without requiring further procedures, by secondary intention. Another alternative to sinus excision is, incision from the midline, or lateral incision (Figs 19.7 to 19.9). Theoretical advantages of this option include: A richer blood supply A dryer environment A less bacteria-rich environment Less sheer with ambulation as compared with incision in the gluteal cleft. Apart from the advantages mentioned, this approach has demonstrated: Faster healing time Decreased wound complications Decreased recurrence rates. Two commonly adopted techniques are described below: One involves lateral incision with sinus cavity curettage and pit removal either separately or en bloc. The other approach involves sinus removal through lateral incision with removal of the midline pits through this lateral incision. As far as lateral incisions are concerned they can be: Closed primarily Left open to heal by secondary intention Closed via flap reconstruction if the excision is extensive.

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Fig. 19.7: Pilonidal pit and sinus excision through midline approach

Although a reported advantage of the lateral approach involves primary closure and healing by secondary intention is typically avoided. Considering the added advantage of primary closure a good number of different types of flap-based options are available, that can be used in the treatment of chronic pilonidal disease. Flap based options are also good for chronic disease because usually chronic disease presents with complex or extensive sinus tracts, which, after excision, can leave a sizable defect. To excise disease and cover the defect with healthy tissue that has rich blood supply, is the basic theory behind flap-based reconstruction.

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Fig. 19.8: Pilonidal sinus with lateral incision and pit excision through another incision

Fig. 19.9: Pilonidal sinus and pits removal through a lateral incision

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Karydakis Flap (Figs 19.10 and 19.11)


The most prevalent Karydakis flap involves the following steps (Figs 19.10A to C): Midline excision of the pilonidal sinus tracts followed by Soft tissue coverage in the form of mobilized fasciocutaneous tissue that is Sutured laterally to the sacrococcygeal fascia to Avoid midline tension. In a huge series Karydakis procedure has demonstrated: A wound complication rate of 8% Recurrence rate of 2%.

Figs 19.10A to C: Karydakis flap

Fig. 19.11: Karydakis procedure

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Figs 19.12A and B: Rhomboid (Limberg) flap

Limberg Flap
Similar in principles to the Karydakis flap, the rhomboid or Limberg flap involves the following (Figs 19.12A and B): Midline excision of the pilonidal disease Deep to the presacral fascia Involves fasciocutaneous coverage. The apparent differences as compared to Karydakis flap is: The flap in this instance is rotational The flap results in flattening of the gluteal cleft. Although the complications are low and rare in the range of 0 to 6%. The Limberg flap has few potential downfalls which include: The large area of tissue mobilization The increased risk of hematoma/seroma Wound dehiscence.

Bascom Flap
Bascom, or cleft-lift, technique is an additional flap option available for pilonidal disease (Figs 19.13A to D). This technique involves: The excision of all diseased tissue with

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Figs 19.13A to D: Bascom flap

The creation of flap-based coverage Extending from Lateral to the midline The flap Completely obliterates the cleft. With the apex located above and lateral to the cleft apex. A triangular incision is performed, and all disease is excised. Hair and granulation tissue are debrided and a skin flap is raised toward the midline. After excess skin is removed, the flap is sutured and closed over a drain. This type of flap has: Healing rates in the range of 80 to 95% Recurrence rates as low as 4%. Two additional local advancement flaps that have also been applied to the management of pilonidal disease, but have been used to provide tissue coverage in other areas of the body are:

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Figs 19.14A and B: V-Y advancement flap

The V-Y advancement flap The Z-plasty. The V-Y advancement flap is (Figs 19.14A and B): Composed of skin Fat Gluteal fascia Can cover defects 8 to 10 cm in size. Typically this flap can be used unilaterally or bilaterally and eliminates the gluteal cleft. Considered as a drawback, the final suture line is midline, and the flap is closed over a drains. Good healing minimal wound complication and minimum recurrence rates, have been documented.

The Z-Plasty (Figs 19.15 and 19.16)


One more flap commonly used in cosmetic surgery has been used with good results in pilonidal disease is the Z-plasty. This flap involves (Figs 19.15A to C): Sinus excision Z limbs. These limbs are marked at a 30-degree angle to the long axis of the wound.

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Figs 19.15A to C: Z-plasty incision

B
Figs 19.16A and B: Z-plasty steps

Flaps of skin and subcutaneous tissue are: Raised Transposed Sutured Obliterating the gluteal cleft. This technique has been reported to have higher wound complication and recurrence rates. Usually, the wounds may require more complex flap reconstruction because after excision larger and deeper wounds are encountered.

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The best option in this setting is the gluteus maximus fascio cutaneous or myocutaneous rotational flap. The flap is raised and rotated into place, thus filling the defect with vascular-rich tissue and obliterating the remaining dead space and gluteal cleft. Drawbacks of the Z-Plasty procedure include: Longer operative duration Operative complexity Higher morbidity with flap failure. For the management of various complex wounds following wide excision and as adjuncts to skin grafting, Vacuum-assisted closure devices that use a negative pressure to wound beds have been used. Though not recommended on a day to day basis, Vaccum assisted closure device application in pilonidal disease, may be considered in selected cases as primary or adjunctive therapy.

The Gluteus Maximus Musculocutaneous Flap


The gluteus maximus musculocutaneous flap consists of the creation of a large rotational buttock flap (Figs 19.17A and B). The procedure permits radical excision of all diseased tissue and fills the dead space with bulky, well-vascularized, and compliant tissue.

B
Figs 19.17A and B: Gluteus maximus musculocutaneous flap

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Large defects can be covered using this approach. This procedure carries the highest degree of difficulty and potential morbidity of all approaches, and is used if other conventional procedures have failed.

Management Options in Special Situations


Treatment of the Unhealed Pilonidal Wound
Irrespective of the surgical procedure used in the primary treatment of pilonidal disease, the unhealed wound, is a frequent postoperative problem. To minimize this complication the suture line should be placed off the midline natal cleft, in case primary closure is decided. Presence of abundant granulation tissue at its base is the main characteristic of the unhealed wound. In case of a small unhealed wound, treatment includes: Curettage Removal of hair from area surrounding the wound Application of silver nitrate Along with strict local hygiene. The best treatment for larger unhealed wounds is to excise the wound and reconstruct the area with a flap procedure. Effective for the treatment of large, unhealed wounds include: Z-plasty Gluteus maximus myocutaneous flap Bascoms cleft closure procedure.

Recurrent Pilonidal Disease


The recurrence rates for pilonidal disease vary widely following primary and subsequent interventions reported to be as high as 50% following primary intervention, and as high as 10 to 30% after subsequent interventions. Irrespective of the type of management, these rates indicate that many patients will continue to have treatment failure despite the type of management chosen.

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Although wound complications at primary intervention have been shown to be predictive. The cause of these failures is not completely known. Management of recurrent disease is similar to that of primary disease. Thorough examination should be performed and other processes excluded, such as inflammatory bowel disease, malignancy, and other differential diagnoses as discussed earlier. Nonoperative adjuncts, such as hygiene and hair control are the basics of management of recurrent disease. An incision and drainage should be performed. If an abscess is present, and associated cellulitis if present should be treated with antibiotics. Depending on the extent of disease, the operative strategy for recurrent disease varies widely, and can range from wide excision with primary closure to the use of more complex flap closure.

Carcinoma in Pilonidal Sinus


Occurring in approximately 0.1% of patients with chronic untreated or recurrent pilonidal disease. Carcinoma arising from a pilonidal sinus is rare. It is believed that similar to carcinoma arising in other ulcerating and chronically inflamed disorders, the process involves the release of oxygen free-radicals by activated inflammatory cells. First reported by Wolff in 1900, and literature has a mention of less than 100 cases ever since. The histopathological cell-type is usually well-differentiated squamous cell. Usually these tumors classically present as an ulcer with rapidly progressing fungating margins, and to determine extent of disease, computed tomographic imaging is an useful adjunct. Treatment includes: Wide, enbloc excision, and often requires Flap reconstruction or grafting. A poor prognostic indicator is the involvement of locoregional lymph nodes.

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Excision versus radiotherapy should be considered, in case of palpable inguinal lymph nodes. Recurrence rate after excision approaches 50%, the reason being, pilonidal sinus carcinoma behaves more aggressively than squamous cell carcinoma at other sites. Though adjunctive radiotherapy can decrease local recurrence, the overall survival is poor.

chapter

Rectal Prolapse

20

Rectal prolapse is defined as a circumferential full-thickness protrusion of the rectum through the anus/A complete rectal prolapse is defined as the protrusion of all layers of the rectal wall through the anal canal. If the rectal wall prolapses but does not protrude through the anus it is called an occult rectal prolapse or a rectal intussusception. A rectal prolapse should be distinguished from a mucosal prolapse; in the latter there is only protrusion of the rectal or anal mucosa (Figs 20.1 and 20.2). Rectal prolapse was described way back in ancient times as early as 1500 BC. Hippocrates suggested in cases of incarcerated prolapse having fomented the part with a soft sponge, and anointed it with a snail, bind the mans hands together, and suspend him head down for a short time and the gut will return and for definitive treatment a caustic potash is applied to the rectal mucosa and after the reduction of the prolapse the thighs are bound together for three days. A plethora of techniques have been devised for the treatment of this disease over the last century; pointing to the fact of: Imperfect understanding of the disorder The absence of an ideal procedure to effectively treat this ailment. Though it is rarely a medical emergency, the condition is embarrassing and can be socially debilitating. Rectal prolapse is commonly associated with fecal incontinence, and specially in women, it is associated with other pelvic floor abnormalities.

Etiology
The precise etiology of rectal prolapse is unknown however two theories of etiology have been proposed:

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Fig. 20.1: Rectal prolapse

Fig. 20.2: Rectal prolapse procidentia

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Prolapse is a sliding hernia through a defect in the pelvic fascia. Prolapse is actually a circumferential intussusception of the rectum. The latter theory is accepted by most clinicians. The majority of patients afflicted with rectal prolapse have a long history of constipation and straining. Common anatomic findings associated with rectal prolapse include: An abnormally deep cul-de-sac Patulous lax and atonic anal sphincters with levator diastasis Redundant sigmoid colon Loss of posterior fixation of the rectum Long rectal mesentry Redundant rectosigmoid True intussusception of the rectum through the sphincters. Whether some or most of these findings are a cause or an effect of rectal prolapse is unclear. However, the goal of most of the modern procedures described for the treatment of rectal prolapse attempt to correct some or all of these abnormalities. Rectal prolapse affects patients at extremes of age. In children, the gender distribution is equal. In adults, it is more common in woman than men. Male patients have an equal incidence per decade of life whereas women have an increased incidence as they age. The disorder is more prevalent in women specially the older age group women with a ratio of 6 to 1. Young men in their 3rd and 4th decade with a predisposing factor like congenital anal atresia are also affected. Women by the virtue of their anatomy, i.e. wide pelvis and because of childbearing are at increased risk of developing prolapse. During vaginal delivery: There is stretching of the pudendal nerves Long-term neurologic damage can occur at this time resulting in perineal descent, prolapse, and incontinence. Although multiple pregnancies are often implicated in the etiology, as many as one-third of patients are nulliparous.

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Predisposing Factors
Rectal prolapse is usually associated with the following conditions: Advanced age Long-term constipation Long-term diarrhea Long-term straining during defecation Pregnancy and the stresses of childbirth Previous surgery Cystic fibrosis Chronic obstructive pulmonary disease Whooping cough Neurologic disease Multiple sclerosis Paralysis (Paraplegia).

Symptomatology
The most common complain of patients with rectal prolapse report a mass protruding through the anus. Early in the development of a prolapsed rectum, the protrusion may occur during bowel movements and retract spontaneously afterwards. The mass protrudes more often as the disease process progresses, especially with straining and Valsalva maneuvers such as sneezing or coughing. Finally, the rectum prolapses with daily activities such as walking and may progress to continual prolapse. As the disease progresses, the rectum no longer spontaneously retracts, and patients may have to manually replace it. This condition may then progress to a point at which the rectum prolapses immediately after being replaced and is continuously prolapsed. Rarely, the rectum becomes incarcerated, and patients cannot replace the rectum. Full-thickness prolapse is distinguished by its concentric rings and grooves as opposed to the radially oriented grooves associated with mucosal prolapse.

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The rectum is often edematous with a fragile mucosa and small ulcerations. Unless there is strangulation, it is always possible to push back the prolapse. Passage of mucus and blood is common. Depending on the patients age, fecal incontinence is associated with rectal prolapse in a good number of patients with a very weak pelvic floor with low external anal sphincter pressures. Incontinence occurs for two reasons: First, the anus is dilated and stretched by the protruding rectum, disrupting the function of the anal sphincter. Second, the mucosa of the rectum is in contact with the environment and constantly secretes mucus, thus making the patient appear to be chronically wet and incontinent. Constipation is common and is found in up to 70% of patients with rectal prolapse. Pre-existing dysmotility, dyssynergic defecation, or intus susception are also possible predisposing factors. Pain is variable.

Diagnosis
Rectal prolapse is a clinical diagnosis that physicians should be able to confirm in the office. The diagnosis is made by inspecting the perineum. The patient is asked to sit on a toilet and strain, after which the rectum should prolapse. Inspection should also include examining the perianal skin for any maceration or excoriations. A digital rectal examination is important to detect concomitant anal pathology and to assess resting tone and squeeze pressure of the anal sphincters and function of the puborectalis muscle. The protruding mass should show concentric rings of mucosa, which are classic signs of rectal prolapse. In cases of small prolapse, it is sometimes difficult to distinguish between mucosal and full-thickness rectal prolapse. Mucosal prolapse typically exhibits radial folds instead of concentric rings.

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If these cannot be clinically distinguished, a defecogram may be of help in differentiating these two conditions. A defecogram is unnecessary in the presence of an obvious rectal prolapse. A detailed history to evaluate incontinence and/or constipation is important, as it plays a role in determining the appropriate surgical procedure. Colonoscopy or flexible sigmoidoscopy with barium enema should be performed to rule out associated mucosal abnormalities.

Work-up Laboratory Studies


No specific laboratory studies aid in evaluation of rectal prolapse. The only laboratory studies that are advocated are those dictated by the patients age and comorbidities.

Imaging Studies
Barium enema/colonoscopy: To exclude any other colonic lesions that need to be addressed simultaneously. The entire colon is evaluated either by colonoscopy or by barium enema prior to surgery for rectal prolapse. Barium enema is a better indicator of the redundancy of the colon. With colonoscopy biopsies should be taken to confirm the diagnosis and to exclude other pathology. Video defecography: Usually performed only in cases where prolapse is not clinically evident. This examination is used: To help document internal prolapse or To distinguish rectal prolapse from mucosal prolapse. Defecography is not necessary for clinically diagnosed fullthickness rectal prolapse.

Other Tests
Anorectal manometry: Anorectal manometry is sometimes used to evaluate the anal sphincter muscles. Anal manometry shows:

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Low resting pressure An absence of the anorectal inhibitory reflex, and patients with coexisting fecal incontinence have low squeeze pressures. In such patients, synchronous levatorplasty should be considered at the time of prolapse repair and may further improve continence. After surgery, either there is no change or improvement of the resting pressure. Squeeze pressure may also improve. The rectoanal inhibitory reflex may also improve after rectopexy. Anal endosonography: Anal endosonography may show asymmetry and thickening of the internal anal sphincter and submucosa. Demonstration of a sphincter defect can be useful if a sphincter reconstruction is being considered. Electromyography: Electromyography has provided insights into the pathogenesis of fecal incontinence but has no place in clinical work-up. Abnormalities can be found in patients with a rectal prolapse, but these results do not predict continence after rectopexy.

Colonic Transit Study


This test is occasionally used to measure colonic transit in a patient with constipation and rectal prolapse. Colonic transit times should be done in patients with a coexisting history of severe constipation so that the correct operation can be chosen. The goal of the test is to help determine the need for colonic resection. Individuals with slow-transit constipation and site markers concentrated in the left and sigmoid colon typically benefit from a synchronous sigmoid colectomy and rectopexy versus rectopexy alone or even perineal rectosigmoidectomy.

Histologic Findings
Solitary rectal ulcers can usually be identified by an experienced pathologist. The prolapsed rectum may have ulcerated mucosa but is otherwise histologically normal.

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Rectal Prolapse Treatment


Though most cases of rectal prolapse are caused by constipation or straining, correcting these may not be enough to correct the prolapse. Most prolapsed rectums worsen without surgery. For infants and children, reducing the need to strain during bowel movements with stool softeners may correct a prolapsed rectum. Strapping the childs buttocks together between bowel move ments may cause the rectum to heal on its own.

Conservative Management
Conservative treatment is normally used: To temporarily ease the symptoms of a prolapsed rectum To prepare the person for surgery. The following are used in different situations: Bulking agents (such as bran or psyllium) Stool softeners Suppositories Enemas Biofeedback may be helpful if paradoxical pelvic floor contraction also exists. An incarcerated rectal prolapse is rare. Several maneuvers to help reduce the prolapse have been described and include sedation, field block with local anesthetic, and sprinkling the prolapse with either salt or sugar to decrease the edema and to reduce the prolapse. Emergency resection is required if the prolapse cannot be reduced and the viability of the bowel is in question.

Surgical Therapy
The goal of all of the surgical techniques involved in correcting a prolapsed rectum is to attach or secure the rectum to posterior part of the inner pelvis. Surgical treatment can be divided into two categories, according to the approach used to repair the rectal prolapse: Abdominal procedures and perineal procedures.

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Correction of rectal prolapse is surgical, the surgeon must decide between a perineal operation and an abdominal procedure. Many procedures have been described employing both perineal and abdominal approaches. Men are at risk for sexual dysfunction with an abdominal approach, therefore this option is chosen cautiously. The risk of impotence for abdominal rectopexy should approach 1 to 2% in skilled hands. The choice of abdominal procedure is often dictated by the extent of the associated constipation and by the surgeons preference. The selection of the operative procedure depends on the following patient factors as these definitely influence the choice of operation: Age Sex Medical condition Extent of prolapse Bowel function Status of fecal continence. And these are the procedure-related factors that influence the choice of operation: Extent of procedure Potential morbidity Recurrence rate Impact on fecal continence and bowel habit Familiarity and ease of technique. In majority of cases, the management of full-thickness rectal prolapse involves surgical intervention. It has generally been accepted that abdominal operations result: Result in more durable repair In lower recurrence rates Are reserved for younger patients The procedures require general anesthesia They may also be associated with high morbidity

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The laparoscopic approach: By minimizing the operative trauma has almost superceded the open approach Can be considered suitable for the elderly population. In many, it can be combined with other procedures, such as: Colpopexy Anterior resection. Perineal operations are only indicated in high-risk elderly patients as these procedures can be performed under a regional anesthetic or even a local anesthetic with intravenous sedation.

Preoperative Preparation
Bowel preparation before surgery should be a full mechanical and antibiotic, regardless of the type of procedure being planned. Perioperative intravenous antibiotics are often used, especially if a mesh is being implanted.

Abdominal Procedures
The most common abdominal operations are resection with or without rectopexy or rectopexy alone. These procedures are performed in: Younger, healthier patients Whose life expectancy is longer. The choice of abdominal procedure is often dictated by: The extent of the associated constipation By the surgeons preference. All of the procedures described, can be performed utilizing an open or laparoscopic technique based on the surgeons experience and comfort.

Anterior Resection
Recommended as the procedure of choice in patients with rectal prolapse and constipation, because they often have a redundant colon, and resection of it, is presumed to improve constipation and cure rectal prolapse. In an anterior resection for rectal prolapse:

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The rectum is completely mobilized to the coccyx posteriorly To the level of the lateral ligaments laterally To the cul-de-sac anteriorly The redundant colon usually sigmoid is resected The left colon is then anastomosed to the top of the rectum. The lateral ligaments or the rectal fascia are then sutured to the presacral fascia with the rectum on tension, without laxity. So that the rectum is held in place and can no longer prolapse. This procedure can be clubbed with a rectopexy, known as resection rectopexy or Frykman Goldberg procedure. Because the bowel is opened for the anastomosis, the rectopexy is accomplished with suture instead of nonabsorbable mesh as the mesh may get contaminated.

Ripstein Procedure
Involves an anterior levator plication reinforced with fascia lata. Modified procedure known as the classic Ripstein repair is undertaken to restore the posterior curve of the rectum. In Ripstein procedure, the entire rectum is mobilized down: To the coccyx posteriorly The lateral ligaments laterally The anterior cul-de-sac anteriorly. A nonabsorbable prosthetic material is then fixed to the presacral fascia 5 cm below the sacral promontory in the midline (Fig. 20.3). The rectum is then placed on tension, and the material is partially wrapped around the rectum to keep it in position. In order to prevent a circumferential obstruction, the anterior wall of the rectum is not covered with the sponge or mesh. The peritoneal reflections are then closed to cover the foreign body. The prosthetic material causes an inflammatory reaction that scars and fixes the rectum into place. The cul-de-sac is obliterated with nonabsorbable sutures. The prosthetic material should not be implanted, if the rectum is inadvertently entered during mobilization, because of risk of infection.

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Fig. 20.3: Marlex rectopexy

Again this procedure should be avoided in patients who have a large component of constipation or a very redundant sigmoid colon because the symptoms are likely to worsen.

Wells Posterior Ivalon Rectopexy


Described by Wells posterior ivalon rectopexy, is the preferred method for correction of rectal prolapse in the United Kingdom. The operation consists of (Fig. 20.4): Posterior rectal mobilization Fixation with a sheet of Ivalon mesh to the sacrum The mesh is secured to the sacral hollow as low as possible with nonabsorbable sutures and then wrapped on either side of the rectum (only three-fourths of the rectum is wrapped). The anterior portion of the rectum must be kept uncovered to avoid narrowing of the lumen.

Rectal Prolapse 465

Fig. 20.4: Wells rectopexy

To exclude mesh from the peritoneal cavity, the peritoneum is closed over the mesh. Meticulous hemostasis is essential, as the formation of pelvic hematoma may contribute to pelvic sepsis and signicant morbidity in this procedure. Recurrence rates, mortality rates, and effects on constipation are comparable to the anterior wrap. However, the advantages of this procedure are: It is associated with a lower incidence of fecal impaction The incidence of strictures is also very low. The most feared complication following this procedure is pelvic sepsis secondary to infected mesh, which may require mesh removal.

Laparoscopic Rectopexy
All the above mentioned procedures in skillful hands can be performed laparoscopically. The patient is placed in a steep Trendelenburgs position. A fourport technique, placed in the lower abdomen, is used.

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Laparoscopic approaches to the management of full-thickness rectal prolapse, including rectopexy alone, or in combination with sigmoid colectomy have been reported to have comparable success rates and morbidity to open surgery, with the added benefit of shorter hospital stays.

Perineal Procedures
Perineal procedures have a higher recurrence rate but a lower morbidity rate and are often performed in the elderly population or in patients who have a contraindication to general anesthetic.

Thiersch Procedure/Anal Encirclement


The history of this procedure is traced back to 1891 when it was described by Thiersch and hence the name. In the earlier days it was described using a wire, but other materials like silastic tubing, and nonabsorbable suture have replaced it. In this procedure a nonabsorbable band is placed subcutaneously around the anus. The goal of this procedure is to prevent the rectum from prolapsing by restricting the size of the anal lumen. Though it does not treat the underlying disorder. The therapy is effective in mechanically preventing the rectum from prolapsing. Complications include: Obstruction with fecal impaction Erosion of the wire with infection. This procedure is not advocated in modern times and is usually reserved for only the most debilitated elderly patients and for patients with the highest surgical risks in whom palliation is the goal.

Perineal Rectosigmoidectomy
Popularized by Altemeier, perineal rectosigmoidectomy can be performed under a general or spinal anesthetic or even a local anesthetic with intravenous sedation (Fig. 20.5). A mechanical and antibiotic bowel preparation is a prerequisite. The prone position is preferred; however, the left lateral (Sims) or lithotomy position can also be effectively used.

Rectal Prolapse 467

Fig. 20.5: Altemeier perineal rectosigmoidectomy

About 1 to 2 cm from the dentate line. A full-thickness circumferential incision is made in the prolapsed rectum. The hernia sac is then entered, followed by delivery of the prolapse. Ligate the mesentery of the prolapsed bowel serially till no further redundant bowel can be pulled down. The bowel is transected and hand sewn to the distal anal canal or stapled using a circular stapler. Some experts in the field advocate plication of the levator ani muscles anteriorly, to improve continence. This operation is relatively safe and effective and is recommended in frail, older patients, because the postoperative morbidity is low. Two limitations to this procedure are: The recurrence rate of prolapse following the procedure Unpredictable behavior in terms of restoring continence. Improvement in incontinence has been reported in the majority of patients in whom levatorplasty is performed.

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Fig. 20.6: Delorme mucosal sleeve resection

Delorme Mucosal Sleeve Resection


First described by Delorme in 1900 this procedure involves mucosal proctectomy (Fig. 20.6). It is indicated in those patients who suffer from full-thickness prolapse limited to partial circumference (e.g. anterior wall) or lessextensive prolapse. This procedure differs from the perineal rectosigmoidectomy (Altemeier) in that only the mucosa and submucosa are excised from the prolapsed segment (Figs 20.4 and 20.5). It can be performed under general, spinal, or local anesthesia. A circumferential incision is made through the mucosa of the prolapsed rectum one centimeter cranial to the dentate line; using electrocautery or better radiofrequency the mucosa and submucosa are stripped from the muscle to the apex of the prolapse and excised. The mucosectomy may be more difficult in patients with prior anal surgery or a history of diverticulitis. The plane of dissection may be facilitated by continued submucosal injection of epinephrine solution as the dissection continues toward the apex of the prolapse.

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The denuded prolapsed muscle is then pleated with a suture and is plicated. The transected edges of the mucosa are then sutured together.

Recurrent Prolapse
Compared with abdominal approaches, perineal operations for prolapsed rectum have a higher risk of recurrence. It is important if a full-thickness rectal prolapse recurs, to re-evaluate the patient for constipation and other pelvic floor abnormalities in the anorectal physiology laboratory with manometry and defecography in order to customize the management to address those issues. Knowledge of the prior repair is essential in these cases, because that information will dictate future options. Because of the divided blood supply the prior dissection may limit the available alternatives. Important factors to be considered before finalizing a procedure for recurrence are: Patient comorbid conditions The residual blood supply of the remaining large bowel History of a prior rectal or sigmoid resection with anastomosis. [A secondary resection carries a high-risk of ischemia to the segment of large intestine between two anastomoses] The type of initial operative procedure performed for prolapsed. Depending on these factors the recurrent prolapse can even be managed by the same procedure performed during the initial surgery.

Postoperative Care
Abdominal Procedures
Depending on whether an anastomosis has been performed intravenous fluids are maintained until liquids are started with the return of bowel function or earlier. With improvement in bowel functions, regular diet can gradually be allowed.

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Patients with an anastomosis are maintained on a low-fiber diet for 2 to 3 weeks. Patients without an anastomosis can be started on a high-fiber diet sooner. Patients with an anastomosis are started on fiber supplementation after 2 to 3 weeks to help prevent the return of constipation and straining. Patients usually have an ileus and incisional pain after surgery. Because the rectal dissection can inhibit bladder function the Foley catheter that is placed perioperatively, is left in place for few days. Duration of hospitalization is dependent on the return of bowel function and the control of incisional pain, but on an average it usually last for 3 to 7 days.

Perineal Procedures
Contrary to abdominal procedures patients who have had perineal procedures do well postoperatively with minimal pain and a short hospital stay. Regular diet can be allowed after 12 to 24 hours as the bowel function returns quickly, because there is no abdominal incision. Patients can be discharged 24 to 72 hours after the procedure.

Follow-up
Follow-up care depends on the type of surgery the patient has been subjected to. The purpose of these visits is: To ensure that all incisions are well healed To see that the patient is not having difficulties with bowel evacuation.

Complications
The complications following surgery for rectal prolapse are few in skilled hands yet those known are as follows: Infection Bleeding Intestinal injury Anastomotic leak Bladder and sexual function alterations

Rectal Prolapse 471

Constipation or outlet obstruction. The frequency of these complications is related to the type of procedure. Other complications that can occur but are not procedure specific are as follows: myocardial infarction, pulmonary embolus, deep vein thrombosis, and hernia.

Infection
The most common source of infection during abdominal procedures is: From inadvertent unrecognized injury to the rectum During mobilization in abdominal procedures Leading to leak of intestinal contents with pelvic abscess and sepsis. In case prosthetic material is implanted in form of Mesh or Ivalon, infection occurs due to presence of foreign material, and the material must be removed. After perineal procedures infection occasionally causes symptoms and is easier to treat because it is superficial.

Bleeding
Two situations commonly known to cause bleeding are: During abdominal procedures, when mesh or the rectum is directly fixed to the presacral fascia the presacral veins can be torn. Leading to a presacral hematoma or to torrential bleeding. Usually difficult to control because the veins exit directly from the bone. Direct pressure to the area for 10 to 15 minutes is the primary maneuver. Titanium thumbtacks can be placed into the bone to tamponade the vessels. If direct pressure fails to control the bleeding. Dissection in the presacral space should be avoided as it often increases bleeding.

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The second common situation for bleeding occurs during The mucosal stripping in a Delorme procedure From wound separation postoperatively.

Bowel Injury
Occurs most frequently during mobilization of the rectum. The injury can usually be repaired without need for intestinal diversion, if it is recognized on table. If the bowel is injured, prosthetic material should not be implanted. Unrecognized injury can lead to abscess formation and pelvic sepsis.

Anastomotic Leak
As a universal fact all procedures that involve a resection of bowel carry a risk of anastomotic leak. Abdominal procedures that are complicated by a leak require reexploration. In case of a small leak the contamination in the pelvis is limited, in such a situation the anastomosis can be revised and protected with a diverting loop ileostomy. If the leak is large with significant dehiscence of the anastomosis, the best option to offer is with a Hartman procedure (colostomy with rectal stump). A major issue which can hamper the management is pelvic sepsis, this makes further dissection in the pelvis challenging, and revising or performing a new anastomosis can be very difficult. Anastomotic leak can also occur after perineal recto sigmoidectomy. Despite the fact that this is a very low anastomosis, leak is rare and the infection is localized and pelvic sepsis is rare.

Alterations in Bladder and Sexual Function


Alteration of bladder and sexual function is very rare in expert hands when the abdominal procedure has been performed properly.

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If dissection is not carried out in the proper plane, the pelvic sympathetic and parasympathetic nerves that run along the rectum can be inadvertently injured and lead to: Bladder dysfunction Impotence, and/or Retrograde ejaculation. This is an important guideline to decide which procedure needs to be offered.

Constipation/Outlet Obstruction
Perineal procedures and anterior resection have a low-risk of outlet obstruction. Abdominal procedures because they fix the rectum to the sacrum can cause outlet obstruction if the rectum is wrapped circumferentially. To treat the problem the fixation needs to be released.

Prevention
Constipation should be taken care of with a high-fiber diet and plenty of fluids. Straining should be avoided during bowel movements. To reduce the probability of patients developing a prolapsed rectum. Patients with long-term diarrhea, constipation, or hemorrhoids should seek medical care to treat these conditions.

chapter

Fecal Incontinence

21

The two major functions of the anorectum are preservation of continence and regulation of defecation. Fecal incontinence (FI) is defined as the involuntary passage of stool or flatus. It includes the involuntary loss of gas, liquid stool, or solid stool, and the symptoms of fecal urgency and soiling. Fecal incontinence is the inability to retain stool and to expell it at a proper time and at a proper place For some people, fecal incontinence is a relatively minor problem, as when it is limited to a slight occasional soiling of underwear, but for other people it involves a considerable loss of bowel control which leads to a restriction of the patients daily activities and impairs the social life and overall quality of life. Fecal incontinence is different from anal discharge of mucous, pus, or blood, which is a symptom of other local anorectal disorders. Though, in the literature, the terms anal incontinence and fecal incontinence are used interchangeably. Fecal incontinence results from the increased speed of peristalsis related to irritability and heightened sensitivity with reduced voluntary control, as well as increased fluid. The frequency of anal incontinence has considerably increased than it was previously thought. An anal sphincter injury secondary to vaginal delivery, is the most common cause of fecal incontinence in the obstetric population. Regardless of delivery method fecal incontinence has been noted in 11% of women, owing to stretch injuries to the pelvic floor and pudendal nerves, indicating that fecal incontinence has multifactorial causes. Fecal incontinence has a significant social and economic impact on the patient and the community. Fecal incontinence remains a challenging disease to evaluate and successfully treat. Most patients embarrassed by their fecal

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incontinence, are reluctant to discuss this with their health care provider, and may become increasingly isolated to avoid the inevitable accidents. It is incumbent on physicians to inquire about such symptoms particularly among female patients. 7 to 16% of healthy adults will admit to incontinence of gas or feces, as estimated in recent studies. The incidence of fecal incontinence is up to two-thirds in women, typically multiparous. As many as 10% of all women may experience new defecatory symptoms following an uncomplicated vaginal delivery. Anal incontinence is a significant burden in the geriatric population. Similar to urinary incontinence, the emotional, psychological, and social problems created by this condition can be both devastating and debilitating.

Factors Maintaining Fecal Continence


Stool volume and consistency Small bowel transit Colon transit Distensibility, tone, and capacity of the rectum Motility and evacuability of the rectum Anorectal angle Anorectal sensory and reflex mechanism Motility of the anal canal Anal canal high pressure zone.

Causes of Anal Incontinence


Anal Sphincter Weakness
Obstetrical rupture [perineal trauma due to childbirth] of anal sphincter (chronic third-or fourth-degree perineal tears). An ultrasound study of 1st time mothers found sphincter injuries in 35%.

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About one-third of the injured women developed fecal in continence or an uncontrollable and powerful urge to defecate within six weeks of giving birth. Injury related to surgical procedures [operations around the sphincter area] Internal sphincterotomy Fistulotomy Low anterior colorectal resection Hemorrhoidectomy Neuropathy stretch injury Obstetric trauma Chronic straining Fecal impaction.

Anatomic Disturbances of the Pelvic Floor


Fistula Rectal prolapse Descending perineum syndrome.

Inflammatory Conditions
Inflammatory bowel disease Crohns disease Ulcerative collitis Radiation enteritis Infectious enteritis. Congenital anomalies Multiple sclerosis Over sedation Parkinson disease Systemic sclerosis Spinal cord injury Stroke Dementia Diabetic neuropathy Diarrheal states.

Neurologic Conditions

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Miscellaneous Causes
Laxative abuse Irritable bowel syndrome Diabetes. Obstetrical trauma is currently believed to be the most common cause of anal incontinence in healthy women. As mentioned earlier, anal incontinence may affect up to 10% of women following an uncomplicated vaginal delivery. Incontinence to flatus and fecal urgency are the most common symptoms experienced in postpartum women. In women who have suffered anal sphincter rupture (i.e. third- or fourth-degree laceration) at the time of delivery. The symptoms are more common and more severe. Mechanical disruption of the anterior sphincter complex Damage to the innervation of the anal sphincters and pelvic floor muscles A combination of both. These are thought to be the cause of damage to the anal continence mechanism at the time of vaginal delivery. On evaluation: All women with symptoms of anal incontinence are found to have had structural defects and usually there is no correlation between nerve latency studies and the development of symptoms in most studies, suggesting that mechanical disruption rather than neurologic injury is the most important cause for anal incontinence. Women who have suffered a traumatic rupture of the anal sphincter at the time of vaginal delivery also appear to have a greater risk of anal incontinence than previously recognized. Another important cause of anal incontinence in women is either rectovaginal and anovaginal fistulae. These fistulae can occur anywhere along the length of the rectovaginal septum. Episiotomy infections, though uncommon, can also result in the formation of a fistulous tract.

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If the fistulous tract originates distal to the dentate line, the fistulae should be considered anovaginal fistulae; defects above this landmark are rectovaginal. Sphincter injuries exist far more frequently when the location of the fistula is within the distal 3 cm of the anal canal since anatomic studies have demonstrated that this is the normal length of the sphincter complex. Failure to recognize and repair such a sphincter injury may result in continued incontinence following a successful fistulectomy.

Nonobstetrical Causes of Anal Incontinence


Although obstetrical trauma is a leading cause of anal incontinence in women, it can also result from a variety of other conditions. Operative or accidental injuries, such as impalement or pelvic fractures, can lead to sphincter trauma which in turn can lead to anal incontinence. Any of the following surgical procedures can cause subsequent anal incontinence: Posterior colporrhaphy Rectovaginal fistula Anal fissure repair Hemorrhoidectomy Therapeutic anal dilation. Urinary incontinence and pelvic organ prolapse can also cause anal incontinence in a significant number of women. Fecal impaction is a leading cause of incontinence, among the elderly and institutionalized individuals. In the geriatric population cognitive dysfunction and rectal prolapse are other important causes of anal incontinence. Particularly with diarrheal states diabetes can be associated with an autonomic neuropathy that can affect the internal anal sphincter and can produce incontinence. Radiation therapy and ulcerative colitis can be associated with rectovaginal fistula formation and radiation proctitis may cause a

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reduction in rectal compliance apart from neurologic or mechanical damage to the rectum. Another important cause of incontinence is occult spinal cord injury or disease which is typically associated with an intact but weak external anal sphincter. Because of varied pathology involved in etiology of fecal incontinence it is essential to go for an accurate assessment and treatment plan, which can be determined through a careful history, physical examination, and selected anorectal physiology studies. Depending on the cause and the response of the patient to prior treatment modalities, treatment of fecal incontinence ranges from conservative to interventional.

Prevalence and Risk Factors


An estimated 7.1% of people suffer from fecal soiling and 0.7% from gross incontinence in the general population. Although the incidence of fecal soiling is apparently same in men and women, women are two times more likely to develop fecal incontinence. Women in particular are at a greater risk for developing fecal incontinence because of pregnancy and childbirth. The tendency for delayed development of fecal incontinence may be influenced by many factors, including menopause and aging. The prevalence of fecal incontinence increases with age. In reality, because of the social stigma and embarrasment the prevalence of fecal incontinence is greater than currently believed and the true incidence may never be known. With increasing age there is a gradual decrease in anal squeeze and resting pressures because of a change in the elastic properties of the anal muscle this is the reason aging is speculated to contribute to the overall risk. Apart from the change in elastic properties, a decrease in anorectal sensory function is also associated with aging. These changes may be more significant in women after menopause.

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Another important fact is that the anal canal is rich in estrogen receptors; therefore, the loss of estrogen from menopause may exacerbate the natural effects of aging. Supporting the above theory is the observation that hormone replacement therapy in patients who had fecal incontinence that showed an increase in their anal pressures and an improvement in their fecal incontinence symptoms. Laxity in the pelvic floor muscles, which gradually comes with aging may further contribute to the risk for developing fecal incontinence. The symptom of rectal urgency is the greatest risk factor for women, actually in some studies exceeding that of obstetric trauma. Other independent risk factors for fecal incontinence include: Age Concomitant diarrhea Cholecystectomy Non-obstetric anorectal injury. Fecal incontinence in women is generally multifactorial. An early injury (i.e. sphincter disruption) may be exacerbated later in life by other factors (i.e. aging, diarrhea, medications) that impair fecal continence.

Mechanisms and Causes


Maintenance of fecal continence depends on anatomic, neurologic, and physiologic components.

The So-called Continence Organ


Muscular continence factors Corpus cavernosum recti Sensoric innervation of anal canal and rectal ampulla Ampulla recti. Because they act in a coordinated fashion to prevent and subsequently allow the passage of stool and flatus, dysfunction of any of these components contributes directly to fecal incontinence.

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The muscles of continence include: The puborectalis, The pelvic floor muscles The internal and external anal sphincters (IAS and EAS, respectively). Each of these muscles derives neurologic control from the sacral nerves 2, 3, and 4; though, individual direct innervation varies. The innervation of the puborectalis muscle is directly by the sacral nerve roots, and that of the EAS by way of the pudendal nerve. The IAS, is also innervated by L5 by way of the hypogastric nerve apart from the innervation from S2, S3, and S4. The puborectalis muscle is actually contracting in a ventral direction in its inactive state and this results in an acute angulation of the rectum between 85 and 110, which in turn essentially creates an outlet obstruction. The puborectalis muscle actively relaxes, at the time of voluntary defecation, and thus opens this angle by at least 15 to allow the passage of stool. Defecography can very clearly demonstrate this relaxation and change in the rectal angle. The basal resting pressure maintained by the IAS, which is an involuntary muscle, effectively blocks the passage of rectal contents. Relaxation of the IAS occurs when the rectum becomes distended (rectoanal inhibitory reflex). The rectum is sensitive to as little as 10 ml of volume and greater amounts of distention trigger this reflex. Relaxation of the IAS results in the rectal contents moving to the anal canal. Depending on the consistency of the sample and the social situation. A process of anal canal sampling induces another reflex to either contract or relax the EAS. Basically these same signals and reflexes occur with the puborectalis muscle. Further augmented control of defecation as necessary is obtained by active squeezing by voluntary control of the EAS.

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With its ability to accommodate to increasing volumes. The rectum also contributes to continence. The feedback from the contracting EAS signals a relaxation of the rectum, thus increasing its capacity. When the urge to defecate occurs at an inconvenient time. This accommodation in capacity allows the rectum to store stool and air. It is directly related to sensation and compliance of the rectum. With increase in the total stool volume, there is decrease in rectal compliance, and the threshold for sensation is lowered which ultimately results in a greater urge for defecation. Dysfunction of multiple components of the continence mech anism are required for the development of fecal incontinence usually requires. Continence is the result of the coordination of several components and typically a dysfunction of one part is compensated for by another. Therefore, a patient with a weakened puborectalis muscle may remain continent because of an intact and functioning EAS. In addition to possible systemic causes, the differential diagnosis of fecal incontinence is broad and includes: Anatomic derangements Neurologic disease Skeletal muscle problems Smooth muscle dysfunction. When fecal incontinence is thought of as a symptom rather than a disease. Frequently when fecal incontinence is influenced by a systemic condition, it is likely to be associated with infection, medications, diet, endocrinopathies, or irritable bowel disease, all of which may respond to treatment and thus improve the fecal incontinence.

Evaluation of Patient with Fecal Incontinence


Multiple factors are involved in the control of these processes involving both physiologic and psychobehavioral mechanisms.

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Investigation of the anorectum should be performed in the context of a global pelvic floor evaluation aimed at both morphology and anatomy, and function. With advances in diagnostic technology, it is now accepted that in the field of functional bowel disorders, although important, symptom-based assessment is unsatisfactory as the sole means of directing therapy. The symptom repertoire of the gut is limited and relatively nonspecific, such that similar symptom profiles may reside in differing pathoetiologies an pathophysiologies. Reliance on clinical symptoms alone as a basis for taxonomy is now obsolete. In a field of practice in which normal physiologic function is so complex. Based on underlying pathophysiology, a robust taxonomy must be paramount. In the assessment of a patient presenting with fecal incontinence, There are three main objectives: 1. To determine the severity of the problem and its impact on the quality of life. 2. To rule out an underlying treatable disease process that may be contributing to the incontinence 3. To appreciate all contributing factors and the means with which to manage them. Follow the following protocol to initiating appropriate treatment: Obtain a thorough history Perform a complete physical examination Obtain appropriately selected objective studies. History taking in fecal incontinence is a very important aspect. Obtain a detailed understanding of how the patient describes their fecal incontinence, including: Bowel habits Activities of daily living Mobility. The most important initial qualities to define are the frequency and consistency of stools and associated urgency.

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Inquiring about changes in the daily routine (such as avoiding meals to prevent fecal incontinence when leaving the home) is essential. To determine the impact of the fecal incontinence on the patients quality of life. To objectively assess patients before and after treatment the following two validated and widely used quality-of-life questionnaires may be of great help: The fecal incontinence severity index score The fecal incontinence quality of life score. Particularly for contributing factors of neurologic origin, as described in the differential diagnosis. It is necessary to fully evaluate the presence of any systemic processes that may be contributing to fecal incontinence. If a particular drug is identified as the culprit. A medication history may result in the simplest solution by substituting that drug without harm to the patient.

Differential Diagnosis of Fecal Incontinence Anatomic Causes


Anorectal trauma Childbirth injury Congenital abnormalities of the anorectum Fistula Rectal prolapse.

Sequelae of Anorectal Infections


Crohns disease Surgery Trauma.

Neurologic Diseases
Central nervous system Brain tumor Dementia Mental retardation Stroke.

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Spinal cord lesions Multiple sclerosis Tabes dorsalis Peripheral nervous system Cauda equina lesions Diabetes mellitus. Perineal descent Polyneuropathies Postpartum pudendal neuropathy Toxic neuropathy Traumatic neuropathy Skeletal muscle diseases Myasthenia gravis Myopathies, muscular dystrophy Smooth muscle dysfunction Abnormal rectal compliance Fecal impaction Proctitis (inammatory or radiation) Rectal ischemia Scleroderma.

Idiopathic

Miscellaneous
Hypothyroidism Irritable bowel syndrome Sedation Severe diarrhea. A detailed history of each pregnancy is important in women, and should include the number of childbirths and their respective details, such as: Method Incidence of tears or episiotomies Birth weight and size Duration of labor. Include specific details concerning any anorectal procedures in the surgical history, such as:

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Hemorrhoidectomy Fistulotomy Lateral internal sphincterotomy Others. Many other surgeries may contribute to fecal incontinence and therefore, should also be documented. Equally important to ascertain are the other causes of anorectal trauma, such as sexual abuse or voluntary anal intercourse. Though obtaining this highly sensitive information may be difficult. Establishing patient rapport is crucial to eliciting a thorough history. A physical examination should follow a thorough history. Inspection of the vagina for findings of: A visible posterior scar (secondary to prior episiotomy or repair of vaginal tears). Uterine prolapse, or The presence of a rectocele Perineal descent. During general inspection of the perineum asking the patient do a Valsalva maneuver may reveal excessive perineal descent if present. A Valsalva may also reveal uterine or rectal prolapse that may not be apparent when the patient is relaxed. Three important aspects of the anus that need to be examined are: 1. The appearance 2. The sensory function 3. The sphincter function. Look for the following during visual inspection of the anus: Scars Skin tags External hemorrhoids A fistula Dermatitis Infection, or A tumor.

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A thorough digital rectal examination is equally important not to miss any of the following: Internal hemorrhoids A rectocele or Enterocele or A mass at the anal verge or A mass above the anal verge. Use of a cotton swab to stroke the perianal skin demonstrates intact anal sensation by what is commonly known as an anal wink. An anal wink, is basically contraction of the EAS, and is presumed to signify an intact anocutaneous contractile reflex. Though not confirmatory of the diagnosis, absence of the anal wink should raise suspicion of a deficit in the peripheral motor or sensory nerves, or of the spinal cord synapses. The motor function of the pelvic floor and sphincter muscles can be evaluated, during the digital rectal examination, by asking the patient to relax, squeeze, and then relax again. It gives a good indication of sphincter function and defects, even though this examination is not as objective as anal manometry or ultrasound. Following a thorough physical examination, further testing may not be indicated but can be used to guide the diagnosis and treatment in certain situations.

Objective Tests of Anorectal Function


Anal Manometry
Quantitative measurements of anal sphincter pressure are provided with anal manometry, by way of signals transmitted through a balloon catheter. Pressure readings from the IAS and the EAS are transmitted by the catheter device, except at the anal verge, where only the EAS can be measured. Basal, or resting, pressures generally indicate IAS tone On the other hand, squeeze pressures reflect EAS function.

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Patients who have fecal incontinence may have lower anal resting pressure and anal squeeze pressure; however, the range of readings is wide with some of the patients having normal pressures despite their symptoms. An abnormally low resting indicates an internal sphincter defect, and An abnormally low squeeze pressure is suggestive of an external sphincter defect.

Rectal Balloon Manometry


This test measures several functional characteristics of the rectum, including: Sensation Compliance Rectoanal inhibitory reflexes (RAIR) The rectoanal contractile response. A balloon catheter is inserted into the rectum and with increasing volumes the following sensations are recorded: First sensation Urge sensation Maximum tolerable volume. Rectal compliance is reflected by pressures generated at each of the increments of volume. A high pressure with a low volume suggests decreased compliance, whereas Low pressures with normal or high volumes suggest increased compliance. The normal volume for first sensation can be as little as 10 ml. Patients who have fecal incontinence can have: Higher sensory thresholds A delayed perception, or Even no sensation of rectal distention. Low rectal compliance as seen with rectal fibrosis can be attributed to these factors and can be associated with rectal urgency: Ischemia Irritable bowel syndrome

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Inflammatory bowel disease Diabetes, or Radiation proctitis. The rectal balloon can also be used to determine the presence of the rectoanal inhibitory reflex, suggested by a decrease in the IAS, or basal, pressure (RAIR) with volumes just above those for first sensation, usually 20 ml. The decrease in IAS resting pressure is countered by increasing pressures in the distal anal canal. This represents the rectoanal contractile response of the EAS and is a necessary event if defecation is to be postponed. Loss of the rectoanal contractile response of the EAS correlates with a pudendal neuropathy; however, the diagnosis should be confirmed with electrophysiology tests.

Electrophysiology Tests
Electromyography (EMG) Pudendal nerve terminal motor latency (PNTML). These are the two most commonly used electrophysiology tests. Electromyography is useful in evaluating the innervation to skeletal (striated) muscles of the pelvic floor, specifically the levator ani and the EAS. An electrical stimulus is passed on to the muscles and sphincter, through needles placed in the skin around the anus: An appropriate degree of contractile response results if inner vation is intact. To reduce the patient discomfort electrodes similar to those used in electrocardiogram have been tried in place of the needle but the response is not as sensitive as the one with needles. The PNTML test is used to evaluate pudendal nerve function. It is a measure of the ability of an electrical signal to travel along the length of the pudendal nerve. A special glove fitted with a dual electrode along the length of the index finger, is used to perform the test. Dual electrode consists of a signal electrode and a recording electrode. When inserted into the anus:

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The signal electrode lies proximally between the sacrum and ischial spine The recording electrode lies over the EAS. The time it takes for the signal to travel down the nerve to the recording electrode is termed the latency, and it is prolonged in cases of pudendal neuropathy. PNTML is also used in the preoperative assessment of patients being considered for sphincter repair, to predict the outcome of the surgery.

Endoanal Ultrasound
Used as a test of choice: For defining the anatomy of the internal and external anal sphincters (Fig. 21.1) For guiding surgical decision making. Endoanal ultrasound (EUS) has revolutionized diagnosis of sphincter injuries as it helps visualize the same even several years after their occurrence, as a matter of fact patients who had late onset postpartum fecal incontinence before EUS was invented were diagnosed with idiopathic fecal incontinence because of the inability to accurately detect sphincter defects (Fig. 21.2). A 360 rotating transducer with a frequency of 10 to 13 MHz is used to perform the EUS. The transducer is inserted into the rectum beyond the anal canal. To reduce interpretation errors, the study needs to be observed during the dynamic phase. EUS can be done using: Two-dimensional (2D) or Three-dimensional (3D) technology. For a two-dimensional imaging the probe is withdrawn gradually and all the three muscle layers of the anal canal are identified: The puborectalis proximally The IAS in the middle The EAS distally. Contrary to 2D, a continuous image of the entire anal canal, using 3D imaging is possible.

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Fig. 21.1: Normal endoanal ultrasound: A is submucosa; B is internal anal sphincter and C is external anal sphincter

Unique characteristics of each muscle help in their identification. The puborectalis muscle appears as a wide V- or U-shaped band with mixed echogenicity and is seen wrapping the posterior portion of the canal. The IAS is seen lying internal to the EAS and lies adjacent to the mucosa/submucosa layer and appears as a continuous hypoechoic band which is thickest in the mid-anal canal. The EAS appears as a continuous hyperechoic band external to the IAS. The normal appearance of the puborectalis mimics a large defect in the EAS noted in the upper anal canal, so due care should be observed while performing EUS in the upper anal canal.

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Fig. 21.2: Posterior external anal sphincter defect marked between the arrows

EUS scores over MRI in following aspects: EUS is a simple and relatively inexpensive test. It can be easily performed in the office or outpatient setting. The lack of radiation exposure makes EUS a safe test for the patient and the physician. Patients tolerate EUS much better and are more likely to be compliant with follow-up when EUS is used. However for accurate interpretation of EUS physicians do require: Knowledge of the pelvic floor anatomy Characteristics of sphincter defects.

Limitations of EUS
Limitations of EUS are few and in most situations performing the study with sedation or under anesthesia may allow completion of the examination.

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Limitations can include: Pain because of an abscess or anal fissure, or The inability to advance the probe because of an obstructing mass. Measurement of perineal body thickness is helpful in the diagnosis of sphincter defects. Interpretations of perineal body thickness: Less than 10 mm: Abnormal, with a high probability of an associated anal sphincter defect. Greater than 12 mm: Normal with no associated defect. Between 10 and 12 mm: One-third have an identifiable anterior defect. EUS for EAS and its defects correlates highly with EMG results, thus EUS helps to eliminate the need for using EMG as a diagnostic tool. The efficacy and ability to aid therapeutic planning makes EUS the test of choice in the evaluation of fecal incontinence in women.

MRI
To evaluate the anal canal and sphincter anatomy. MRI is used in a similar way as EUS. MRI is very expensive, despite its accuracy. Thus, EUS is still considered the primary choice to define the sphincter anatomy.

Treatment
The standard protocol to follow in management of fecal incontinence is to proceed in a stepwise fashion. The first step is to treat the systemic conditions that cause fecal incontinence, followed by the consideration of surgical repair of anatomic defects. A detailed history and careful physical examination begin the evaluation.

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Surgical or nonsurgical interventions are individualized for each patient with a primary goal of improving quality of life. A good number of patients improve as far as their symptoms are concerned with nonsurgical treatment, which includes: Treatment of systemic disease Dietary modification Drug therapy Establishment of a bowel routine. Priority in given to management of relatively serious conditions like malignancy and fecal incontinence work-up is postponed.

Nonsurgical Options
Nonsurgical treatment is recommended for patients not fit for surgery, not willing to go for surgery and in the period used for preparing the patient for surgery. It begins with modification in the diet. First and important step is to record and detect the offensive items like citrus or spicy foods, caffeine, and alcohol, that may be associated with fecal incontinence in certain individuals, by maintaining a food diary. The irritant load to the GI tract can be reduced by avoiding these items in sensitive patients. Similarly avoiding lactose or adding a lactose supplement in patients who are lactose intolerant is always helpful. To improve stool consistency, addition of psyllium fiber as a bulking agent may lead to improvement in fecal incontinence. Equally effective are constipating agents, as a part of pharmacologic therapy. Loperamide and diphenoxylate HCl with atropine, are the two most commonly used drugs. Loperamide is currently the treatment of choice for fecal incontinence because at a dose of 4 mg before meals. It not only thickens the stool, but also has been shown To increase anal sphincter tone Improves continence mechanisms.

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Effective dose though variable should not exceed 16 mg/d. Used in a similar manner, diphenoxylate HCl with atropine should be avoided in patients on anticholinergics because of side effects from atropine. Caution must be observed when adjusting the dose of either agent, to avoid the development of symptomatic constipation. The patients ability to cope with their symptoms can be increased greatly by: Educating addicted patients on proper skin care Providing resources to improve hygiene. Encouraging the patient to establish a bowel regimen. The use of defecatory aids such as enemas or suppositories, may be advocated for this routine a committed and willing individual. It should be done at the same time each day, sometimes 30 minutes after a meal. Biofeedback training Pelvic floor exercises. These are positively helpful options in the treatment of fecal incontinence and do have a place in clinical use, because of the following evident advantages: The low cost Noninvasiveness Beneficial nature of the training and exercises. Yet what is missing is standardization of uniform parameters with respect to type, duration, and number of sessions or outcome measures. Anal manometry does not predict the success of biofeedback training, however, can help identify patients who are good candidates for these options. The goals of training and exercises are: To improve rectal sensation and perception Strengthen the EAS Restore coordination of the voluntary continence mechanisms. Depending on the patients specific symptoms, training can be focused on the goals individually or together.

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B
Figs 21.3A and B: Overlapping sphincteroplasty repair

Surgical Options Overlapping Sphincteroplasty Repair (Figs 21.3 to 21.5)


Overlapping sphincteroplasty is the most common and most successful surgical treatment advocated for fecal incontinence. Popularized since 1971, the overlapping technique is now the standard procedure for repair.

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Indications: In patients with anterior sphincter defects, who have failed conservative therapy. Limitations and drawbacks: Improvement in function is not guaranteed, despite the technical success of overlapping sphincteroplasty, however, significant symptom improvement can be achieved. Another drawback is that the initial improvement does not seem to be durable. Not even half the patients report satisfactory continence 5 to 10 years post repair. Though none of these factors are contraindications to overlapping sphincteroplasty, they are presumed to be responsible for the decreased success rates, and include: Age Duration of incontinence Obesity Pudendal neuropathy. As long as there is a definable anal sphincter defect and the patient is a good surgical candidate she can be offered a sphincter repair. Acute failures are known and are typically attributable to disruption of the sutures with development of a recurrent anal sphincter defect. If a patient after surgery presents with repeat symptoms of fecal incontinence, evaluation is no different than a patient who presents for the first time and if a sphincter defect is detected, repeat repair is not contraindicated. The results with repeat repair have been found to be comparable to the first time repair only care needs to be observed is that after multiple repairs, consideration may be given to placing a temporary stoma during the repeat overlapping sphincteroplasty.

Operative Procedure
Preparation
Preoperative preparation involves a full bowel preparation Administration of broad-spectrum IV antibiotics. Insertion of a Foleys catheter.

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Fig. 21.4: A curvilinear incision is made between the anus and vagina

The surgery can be performed under spinal, epidural or general anesthesia. Patient is best positioned in the prone-jackknife or a Lithotomy position. After a transverse or curvilinear skin incision, dissection is carried laterally and the ischiorectal fossa is identified and an endoanal flap is raised (Fig. 21.4). The medial border is the external anal sphincter which can easily be identified. Dissection cephalad in the rectovaginal septum is carried out, after each limb of muscle is identified. At this stage to facilitate dissection a finger is placed in the vagina or rectum. Due care should be exercised at the 3 oclock and 9 oclock positions, because the pudendal nerve inserts into the EAS here by way of the ischiorectal fossa. Through the scar tissue, the sphincter complex is divided in the midline, but the scar tissue is left intact to provides a stronger foundation for the suture repair, because the sutures are less likely to pull through.

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Fig. 21.5: Overlapping sphincteroplasty

If during surgery there is a feeling that there is Significant pelvic floor laxity or That the anal canal will be short. The levator ani can be plicated before reapproximation of the sphincters. The IAS too can be plicated at this time. If it is intact but lax. Sphincter is overlapped and suture repair is carried out with horizontal mattress sutures. If the IAS cannot be easily dissected the chances of repairing it separately are remote, in these situations overlap of the IAS and EAS in bulk is commonly advocated.

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Fig. 21.6: Wound closed in a T-shaped or Y-shaped Incision after a V-Y advancement flap is raised over a drain, this T or Y-shaped incision helps lengthen the perineal body

If the repair is found extremely difficult, intraoperatively, the decision for a stoma might be considered. If there is redundancy of skin, a V-Y closure (Fig. 21.6) may be necessary. Otherwise routinely the skin is closed in a longitudinal fashion. To allow drainage of accumulated, if a large area of dead space results after the repair, the center of the skin closure may be left open.

Postanal Repair
This procedure involves elongating the anal canal to improve fecal incontinence. The primary indications of this procedure are: Patients who have fecal incontinence without an anal sphincter defect or In those who have recurrent fecal incontinence status post OLSR with intact repair. Patients who have neuropathic fecal incontinence may also benefit from a postanal repair. The goals of the procedure are to: Re-establish the normal resting anorectal angle

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Lengthen the anal canal Tighten the anus at the sphincter level. The overall short-term results reported with this procedure are really good but long-term outcome for significant improvement is not good hence this procedure is rarely considered, yet the option always remains open.

Dynamic Graciloplasty
The gracilis muscle is a long muscle at the medial side of the upper leg. Because it is an auxiliary muscle for the adductor muscles, without the risk of hampering the adductor function it can be detached from its insertion. This muscle can be freed from its insertion up to the neurovascular bundle. It can then be folded in the upper leg, and tunnelled sub cutaneously to the perineum. The main characteristic of this muscle for use in fecal incontinence management is that it is long enough to encircle the anal canal and to be attached to the periosteum of the inferior ramus of the pubic bone. The best indications of dynamic graciloplasty are patients who cannot be helped with sphincter repairs: Patients with a completely destroyed anal sphincter or A large gap between both ends of the sphincters. Though because of its typical anatomy, this muscle is probably the best replacement of the destroyed sphincter, intrinsically it is the worst muscle for sphincter function. The reason being its composition of a minority of type one fibers (long acting, slow twitch) and a majority of type two fibers (short acting, fast twitch). The fiber composition makes the gracilis a fatigable muscle, as against necessity of an automatic long-term nonfatigable contraction of the sphincter, for continence. This can be achieved by chronic low-frequency stimulation, which can change the fiber composition of gracilis and change it to a nonfatigable muscle that contracts on demand of the stimulator.

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The electrical stimulation is given by an implanted stimulator that is placed very close to the gracilis nerve, through an intramuscular electrode. A handheld control is used to open the permanently closed muscle by switching off the stimulator. After the act of defecation is completed the stimulator can be switched on and the anus can be closed again with the same control. The results vary from surgeon to surgeon and are dependent on their experience. The complication rate of this intervention is high but most problems are treatable without influence on the final result.

Sacral Nerve Stimulation


Sacral nerve stimulation for fecal incontinence was first described in 1995. The credit should go to the urologists who started using sacral nerve stimulation in management of urinary incontinence, the curiosity of colorectal surgeons increased after the observation that patients with double incontinence, treated for their urinary incontinence, developed improved fecal control. The best indication for sacral nerve stimulation is: Fecal incontinence in patients with intact anal sphincters or For patients who had an unsuccessful anal repair in the past. Also works well in patients with neurogenic incontinence. Because this procedure has an option to test the stimulation before the decision for a permanent implant is made, it is gaining popularity. The mechanism of action is not clear, it is presumed that the proprioceptic fibers are triggered and reflexes suppressed or enhanced.

Steps for Performing the Test


The patient is placed in the prone position. A needle is brought in the foramen of S3. Contraction of the anus and pelvic floor can be achieved by a high-voltage stimulation on the needle.

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Apart from the contraction, the stimulation also gives a tingling sensation in the anovaginal region in women and in the anoscrotal region in men, suggestive of the position of the needle tip in the proximity of the third sacral nerve. Using this needle as a guide a test wire is brought through and the needle is withdrawn. The test wire is glued to the skin of the buttock and connected to an external screener. A low voltage just above the threshold for sensation is used to start the stimulation and after that the patient is sent home for a 3-week period. The patient is advised to maintain a diary for all defecations, urgencies, and incontinence episodes, which is compared to a similar diary maintained three week before the test stimulation. If there is improvement in continence, the test electrode can be replaced by a permanent electrode, which is fixed to the sacrum and connected to an implantable stimulator. The latter is implanted in the lower abdominal wall or in the buttock. The average duration that a stimulator usually lasts for is around 8 years. An average success rate of approximately 80% is observed. Looking at the positive long-term results the urologists get, similar results can be expected in management of fecal incontinence. One major limiting factor is the cost of the device. Though rare complications are mostly related to infection.

Secca Procedure
Radiofrequency energy delivery also known as Secca procedure; is a newer modality for treating fecal incontinence. It is recommended in patients with no definite sphincter defect, and as an adjunct to post sphincter repair. Patients who have IBD, chronic diarrhea, anal fissure, or abscesses should not under go this treatment. In this procedure radiofrequency energy is delivered to the sphincter muscles resulting in a heat injury, which in turn is presumed to trigger collagen contraction and deposition.

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Fecal Diversion
After failure of all other treatments, a stoma is typically considered the last resort. For those who cannot tolerate the morbidity of repeated surgeries or for those who do not desire to incur the potential for failure. It may also be considered as first-line therapy. It can also be offered to patients being referred to speciality centers before making a final decision on the qualification of other treatment options. Though not a treatment of choice, a permanent ostomy can ultimately free the incontinent patient from embarrassment, social isolation, and loss of control or independence.

Injectable Bulking Agents


In broad terms, an agent should be biocompatible, nonmigratory, nonallergic, nonimmunogenic, noncarcinogenic, easy to inject and able to produce durable results. Multiple agents have been investigated and range from biologic (autologous fat, collagen, stem cells) to synthetic (carbon-coated beads, polytetrafluoroethylene, silicone).

Indications
An intact but weak IAS or An isolated IAS defect. The procedure is relatively vary simple and easy to learn. They can be performed in the outpatient setting under local anesthesia. There are two main options for the method of injection: The first is to use a method similar to that for injecting phenolin-oil into piles, where the product is injected via a proctoscope into the submucosa above the dentate line. The second method is trans-sphincterically through a long tract to avoid product back leakage. Immediate results with most agents seem to be good with an improvement in symptoms and quality of life.

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Results vary with the type of agent used but the best seem to be associated with agents that do not migrate or biodegrade. Complications from the procedure relate primarily to the migration of the agents.

Artificial Sphincter
Artifical anal sphincter is an effective solution for motivated patients and experienced surgeons. The procedure should also be performed by specialized colorectal surgeons in specialized institutions. The artificial sphincter is considered in patients who have absent or nonworking intact anal muscles.

History of Artificial Bowel Sphincter (Fig. 21.7)


The earlier versions of the sphincter looked like this: Common problems faced with these type of artificial sphincters: Fibrosis Valve malfunction

Fig. 21.7: Historic artificial anal sphincter

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Infection Penetration Incomplete rectal evacuation. The new AMI anal band scores over the other artificial sphincters in that (Figs 21.8 and 21.9): New designed valve Anal band available in different sizes Postimplantation calibration possible Each part exchangeable in LA The system consists of: Soft anal band implant in 3 sizes plus 2 extension parts Valve Activator Calibration port (Titanium) Scale.

Fig. 21.8: New adjustible artificial anal sphincter Courtesy: AMI GmbH (Austria)

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Implantation Procedure and Device Functioning


The scale is used for measuring the required size of the band, which will be placed inside the surgically created circular pocket around the anal sphincter. The adjustable, artificial sphincter (the band) encircles the non functioning anal sphincter. Valve: Small, reliable convex. When the valve is activated, fillliquid of the system moves back from the band to the activator. The artificial sphincter is opened and defection is possible. The valve is activated by applying finger-pressure on the skin above the valve. Activator: Strong, reliable and small balloon, made from silicone. Applying pressure (with the palm) on the skin above the activator, moves the fill-liquid of the system back to the band. The artificial sphincter is closed and continence is achieved. The status of the artificial sphincterOPEN or CLOSED (Fig. 21.14) can be checked at any time. Protruding skin above the activator indicates an open sphincter. Flat skin indicates that the sphincter is closed. Calibration port: Titanium port with anti-kink-protection, used to adjust the patient required fill volume of the system.

Preoperative Work-up and Prepration


Complete functional tests and major preoperative profile. Preoperative systemic IVantibiotics Orthograde lavage to clean the entire bowel.

On Table (Figs 21.10 to 21.13)


No changes between preparation of perianal and abdominal wound area Subcutaneous implantation of gentamycin containing collagen sponge in each incision Changing of surgical gloves and all instruments after finishing perianal part and before continuing with the abdominal part of the operation

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Fig. 21.9: Components of the new adjustible artificial anal sphincter Courtesy: AMI GmbH (Austria)

If injury of vagina: Suture it and proceed If perforation to anus and/or rectum: Suture it, close anal wounds without anal incontinence implantation, change gloves and instruments, proceed to the abdominal part. Only use sterile water for injection to fill all tubes and valve and activator, never use NaCl After closure of all wound: manometry: Empty anal incontinence: < 20 mm Hg Closed anal incontinence: 60100 mm Hg (Fig. 21.15) If pressure is too low: Fill up using calibration port

Fecal Incontinence 509

Fig. 21.10: First step of implantation of artificial anal sphincter

Figs 21.11A and B: Schematic implantation of the artificial anal sphincter around a colostomy to make it continent Courtesy: AMI GmbH (Austria)

510 Anorectal Surgery

Fig. 21.12: Artificial anal sphincter around a colostomy

B
Figs 21.13A and B: Postoperative contrast study to demonstrate continence with artificial anal sphincter Courtesy: AMI GmbH (Austria)

If pressure is too high: Discharge or use a larger anal incontinence. The success of the artificial anal sphincter which was limited primarily by its complications, which include infection, erosion into adjacent structures or through the skin, and device failure is not an

Fecal Incontinence 511

Fig. 21.14: Anal band in action Courtesy: AMI GmbH (Austria)

Fig. 21.15: Tonometer demonstrating continence after anal band implantation Courtesy: AMI GmbH (Austria)

issue with anal band. The chance of infection is low device failure is not a major issue as the entire device never needs to be explanted, only the part that is non-functioning is the one that nees to be changed.

512 Anorectal Surgery

In patients who do not incur a complication, successful outcome is high and durable.

Future Perspectives
Because management of incontinence requires an accurate multi modal diagnostic assessment. The effectiveness of treatment of double fecal and urinary incontinence can be improvized by increased integration of knowledge and cooperation between: Coloproctologists Urologists Gynecologists. Treatment options may include rehabilitative procedures, surgery, or both. What needs to be specified and defined precisely are the indications for: The behavioral approach Prosthetic/reconstructive surgery, or Sacral nerve stimulation.

Index
Page numbers followed by f refer to figure

Abdominal distention 150, 193 pain 177, 205, 206 procedures 462, 469 ultrasound 284 Abnormal anorectal anatomy 91 rectal compliance 485 sacrum 284 Abscess 55, 315, 342, 359 Acne vulgaris 384 Acquired immunodeficiency syndrome 376 Actinomycosis 372, 373, 396, 434 Activities of daily living 483 Acute abscess 405 anal fissure 314 appendicitis 150 bacterial colitis 137 cardiorespiratory compromise 121 colonic infection 91 diverticulitis 89, 91 fissure in ano 55, 121, 289, 293, 294f pain 314 peritonitis 128 pilonidal abscess 429, 432 severe diverticulitis 128 sigmoid diverticulitis 139 suppuration 432 Adenocarcinoma 22 of rectum 396 Adequate daily water intake 274 Advanced renal disease 167 Advantages of mucosal advancement flap 413 procedure 334 Alpha-1 receptor antagonists 300 Altemeier perineal rectosigmoidectomy 467f

Alterations in bladder and sexual function 472 Altered bowel habits 52, 55 Ambiguous genitalia 283 Ambulatory anorectal surgery 153 Amebiasis 373 Amoebic colitis 137 Ampulla recti 480 Amyloidosis 167 Anal canal 21, 22, 22f, 55, 119 high pressure zone 475 stenosis 121 cancer 290 carcinoma 58 encirclement 466 endosonography 85, 87f, 459 fissure 128, 241, 242, 256, 315, 342, 354, 359 repair 478 fistula 241, 256, 434 plug 424, 426f incontinence 315, 354 manometry 100, 102, 158, 186, 403, 487 maximum pressure 106 portion 27 sonography 85 sphincter 165 weakness 475 stenosis 128, 167, 315, 359 stricture 354 tonometry 104, 242 device 106 tumor 315 wall 61 Anastomotic leak 470, 472 Anatomic disturbances of pelvic floor 476 Ancient Indian surgical instruments 3f Anemia 64

514 Anorectal Surgery


Angiotensin converting enzyme inhibitors 300 Angulation of rectum 135f Annular carcinoma 55 Anococcygeal body 20, 37 ligament 36 triangle 44, 45f Anogenital warts 315 Anorectal abscess 314, 315, 368, 375f angle 475 biofeedback 205 cancer 241 Crohns disease 128, 137 disease 63 disorders 52, 84 dysfunction 68 fistula 315 function 487 group 27 lymphatics 27 malformations 275 malignancy 120 manometry 184, 458 membrane 13 muscle 31f ring 35 neoplasm 128, 137 pain 120, 270 physiologic tests 232 sensory and reflex mechanism 475 spaces 369f, 394f stenoses 13 stricture 139 surgery 5, 6 trauma 484 ulcer 128 ultrasonography 158 Anorectum 100 Anoscopy 61, 119, 404 demonstrating normal mucosa and polyps 126f Anterior pull of puborectalis muscle 33f rectal wall support 217 resection 462 superior iliac spine 38f Anthraquinones 198 Antibiotic prophylaxis 145 Anticholinergics 168 Anticonvulsants 170 Antidepressants 170 Antihistamines 170 Antispasmodics 170 Anxiety 365 Appendicitis 396 Arterial supply 22, 310 of rectum and anal canal 26f Artificial anal sphincter 505f, 506f, 508f-510f around colostomy 509f sphincter 505 Ascorbic acid 76 Atomizer wand 362 Autonomic neuropathy 167

Bacteremia 150 Bacterium minutissimum 258 Balloon defecation therapy 239 training 238 expulsion 184 test 186 Band ligator and slotted proctoscope 326f Barium enema 403, 458 Bartholin cyst 397 gland abscess in females 396 Bascoms cleft closure procedure 450 flap 445, 446f Bhagandara yantra 3f Bilateral oopherectomy 155 tubal ligation 155 Bimanual examination 61 Biofeedback training 246 Biopsy forceps 69 Bladder 20 and sexual function alterations 470 augmentation 287 dysfunction 473 Bleeding 63, 65, 149, 162, 418, 470, 471 per rectum 52, 61, 315

Index 515
Botulinum A toxin injection 298 Bowel frequency 205 function 461 habits 483 injury 472 motility 48 preparation 143 Bowens disease 261 Brain tumor 484 Branch of superior hemorrhoidal artery 339f Bulbocavernosus 212 Bulk forming laxatives 190, 191 Bulky hemorrhoidal disease 365 Chronic constipation 55, 160, 215, 271 cough 215 discharge 56 fissure in ano 289, 294 illness 168 ischiorectal abscess 55 medical immunosuppression 376 obstructive pulmonary disease 215, 456 pain 354, 315 pilonidal sinus 432 proctalgia 244 straining 476 Cinedefecography 274 Classification of fistula in ano 398f Cloacal anomalies 281 exstrophy 282 Clostridium botulinum 204, 298 difficile colitis 137 Coccygeal sinus 434 Coccygeus 21 Coccyx 20 Colchicine 261 Colectomy 206 Collagen disorders 215 Collitis 54 Colloid carcinoma of rectum 56 Colon cancer 64, 167 Colonic distention 93 necrosis 128 transit study 459 Colonoscopic tattooing 151 Colonoscopy 141, 405, 458 Colorectal and anal disease 260 cancer 163 Colpocystodefecography 226 Common course of track of fistula 398, 399 Complete blood count 154 excision of internal opening 414 mechanical colonic obstruction 91

Cachexia 56, 57 Calcium channel blockers 298 containing antacids and supplements 168 dobesilate 320 Calibration port 507 Cancer 295, 396 therapies 376 Candida albicans 258 Carbon dioxide 94, 194 Carbuncle 434 Carcinoma ampulla of rectum 55 in pilonidal sinus 451 of anal canal 55 of rectum 57 Cardiac malformations 284 Cathartic colon 197 Caucasian race 430 Cauda equina lesions 485 Causes of anal incontinence 475 chronic constipation 168 Cellulitis 342 Central nervous system 484 disorders 167 Chagas disease 167 Chest wall 428 Childbirth injury 484 Cholecystectomy 480

516 Anorectal Surgery


Complex AIDS 412 flap reconstruction 438 matrix 424 Complicated pilonidal sinuses 434 Composed of skin 447 tomographic 89 Computerized tomography scan 157 Concomitant diarrhea 480 Concurrent systemic illness 437 Condyloma acuminata 315 of rectum 55 Condylomata 58 Congenital abnormalities of anorectum 484 aganglionic megacolon 169 anomalies 476 anorectal malformation 169 megacolon 14, 15f Congestive heart failure 92 tissue and smooth muscle 310 laxity 366 Conservative sphincterotomy 303 Constipation 102, 159, 241, 366 in children 168 in elderly 168 in pregnancy 177 Construction of stoma 206, 207 Continent diversion 287 Contracts bowel 18 smooth muscle 18 Contrast enema 274 Copious mucous discharge 270 Corpus cavernosum recti 480 Corrugator cutis ani muscle 32 Crohns disease 54, 56, 89, 144, 290, 295, 372, 396, 400, 410, 415, 420, 476, 484 affecting anal canal 315 and hemorrhoids 366 fistulae 420 stulae 412, 420, 421 Cryotherapy 328 Cryptococcal infection 373 CT colonography 89 scan 403 Curves of rectum 17f Curvilinear incision 498f Cutting seton 411 Cyclobenzaprine 246 Cyst 58 Cystic fibrosis 169, 456 Cystocele 216, 218 Cystodefecography 81

Darbhakrti khala mukha sala 3f Deep postanal space 368 Defecation reflex 50 Defecatory dysfunction 168 Defecography 81, 186 Degenerative disease 168 Degree of abdominal push 236 Dehydration 168 Delayed wound healing 418 Delorme mucosal sleeve resection 468, 468f procedure 224 for rectal prolapse 219 Dementia 168, 476, 484 Dennonvillers fascia 20 Depression 182 Dermal island advancement flap 416 Dermatitis 486 Dermatological causes of pruritus ani 257 conditions and neoplasia 260 Dermatomyositis 167 Dermoid cysts 386 Descending perineum syndrome 476 Development of gastrointestinal tract 11f Diabetes 477 insipidus 169 mellitus 167, 262, 485 Diabetic neuropathy 476 Diarrhea 309, 395 Diarrheal states 476 Diazepam 246

Index 517
Dietary modifications 188 Digital rectal examination 60, 70, 73f, 316, 404 Diphenylmethane derivatives 199 Disadvantages of intravenous contrast 95 Distal anorectal masses 119 Distention 206 Diuretics 170 Diverticular abscess 128 Diverticulitis 395, 396 Docusate sodium 200 Doppler guided hemorrhoidal artery ligation 335 Drainage of abscess 378f horseshoe abscess 380f supralevator abscess 379f Draining seton 411, 412 Dull ache 244 Duration of incontinence 497 Dvitala yantra 3f Dynamic graciloplasty 501 MRI defecography 97 Dyssynergic defecation 174 Dysuria 373 Enterocele 82, 210, 218, 225 Eradicating fistula 405 Eradication of perianal sepsis 406 Erosions 264 Erythrocyte sedimentation rate 61, 183 Esophageal atresia 284 Evacuatory difculty 223, 225 Evaluate sphincter tone 317 Exact position of swelling 55 Exaggerated skin folds 264 Examination of perineum 404 under anesthesia 74, 404 Excessive perineal descent 175 Exstrophy of cloacal membrane 14 Extension of pilonidal abscess 372 Extensive soft tissue cellulitis 379 Extent of procedure 461 prolapse 461 External anal sphincter 86, 299 and internal sphincters 275 hemorrhoidal thrombosis 354 hemorrhoids 316, 486 opening 395 skin tags 58 sphincter 30 muscles 370 Extrarectal group 27 Extrasphincteric stulae 422 Extrinsic compression 167

Echo sounder 336 Echocardiogram 284 Eczema 56, 315 Edema of dermis 262 Electrocardiogram 155 Electrocoagulation 329 Electrogalvanic stimulation 246 Electromyography 114, 117, 459, 489 Electrophysiology tests 489 Elements of anorectal manometry 101 Embryology 10 Endoanal ultrasound 490 Endocrine disorders 167 Endorectal ultrasonography 157 Endoscopic and surgical significance of rectum 18 Endoscopy 119 Enlarging gravid uterus 177

Failed colonoscopy 90 Fascia 20 Fecal contamination of perineum 256 continence 475 diversion 504 impaction 418, 476, 485 incontinence 102, 225, 242, 359, 361, 474, 482, 484 occult blood test 75 Feeling of incomplete emptying 223 obstruction 242

518 Anorectal Surgery


Fergusons hemorrhoidectomy 355, 363 procedure 358 technique 355 Fever 56 Fibrin glue 422, 423f Fibromuscular obliteration 271 First degree hemorrhoids 311 Fissure 57, 264 in ano 59, 66, 289, 290f, 302, 315, 316 Fistula 315, 342, 359, 476, 484 in ano 56, 58, 66, 391 evaluation 119 Fistulectomy 409 Fistulography 79, 402 Fistulotomy 408, 418, 476, 486 Flexible sigmoidoscopy 137 Flexiprobe new modified proctoscope for rectoanal repair 344f Fluid intake 170, 187 overload 359 Foleys catheter 497 Forceps 336 Foreign bodies 119 Formation of skin tags 359 Fourth degree hemorrhoids 312 Freis test in lymphogranuloma inguinale 62 Fulminant colitis 128 Function of external anal sphincter 49 internal anal sphincter 48 Functional anatomy of pelvic floor 165f anorectal disorders 241 pain 102 fecal retention 176 Fungal infection 257, 315 Furuncle 386, 434 Gluten enteropathy 169 Gluteus maximus musculocutaneous flap 449, 449f myocutaneous flap 450 Glyceryl trinitrate 259, 297 Gollighers Classification 310 Goodsalls rule 58, 58f, 59f, 401f Granuloma inguinale 386 Greater patient satisfaction 348 Guar gum 193

Gastrointestinal transit 177 Genupectoral position 252f Giant cells 385 Gluteal fascia 447

Harmonic scalpel and ligasure 361 Heavy metal poisoning 167 Hematologic malignancy 412 Hemorrhage 354 Hemorrhoid 306, 366 evaluation 119 injection syringe and needle 324f Hemorrhoidal artery ligation 341 Hemorrhoidectomy 356, 396, 476, 478, 486 Hepatitis 420 Hidradenitis suppurativa 372, 383, 396, 397, 434 High definition colonoscopy 152 fiber diet 169 imperforate anus on radiography 14f ligation of hemorrhoidal pedicle 359 suspicion of cancer 141 trans-sphincteric fistulotomy with seton 410f Hirschsprungs disease 102, 113, 169 History of artificial bowel sphincter 505 fistula in ano 391 surgery 1 HIV infection 395 Home training devices 238 Hormonal therapy 387 Horseshoe abscess 377 Human immunodeficiency virus infection 295 Hydrogen 194 Hydrops of epidermis 262

Index 519
Hyperbaric oxygen 300 Hypercalcemia 167 Hyperthyroidism 167, 262 Hypertrophied anal papilla 289 Hypoechoic anococcygeal ligament 86 Hypokalemia 167 Hypothyroidism 167, 169, 182, 485 Intersphincteric abscess 241, 374 groove 299 space 368 Intertrigo 257 Intestinal injury 470 pseudo-obstruction 167 Intra-abdominal hemorrhage 150 Intramural fistulization and abscess formation 354 Iron deficiency anemia 262 supplements 177 Irregular proliferation of stratum mucosum 262 Irritable bowel syndrome 176, 477, 485, 488 Ischemia 488 Ischioanal fatty spaces 86 fossa 21 space 368 Ischiococcygeus 36 muscle 38 Ischiorectal abscess 374, 375 fossae 41, 42f Island flap anoplasty 416 Itching 63, 68

Idiopathic inflammation 264 Iliococcygeus 36 muscle 38 Immunodecient patients with neutropenia 412 Imperforate anus 14, 91, 121, 276, 283 before and after surgery 13f in females 278f in males 279f Important steps of anoscopy 124f Incision with marsupialization 438 Incomplete rectal evacuation 506 Incontinence 228 Increased estrogen 177 progesterone 177 Infected inclusion cysts 396 Infection 315, 342, 372, 470, 471 Infectious enteritis 476 proctitis 128 Inferior rectal artery 22, 25 Inflammatory bowel disease 315, 395, 396, 476, 489 cells 385 Infrared coagulation 329 Injury of vagina 508 Integrity of perineal body 217 Intermediate anomalies 13 Intermuscular sulcus 35f Internal anal sphincter 86, 289, 292 and external hemorrhoids 311f hemorrhoids 119, 315, 321 iliac 25 procidentia 222 sphincter 33 sphincterotomy 476

Jackknife position 131 Jeep riders disease 428

Kanka mukha svastika 3f Karna sodnana 3f Karydakis flap 444, 444f procedure 444f Kazumasa morinaga 335 Knee-elbow position 57 Knot pusher 336, 337f

Lactulose 194

520 Anorectal Surgery


Laparoscopic rectocele repair technique 221 rectopexy 465 Laser surgery for hemorrhoids 361 Lateral incision and excision of midline pits 439 internal sphincterotomy 301, 302, 302f, 303, 304, 486 ligaments of rectum 21 Laxative abuse 477 Less postoperative pain 348 Leukemia 262 Leukocytosis 150 Leukopenia 420 Levator ani 21, 370 muscle 36 syndrome 242, 243 plate integrity 217 spasm 244 Lichen planus 257 sclerosus 261 Ligation of intersphincteric fistula tract 426 Limberg flap 445 Linen and disposable gloves 130 Lithotomy position 57 Liver disease 262 Local irradiation 400 Localize pain 317 Longitudinal muscle 34 Long-term constipation 456 diarrhea 456 straining during defecation 456 Low anomalies 13 anterior colorectal resection 476 lesions 277 Lower abdominal and back pain 225 border of gluteus maximus 370 sacrum 37 Lubiprostone 204 Lubricant jelly 130 Lymphatic drainage 22 of rectum and anal canal 28f Lymphogranuloma venereum 373, 396 Lymphoma 262, 396

Magnetic resonance imaging 402, 403 Malignancy 22, 315 Management of constipation 186 pruritus ani 266 Mantoux test in tuberculosis 62 Manual dilatation of anus 300 Marlex rectopexy 464f Maximal tolerable rectal volume 116 Measurement of hemoglobin level 183 Median sacral and rectal vessels 20 artery 25 Medical causes of secondary constipation 167 Menopause 155 Mental retardation 484 Metabolic disorders 163 Methocarbamol 246 Methylcellulose 193 Microballoon devices 103 Microtransducer arrays 103 Middle rectal artery 25 Milligan septum 34 Morgan hemorrhoidectomy 357 Minors triangle 46f Modified Ferguson hemorrhoidectomy 355f proctoscope for rectoanal repair 345f Motility and evacuability of rectum 475 of anal canal 475 Motor fibers 29f Mucosal advancement flap 413, 414f, 418 prolapse 316 Mucus and pus discharge 52, 54 Multiple fistulae 410 sclerosis 48, 167, 456, 476, 485

Index 521
Muscular dystrophy 485 Myasthenia gravis 485 Overlapping sphincteroplasty 499f repair 496, 496f Overt rectal prolapse 210, 228

Narcotics and anticholinergic drugs 359 Natural phlebotonic 319 Nature of bleeding 53 Necrotizing anorectal infection 381 Needle holder 337f Neoplasia 264 Nerve supply of rectum and anal canal 29f Neurologic disease 456, 482 Neuromuscular disorders 167 Neuropathy stretch injury 476 Nodes 21 Nonanatomic repair 220 Nonobstetric anorectal injury 480 Nonobstetrical causes of anal incontinence 478 Nonpharmacologic therapy 435 Nonspecific pelvic pain 271 proctitis 127, 137 Nonsteroidal anti-inflammatory drugs 76 Normal endoanal ultrasound 491 transit constipation 170 vaginal caliber and length 217

Obesity 215, 431 Obstetric trauma 476 Obstructed defecation 223, 228 syndrome 209 Obstructing rectoceles 175 Obstructive defecation 214 Obturator internus 21 Occasional contrast reactions 95 Operations for defecatory disorders 208 Operative trauma 359 Opioids 170 Oral medication 319 Organ transplant 412 Osmotic laxatives 191, 193 Osteomyelitis 434

Pagets disease 261 Pain 52, 53, 54, 63, 66, 314, 359, 394 after defecation 66 Painful hemorrhoids 177 Painless bleeding 312, 313 Pancreatitis 420 Panhypopituitarism 167 Papillomas 256 Papillomata 58 Para-aortic lymph nodes 22 Paradoxic contraction of pelvic floor muscles 272 Paradoxical contraction 233 Paralysis 456 Paraplegia 456 Pararectal spaces 42f Parasympathetic fibers 29f Parkinson disease 476 Partial thromboplastin time 154 Pediculosis pubis 257 Pelvic dyssynergy 210 floor dysfunction 165, 166 dyssynergia 102, 174, 233, 242 floor muscles 481 inammatory disease 396 neuromuscular function 216 organ prolapse 210 pain and pressure 223, 228 pressure 225 and congestion 367 splanchnic nerves 20 tension myalgia 244 triangles 39 Peppermint oil 261 Perfused catheters 103 Perianal abscess 55, 56, 66, 374, 437 condyloma 120 Crohns disease 386 cryptoglandular fistulas 386 hematoma 55

522 Anorectal Surgery


itching 52 plaques 260 rashes 316 region 61 space 40, 368 thrombosis 342 viral infections 258 Perineal descent 485, 486 syndrome 253 fecal contamination 256 groove 13 group 27 procedures 466, 470 rectosigmoidectomy 466 skin 217 Perineopelvic spaces 39 Peripheral nervous system 485 Peripherally acting opioid antagonists 204 Peritoneal signs 150 Peritoneum 21 Persistent anal membrane 13 Pheochromocytoma 167 Phosphate enemas 201 Piles 57, 306 Pilonidal abscess 429 cyst 429, 386 disease 396, 397, 429, 432 sinus 428 with midline pits 430f, 433f with pits 433f tract 429f Piriformis 20 Pitfalls of CT colonography 96 Polyethylene glycol 195, 196 Polyneuropathies 485 Polyposis 57 Polyps 315 Poor preoperative sphincter pressures 410 Porphyria 167 Position for sigmoidoscopy 131f Positive fecal occult blood test 141 Posterior colporrhaphy 478 fornix 20 pull of superficialis muscle 33f vaginal wall 217 Postmenopausal status 215 Postoperative pain 361 Postpartum pudendal neuropathy 485 Postpolypectomy coagulation syndrome 149 Postradiation stenosis 89 Potential morbidity 461 Pre-existing incontinence 400 Pregnancy 167 and hemorrhoids 366 and stresses of childbirth 456 Premenstrual flare-ups 384 Presacral cyst 397 Presence of multiple tracts 400 Preserving anal sphincter 405 Pressure sensation high in rectum 244 Previous fistulotomy 410 pelvic surgery 89 surgery 456 Principles of disease 307 Proctalgia fugax 242, 246 Proctitis 315, 485 Proctoscope 68 Proctosigmoidoscopy 405 Profundus muscle 32 Progressive systemic sclerosis 167 Prolapse rectum 55 Prolapsed hemorrhoids 315, 316 internal hemorrhoids 53 rectal polyp 55 thrombosed piles 55 Prolapsing hemorrhoids 256 Promote wound healing 320 Prospective stool diaries 232 Prostate 20 Prosthetic devices 379 valves 379 Prucalopride 203 Pruritus ani 52, 56, 65, 242, 255, 315 Pseudo-obstruction 169

Index 523
Pseudopolyps 359 Psoriasis 257, 260 Psychosocial stress 177 Psyllium husk 192 Pubococcygeus 36 muscle 36 Puborectalis 36 muscle 36, 37 syndrome 244 Pudendal nerve motor latency test 30 terminal motor latency 118, 489 neuropathy 497 terminal motor nerve latency 242 Purified flavonoid fraction 319 Purpose of performing anal tonometry 105 Purse string suture 350f Pyriformis syndrome 244 ischemia 485 pain and bleeding 242 polyp 53, 316 portion 27 prolapse 53, 57, 82, 120, 256, 315, 316, 453, 454f, 476, 484 procidentia 454f schistosomiasis 373 sensation 116 trauma 315 tumor 315 ulcer 137 ulceration 227, 270 valves 134f wall 61 Rectoanal coordination 235 inhibitory reflex 116, 488 repair 343, 346f Rectocele 167, 210, 211, 213f Rectoperineal stula 280, 281 Rectosigmoid junction 55 Rectourethral stula in boys 276 Rectouterine pouch of Douglas 20 Rectovaginal fistula 478 septum 212f space 44 Rectovesical pouch 20 Rectovestibular fistula in female 12f girls 276 Rectum 16 Recurrence rate 461 Recurrent stula 400, 410 pilonidal disease 434, 450 prolapse 469 Regional lymph nodes 61 Relations of rectum 19f Relationship of anterior limit of pubis 38f Relaxes bowel 18 smooth muscle 18 Removal of primary and secondary tracts 414 Renal failure 262

Quality of bleeding 53 pain 54 perianal skin 257 stool 257 Quinidine 261

Radiation enteritis 476 proctitis 127, 137, 489 therapy 396 Radiofrequency coagulation and excision 333 equipment 333f Radiotherapy and ergotamine suppositories 272 Rash in perianal skin 56 Recent colonic surgery 128 Rectal atresia 281, 283 balloon manometry 112, 488 bleeding 120, 223, 270 contents 61 intussusception 175, 210, 222, 228

524 Anorectal Surgery


Repair of rectocele 219f Retrograde ejaculation 473 Retroperitoneal abscess 150 Retrorectal space 43, 43f, 368 Retrovesicular fistulas 280 Rhomboid flap 445f Right lateral position 57 Rigid sigmoidoscope 68, 129f, 130f, 133f Ringworm 257 Ripstein procedure 463 Role of antibiotics 436 intravenous contrast 95 spasmolytics 94 Rubber band ligation 325 Ruptured thrombosed hemorrhoids 315 cortisol 183 glucose 183 parathyroid hormone 183 protein electrophoresis 183 Seton placement 409 Severe anal pain from anal diseases 139 coagulopathy 128 colonic pseudo-obstruction 91 diarrhea 485 infectious colitis 91 neutropenia 128 pain 354 with hypersensitivity 365 rectal pain 121, 373 secondary hemorrhage 342 thrombocytopenia 128 Sexual function 228 Sexually transmitted diseases 315 infections 264 Shy-Drager syndrome 167 Side opening scope 119 Sigmoid colon 55 Sigmoidocele 82, 167 Sigmoidoscope 138f Significant abdominal pain 162 Sims position 57, 130 Simhamukha swastika 3f Simulated defecation 186 Sinus excision 447 Sitz baths 246, 364 Skeletal muscle diseases 485 problems 482 Skin carbuncle 386 excoriation 395 furuncles 434 lesions 316 tags 256, 316 tuberculosis 386 Slow transit constipation 171 Small bowel 20 series 403 transit 475 Smooth muscle dysfunction 482, 485 Soiling 68, 314

Sacral and coccygeal roots 20 nerve stimulation 502 Sacrococcygeal regions 316 Sacrotuberous ligament 370 Sacrum 20 Saline 201 Scabies 257 Scalp 428 Scars in perianal skin 60 Scissors 336 Scleroderma 485 Sclerotherapy 322 Secca procedure 503 Second degree hemorrhoids 312 Secondary hemorrhage 359, 360 Seminal vesicle 20 Sensoric innervation of anal canal and rectal ampulla 480 Sensory fibers 29f function 486 training 237 Sentinel pile 58, 289 Septicemia 342 Sequelae of anorectal infections 484 Serum calcium 183

Index 525
Solitary rectal ulcer syndrome 242, 270, 271 Sorbitol 195 Space contains 40 Sphincter 30 function 486 Spinal cord abnormality 169 injury 167, 476 lesions 485 Spine radiographs 284 Splenic rupture 150 Spurious diarrhea in morning 55 Squamous cell carcinoma 22 of anus 396 portion of anal canal 316 Staging of cancers 90 Staphylococcus aureus 258, 385 Stapled hemorrhoidectomy 348 Status of estrogenation 216 fecal continence 461 Stenosing tumors 89 Steps of hemorrhoidal artery ligation 346f Milligan-Morgan open hemorrhoidectomy 358f Steroid therapy 395 Stimulant laxatives 191, 197 Stool softeners 190, 200, 274 Strenuous defecation 271 Stroke 167, 476, 484 Strong insertions of glutei muscles 36 Structures around rectal wall 61 Subcutaneous abscesses 385 emphysema 150 muscle 30 Submucous space 40 Superficial external sphincter muscles 275 part of external anal sphincter 212 postanal space 368 transverse perinei muscles 212 Superficialis and subcutaneous muscles 37f fibers 36 muscle 32 Superior hemorrhoidal artery ligation 341f Supralevator abscess 374, 375 anomalies 12 space 42, 368 Surgical hemorrhoidectomy 354 therapy 460 Sushruta performing surgery 8f Suture dehiscence 354 Swelling 52, 55, 65, 394 Sympathetic trunk 20 Synthetic phlebotonic 320 Syphilis 290, 295 Syphilitic granulomas 434 Systemic sclerosis 476

Tabes dorsalis 485 Tenesmus 52, 55, 56 Thiersch procedure 466 Third degree hemorrhoids 312 sacral vertebra 18 Threadworm 257 infestation 56 Throbbing pain 66 Thrombosed external hemorrhoids 364 hemorrhoid 241, 315, 316, 418 internal hemorrhoids 364 Thrombosis 316 Thyroid function 183 Tight anal stricture 91 Timed toilet training 188 Toilet paper dye 259 Total colectomy 206 fistulectomy 414 hysterectomy 155 pelvic organ prolapse 228 Toxic colitis 91, 139 megacolon 91, 128 neuropathy 485 Traditional sphincterotomy 303

526 Anorectal Surgery


Transanal rectal advancement flap 415 repair 222 Transperineal repair 221 Transrectal repair 218 Transverse perineal muscles 370 Trauma 272, 396, 484 Traumatic neuropathy 485 Trendelenburgs position 465 Tuberculosis 56, 295, 372, 373, 395, 396 Tuberculous granulomas 434 Tumors 316 Types of abscesses 374 hemorrhoids 311f mucosal thickness 216 reconstruction 287 tears 486 ulceration 227 vault prolapse 216, 227 Valsalva maneuvers 456 Valve malfunction 505 Valvular heart disease 379 Vascular supply of rectum and anal canal 23, 24f Venous drainage 22 drainage of rectum 25 and anal canal 26f plexus 310 radicals 40 Vertebral anomalies 284 Very recent colonic surgery 91 Video assisted anal fistula treatment 427 colonoscope 142f defecography 102, 458 sigmoidoscope 138f Vitamin C 76 V-Y advancement flap 447, 447f

Ulceration of vaginal mucosa 226 Ulcerative carcinoma of rectum 55 colitis 56, 89, 372, 476 infective carcinoma of rectum 54 Umbilicus 428 Unexplained weight loss 141 Urethra 87 Urinary defects 284 problems 354 retention 359, 360, 418 Urine 62 porphyrins 183 Use of anorectal manometry 102 birth control pills 384 clonidine for proctalgia fugax 253 polyethylene glycol 239 U-shaped pubirectalis muscle 86, 87f Uterus 20

Warts 58 Weight loss 162 Wells posterior ivalon rectopexy 464 Wet wipes 259 Whooping cough 456 Wireless capsule endoscopy 152

X Z

Xylocaine jelly 336 Z limbs 447 Z-plasty 447, 450 incision 448f steps 448f

Vaginal mucosa 217

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