ANAL PAIN JAMES FRANCOMBE CONSULTANT COLORECTAL SURGEON WARWICK HOSPITAL ANAL PAIN •RELATIVELY COMMON •SEE OFTEN IN CLINICS •SEE OFTEN AS EMERGENCY •TREATMENT PERCEIVED EASY •TREATMENT CAN BE DIFFICULT •OUTCOME VARIABLE ANAL PAIN AETIOLOGY • FISSURE IN ANO •ABSCESS/SEPSIS/FISTULA •TRAUMATIC •NEOPLASTIC •THROMBOSED HAEMORRHOIDS •THROMBOSED PERIANAL HAEMATOMA •RECTO-ANAL INTUSSUSCEPTION HAEMORRHOIDS DO NOT CAUSE PAIN ....... UNLESS THROMBOSED THEY ITCH, FEEL SWOLLEN, UNCOMFORTABLE, ANGRY, FLARE UP BUT THEY DO NOT CAUSE PAIN UNLESS THROMBOSED THROMBOSED HAEMORRHOIDS PAIN RELIEF LAXATIVES SPHINCTER RELAXATION ( ANOHEAL/GTN) ‘THE FROZEN FINGER’ IF ALL ELSE FAILS SURGICAL EXCISION THROMBOSED PERIANAL HAEMATOMA THROMBOSED PERIANAL HAEMATOMA  PAINFUL  ACUTE ONSET  MAY HAVE BEEN STRAINING/COUGHING PROLONGED SITTING  SPONTANEOUS THROMBOSED PERIANAL HAEMATOMA TREATMENT  ANALGESIA  ANOHEAL  LAXATIVES  ICE-PACK USUALLY RESOLVE SPONTANEOUSLY THROMBOSED PERIANAL HAEMATOMA TREATMENT SURGICAL IF MEDICAL FAILS  INCISE AND DRAIN LA (SKIN TAGS)  EXCISE ?GA (NO TAGS) FISSURE IN ANO •COMMON •PAINFUL DEFECATION ‘PASSING GLASS’ •BLOOD SPOTS AND DRIPS •INTERMITTENT •PAIN  AFTER 1-2 HOURS •OFTEN CONSTIPATED ‘HARD MOTION’ FISSURE IN ANO ISCHAEMIC ULCER -USUALLY POSTERIOR SPHINCTER SPASM - POOR BLOOD SUPPLY NATURALLY SLOW TO HEAL DUE TO ABOVE FISSURE IN ANO TREATMENT DECREASE PAIN -LIGNOCAINE GEL REGULATE BOWELS -LAXATIVE SPHINCTEROTOMY -CHEMICAL -SURGICAL FISSURE IN ANO SPHINCTEROTOMY -CHEMICAL •DILTIAZEM 2% TOPICAL BD 6 WEEKS •RCT BETTER THAN GTN (LESS SIDE EFFECTS) •BOTOX INJECTIONS •HEALS 75% AT 6 WEEKS •RELAPSE MAY BE HIGH FISSURE IN ANO SPHINCTEROTOMY -SURGICAL BEWARE OF WOMEN POST CHILD BIRTH FAILED MEDICAL /BOTOX TREATMENT TAILORED SPHINCTEROTOMY OPEN IF POSSIBLE UPTO 10% GAS INCONTINENCE-USUALLY TEMPORARY. FISSURE IN ANO POOR MEDICAL RESPONSE TO TREATMENT SENTINEL TAG LONG HISTORY >6 MONTHS FIBRES OF IAS EXPOSED ABSCESS •COMMON •EMERGENCY •CRYPTOGLANDULAR THEORY OF ORIGIN •PERCEIVED ‘JUST AN ABSCESS’ •USUALLY LEFT TO JUNIOR SURGEON •POOR OPERATION ABSCESS •ACUTE SITUATION •INCISE AND DRAIN •BIOPSY SKIN (?CROHNS) •RIGID SIG AND PROCTOSCOPY(?CA ?FISTULA) •PACK GENTLY (IF AT ALL –NEW EVIDENCE) FISTULA •ABNORMAL CONNECTION BETWEEN 2 EPITHELIASED SURFACES. A TUNNEL •DEVELOP FROM ABSCESS (25% FORM FISTULA) •DISCHARGE INTERMITTENTLY PRECEDED BY PAIN FISTULA CLASSIFICATION INTERSPHINTERIC TRANS-SPHINCTERIC SUPRALEVATOR EXTRASPHINCTERIC +/- SECONDARY TRACTS/HORSESHOE FISTULA TREATMENT INTER-SPHINTERIC LAY OPEN TRANS-SPHINCTERIC LOW -LAY OPEN HIGH -SETON/FLAP/PLUG FISTULA TREATMENT TO CURE MEANS TO CUT OPEN TO CUT OPEN MEANS TO CUT SPHINCTER CUT SPHINCTER CUTS CONTINENCE MORE YOU CUT THE MORE THEY LOOSE CONTINENCE DECREASES WITH AGE FUNCTIONAL LENGTH OF FEMALE ANAL SPHINCTER APPROX 2 CM. CUT 6MM THEN 30% OF SPHINCTER CUT ----CHANCE INCONTINENCE APPROX 30% ANAL ANATOMY NEOPLASTIC USUALLY SQUAMOUS CELL CA HOWEVER VARIETY MELANOMA, LOW RECTAL CA CLEAR CELL CA RARIETIES TRAUMATIC  SELF INDUCED-SEXUAL GAMES  INFLICTED- TRUE TRAUMA EITHER RTA, CHILDBIRTH, IMPALEMENT STUPIDITY-USUALLY WHILST UNDER THE INFLUENCE!!!!!!! RECTOANAL INTUSSUSCEPTION  VERY EARLY PROLAPSE  RECTUM TELESCOPES INTO ANAL CANAL  MAY SEE ON SIGMOIDOSCOPY  SEEN ON DEF. PROCTOGRAM  MAY LEAD TO COMPLETE PROLAPSE  CAN CAUSE PAIN,OFTEN MULTIPLE INVESTIGATIONS-ALL NORMAL RECTOANAL INTUSSUSCEPTION TREATMENT  BIOFEEDBACK  DEFECATORY DYNAMIC RETRAINING  LAPAROSCOPIC ANTERIOR RECTOPEXY