Part 2 book “Anorectal aurgery” has contents: Functional anorectal disorders, anorectal malformations, fissure in ano, hemorrhoids, anorectal abscess, hidradenitis suppurativa, fistula in ano, pilonidal sinus, rectal prolapse, fecal incontinence.
Functional Anorectal Disorders chapter 12 A functional anorectal disorder is defined 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 defined 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: 242 Anorectal Surgery • Rectal pain and bleeding • Digitalization • Incomplete evacuation • A feeling of obstruction Because many findings can be seen in normal patients as well, and the symptoms are nonspecific it makes the patient evaluation and diagnosis difficult 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 not allow recognition of discrete causes in individual patients and so 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 244 Anorectal Surgery 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 significant 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 floor 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 Functional Anorectal Disorders 245 • 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: Chronic or recurrent rectal pain or aching and discomfort Episodes last 20 minutes or longer Other causes of rectal pain such as ischemia, inflammatory bowel disease cryptitis, intramuscular abscess, fissure 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 satisfied and these physical signs are present, or • A “possible” diagnosis if the symptom criteria are met but the physical signs are absent 246 Anorectal Surgery 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 Crohn’s 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 Functional Anorectal Disorders 247 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 rectum”—It 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 five 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 identification 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 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 248 Anorectal Surgery Diagnostic Criteria Recurrent episodes of pain localized to the anus or lower rectum Episodes last from seconds to minutes There is no anorectal pain between episodes Proctalgia may be classified into severe and mild attacks Occuring usually between and 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 Functional Anorectal Disorders 249 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 250 Anorectal Surgery Clinical Evaluation Diagnosis is based on symptoms alone There are no physical examination findings 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 pathophning 414 mechanical colonic obstruction 91 ... surgery 128 Rectal atresia 28 1, 28 3 balloon manometry 1 12, 488 bleeding 120 , 22 3, 27 0 contents 61 intussusception 175, 21 0, 22 2, 22 8 ischemia 485 pain and bleeding 24 2 polyp 53, 316 portion 27 prolapse... neuromuscular function 21 6 organ prolapse 21 0 pain and pressure 22 3, 22 8 pressure 22 5 and congestion 367 splanchnic nerves 20 tension myalgia 24 4 triangles 39 Peppermint oil 26 1 Perfused catheters... Enterocele 82, 21 0, 21 8, 22 5 Eradicating fistula 405 Eradication of perianal sepsis 406 Erosions 26 4 Erythrocyte sedimentation rate 61, 183 Esophageal atresia 28 4 Evacuatory difficulty 22 3, 22 5 Evaluate