Anorectal Diseases

Any patient with anal/perianal symptoms requires a careful history and physical, including a
digital rectal examination. Other studies such as defecography, manometry, CT scan, MRI,
contrast enema, endoscopy, endoanal ultrasound, or examination under anesthesia may be
required to arrive at an accurate diagnosis.
Hemorrhoids
Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smoothmuscle fibers that are located in the anal canal (see Fig. 29-4). Three hemorrhoidal cushions are
found in the left lateral, right anterior, and right posterior positions. Hemorrhoids are thought to
function as part of the continence mechanism and aid in complete closure of the anal canal at
rest. Because hemorrhoids are a normal part of anorectal anatomy, treatment is only indicated if
they become symptomatic. Excessive straining, increased abdominal pressure, and hard stools
increase venous engorgement of the hemorrhoidal plexus and cause prolapse of hemorrhoidal
tissue. Bleeding, thrombosis, and symptomatic hemorrhoidal prolapse may result.
External hemorrhoids are located distal to the dentate line and are covered with anoderm.
Because the anoderm is richly innervated, thrombosis of an external hemorrhoid may cause
significant pain. It is for this reason that external hemorrhoids should not be ligated or excised
without adequate local anesthetic. A skin tag is redundant fibrotic skin at the anal verge, often
persisting as the residua of a thrombosed external hemorrhoid. Skin tags are often confused with
symptomatic hemorrhoids. External hemorrhoids and skin tags may cause itching and difficulty
with hygiene if they are large. Treatment of external hemorrhoids and skin tags are only
indicated for symptomatic relief.
Internal hemorrhoids are located proximal to the dentate line and covered by insensate anorectal
mucosa. Internal hemorrhoids may prolapse or bleed, but rarely become painful unless they
develop thrombosis and necrosis (usually related to severe prolapse, incarceration, and/or
strangulation). Internal hemorrhoids are graded according to the extent of prolapse. First-degree
hemorrhoids bulge into the anal canal and may prolapse beyond the dentate line on straining.
Second-degree hemorrhoids prolapse through the anus but reduce spontaneously. Third-degree
hemorrhoids prolapse through the anal canal and require manual reduction. Fourth-degree
hemorrhoids prolapse but cannot be reduced and are at risk for strangulation.
Combined internal and external hemorrhoids straddle the dentate line and have characteristics of
both internal and external hemorrhoids. Hemorrhoidectomy often is required for large,
symptomatic, combined hemorrhoids. Postpartum hemorrhoids result from straining during
labor, which results in edema, thrombosis, and/or strangulation. Hemorrhoidectomy is often the
treatment of choice, especially if the patient has had chronic hemorrhoidal symptoms. Portal
hypertension was long thought to increase the risk of hemorrhoidal bleeding because of the
anastomoses between the portal venous system (middle and upper hemorrhoidal plexuses) and
the systemic venous system (inferior rectal plexuses). It is now understood that hemorrhoidal
disease is no more common in patients with portal hypertension than in the normal population.

Rectal varices, however, may occur and may cause hemorrhage in these patients. In general,
rectal varices are best treated by lowering portal venous pressure. Rarely, suture ligation may be
necessary if massive bleeding persists. Surgical hemorrhoidectomy should be avoided in these
patients because of the risk of massive, difficult-to-control variceal bleeding.
Treatment
Medical Therapy
Bleeding from first- and second-degree hemorrhoids often improves with the addition of dietary
fiber, stool softeners, increased fluid intake, and avoidance of straining. Associated pruritus may
often improve with improved hygiene. Many over-the-counter topical medications are desiccants
and are relatively ineffective for treating hemorrhoidal symptoms.
Rubber Band Ligation
Persistent bleeding from first-, second-, and selected third-degree hemorrhoids may be treated by
rubber band ligation.
Mucosa located 1 to 2 cm proximal to the dentate line is grasped and pulled into a rubber band
applier. After firing the ligator, the rubber band strangulates the underlying tissue, causing
scarring and preventing further bleeding or prolapse (Fig. 29-31). In general, only one or two
quadrants are banded per visit. Severe pain will occur if the rubber band is placed at or distal to
the dentate line where sensory nerves are located. Other complications of rubber band ligation
include urinary retention, infection, and bleeding. Urinary retention occurs in approximately 1%
of patients and is more likely if the ligation has inadvertently included a portion of the internal
sphincter. Necrotizing infection is an uncommon but life-threatening complication. Severe pain,
fever, and urinary retention are early signs of infection and should prompt immediate evaluation
of the patient usually with an examination under anesthesia. Treatment includes dbridement of
necrotic tissue, drainage of associated abscesses, and broad-spectrum antibiotics. Bleeding may
occur approximately 7 to 10 days after rubber band ligation, at the time when the ligated pedicle
necroses and sloughs. Bleeding is usually self limited, but persistent hemorrhage may require
examination under anesthesia and suture ligation of the pedicle.

Fig. 29-31.

Rubber band ligation of internal hemorrhoids. The mucosa just proximal to the internal
hemorrhoids is banded.

Infrared Photocoagulation
Infrared photocoagulation is an effective office treatment for small first- and second-degree
hemorrhoids. The instrument is applied to the apex of each hemorrhoid to coagulate the
underlying plexus. All three quadrants may be treated during the same visit. Larger hemorrhoids
and hemorrhoids with a significant amount of prolapse are not effectively treated with this
technique.
Sclerotherapy
The injection of bleeding internal hemorrhoids with sclerosing agents is another effective office
technique for treatment of first-, second-, and some third-degree hemorrhoids. One to 3 mL of a
sclerosing solution (phenol in olive oil, sodium morrhuate, or quinine urea) are injected into the
submucosa of each hemorrhoid. Few complications are associated with sclerotherapy, but
infection and fibrosis have been reported.
Excision of Thrombosed External Hemorrhoids
Acutely thrombosed external hemorrhoids generally cause intense pain and a palpable perianal
mass during the first 24 to 72 hours after thrombosis. The thrombosis can be effectively treated
with an elliptical excision performed in the office under local anesthesia. Because the clot is
usually loculated, simple incision and drainage is rarely effective. After 72 hours, the clot begins
to resorb, and the pain resolves spontaneously. Excision is unnecessary, but sitz baths and
analgesics often are helpful.
Operative Hemorrhoidectomy
A number of surgical procedures have been described for elective resection of symptomatic
hemorrhoids. All are based on decreasing blood flow to the hemorrhoidal plexuses and excising
redundant anoderm and mucosa.
Closed Submucosal Hemorrhoidectomy
The Parks or Ferguson hemorrhoidectomy involves resection of hemorrhoidal tissue and closure
of the wounds with absorbable suture. The procedure may be performed in the prone or
lithotomy position under local, regional, or general anesthesia. The anal canal is examined and an
anal speculum inserted. The hemorrhoid cushions and associated redundant mucosa are
identified and excised using an elliptical incision starting just distal to the anal verge and
extending proximally to the anorectal ring. It is crucial to identify the fibers of the internal
sphincter and carefully brush these away from the dissection to avoid injury to the sphincter. The
apex of the hemorrhoidal plexus is then ligated and the hemorrhoid excised. The wound is then
closed with a running absorbable suture. All three hemorrhoidal cushions may be removed using
this technique; however, care should be taken to avoid resecting a large area of perianal skin to
avoid postoperative anal stenosis (Fig. 29-32).

Fig. 29-32.

Technique of closed submucosal hemorrhoidectomy. A. The patient is in prone jackknife

position. B. A Fansler anoscope is used for exposure. C. A narrow ellipse of anoderm is excised.
D. A submucosal dissection of the hemorrhoidal plexus from the underlying anal sphincter is
performed. E. Redundant mucosa is anchored to the proximal anal canal, and the wound is
closed with a running absorbable suture. F. Additional quadrants are excised to complete the
procedure.

Open Hemorrhoidectomy
This technique, often called the Milligan and Morgan hemorrhoidectomy, follows the same
principles of excision described above in Submucosal Hemorrhoidectomy, but the wounds are
left open and allowed to heal by secondary intention.
Whitehead's Hemorrhoidectomy
Whitehead's hemorrhoidectomy involves circumferential excision of the hemorrhoidal cushions
just proximal to the dentate line. After excision, the rectal mucosa is then advanced and sutured
to the dentate line. Although some surgeons still use the Whitehead hemorrhoidectomy
technique, most have abandoned this approach because of the risk of ectropion (Whitehead's
deformity).
Procedure for Prolapse and Hemorrhoids/Stapled Hemorrhoidectomy
Procedure for prolapse and hemorrhoids (PPH) has been proposed as an alternative surgical
approach. The term PPH has largely replaced stapled hemorrhoidectomy because the procedure
does not involve excision of hemorrhoidal tissue, but instead fixes the redundant mucosa above
the dentate line. PPH removes a short circumferential segment of rectal mucosa proximal to the
dentate line using a circular stapler. This effectively ligates the venules feeding the hemorrhoidal
plexus and fixes redundant mucosa higher in the anal canal. Critics suggest that this technique is
only appropriate for patients with large, bleeding, internal hemorrhoids, and is ineffective in
management of external or combined hemorrhoids. Nevertheless, several recent studies suggest
that this procedure is safe and effective, is associated with less postoperative pain and disability,
and has an equivalent risk of postoperative complications when compared to traditional
hemorrhoidectomy.87,88
Complications of Hemorrhoidectomy
Postoperative pain following excisional hemorrhoidectomy requires analgesia usually with oral

narcotics. NSAIDs, muscle relaxants, topical analgesics, and comfort measures, including sitz
baths, are often useful as well. Urinary retention is a common complication following
hemorrhoidectomy and occurs in 10 to 50% of patients. The risk of urinary retention can be
minimized by limiting intraoperative and perioperative IV fluids, and by providing adequate
analgesia. Pain also can lead to fecal impaction . Risk of impaction may be decreased by
preoperative enemas or a limited mechanical bowel preparation, liberal use of laxatives
postoperatively, and adequate pain control. Although a small amount of bleeding, especially with
bowel movements, is to be expected, massive hemorrhage can occur after hemorrhoidectomy.
Bleeding may occur in the immediate postoperative period (often in the recovery room) as a
result of inadequate ligation of the vascular pedicle. This type of hemorrhage mandates an urgent
return to the operating room where suture ligation of the bleeding vessel will often solve the
problem. Bleeding may also occur 7 to 10 days after hemorrhoidectomy when the necrotic
mucosa overlying the vascular pedicle sloughs. Although some of these patients may be safely
observed, others will require an examination under anesthesia to ligate the bleeding vessel or to
oversew the wounds if no specific site of bleeding is identified. Infection is uncommon after
hemorrhoidectomy; however, necrotizing soft tissue infection can occur with devastating
consequences. Severe pain, fever, and urinary retention may be early signs of infection. If
infection is suspected, an emergent examination under anesthesia, drainage of abscess, and/or
dbridement of all necrotic tissue are required.
Long-term sequelae of hemorrhoidectomy include incontinence, anal stenosis, and ectropion
(Whitehead's deformity). Many patients experience transient incontinence to flatus, but these
symptoms usually are short lived, and few patients have permanent fecal incontinence. Anal
stenosis may result from scarring after extensive resection of perianal skin. Ectropion may occur
after a Whitehead's hemorrhoidectomy. This complication is usually the result of suturing the
rectal mucosa too far distally in the anal canal and can be avoided by ensuring that the mucosa is
sutured at or just above the dentate line.
Anal Fissure