resting vs squeezing tone
- resting– internal sphincter function; most important for continence
- squeezing– voluntary/external sphincter & pelvic tone; gives info about constipation and defacation
test for rectal prolapse or prolapsing hemorrhoids
valsalva maneuver
- when a vascular tissue covered by mucosa bleeds or enlarges & goes into anal canal
- likely loss of connective tissue support making it more likely to be affected by straining or hard stools
- risk factors includes pregnancy and lengthy periods on toilet
hemorrhoids
grade hemorrhoids from 1 to 4
- no proplapse
- prolapse w/ straining but retracts after
- needs manual reduction
- not manually reducible
- painless bright red bleeding w/ bowel movements
- sometimes feeling of protrusion/prolapse, mucus or fecal leaking
- can be clotted blood
- prolapse can cause aching pain if not reducible
- can be soft & squishy
internal hemorrhoids
- PAST dentate line– painful or more irritating/very tender w/ thrombosis (painful swelling)
- can be purple or blue
- hx of constipation, diarrhea, heavy lifting
- thrombosed– sudden onset of pain, edema; can become strangulated
external hemorrhoids
which hemorrhoid is more likely to bleed more?
internal hemorrhoids
how are hemorrhoids treated
- conservatively– more fluids, fiber, gentle hygiene; less time on toilet & straining
- limited evidence for steroids and OTCs are mostly for sx relief only
for which hemorrhoid is banding procedure done?
internal hemorrhoids (grade 1& 2); especially if there is iron deficiency anemia or persistent bleeding
how are thrombosed external hemorrhoids treated? (2)
w/in 4 days of onset w/ clot excission, removal of skin over area
alternatively: conservative tx w/ pain control
- tear to midline, mostly posterior, anal canal distal to dentate line so its very painful
- feels like shard of glass w/ defecation & after; stools can be hard or loose
- bright red blood w/ wiping or in toilet bowl but can be a LOT
- sentinel skin tag– tender
anal fissures
if the anal fissure is not midline, list 5 ddx as the cause
- TB
- HIV
- syphilis
- psoriasis/skin condition
- anal carcinoma
risk factors for anal fissures & differentiate acute from chronic
- RF: anal intercourse, foreign object insertion, straining, hard stools
- acute: clean edge like paper cut
- chronic: more than 8-12 wks; heaped up, indurated
trauma + internal anal sphincter muscle spasm w/ relative ischemia + sentinel skin tag or hypertrophied anal papilla proximal to fissure
this describes the pathophys for what?
anal fissures
treatment of anal fissure (3) & if non healing (2)
- sitz baths, fiber, fluids
chronic– relax smooth muscle & get more blood flow with: - topical CCB (diltiazem, nifedipine)
- nitroglycerin
if non healing: botox or surgery
- residual redundant skin from past inflammation and thrombosis
- painless
- can be from old thrombosed external hemorrhoids, pregnanct, chrons, etc.
skin tags
- itching caused by irritants, infections, cancer
perianal itching
tx of perianal itching (3)
if at night: benadryl or hydroxyzine
if seepage: cotton ball w/ zinc ointment (desitin)
if ongoing: derm or colorectal referral
- caused by low risk HPV and transmitted via anal sex or other direct skin contact
- asymptomamtic, bleeding w/ defecation, rectal leakage btwn bowel movement, anal pruritis
- strong association btwn perianal and anorectal lesions
condyloma accuminata
tx of condyloma accuminata (4)
- if small– topical cytotoxins (podophyllin, trichloracetic acid)
- topical immunomodulators (imiquimod)
- cryotherapy
- larger– surgical excision and fulguration
f/u every 6-12 mo d/t rik for anal intraepithelial neoplasia or cancer
what is perirectal abcess?
what causes it?
how is it treated?
- infected cavity w/ pus near anus or rectum; often involves anal glands
- etiologies– infection, crohns
- immediate surgery referral for I/D under anesthesia
- swelling, fluctuance, tenderness, induration, erythema
- systemic sx of fever and malaise
- persistent worsening pain
these are sx of what
perirectal abscess
- can progress from abscess- tunnel from infection to external skin
- palpable cord between anus and abscess
- sx– recurrent, progressive pain and increasing size followed by drainage
- induration w/ thin epidermal coveral, drainage, tubelike firmness
perianal fistula
how are perianal fistulas treated?
surgery– fistulotomy, seton placement
