There is pain usually on defecation that prevents proper sitting and causes immobility(commonly due to abscess, thrombosed haemorrhoids, or acute fissure-in-ano). Painless bleeding is commonly due to haemorrhoids but may be due to colorectal carcinoma.
A patient with a perianal mass complains of feeling a mass(usually prolapsed haemorrhoids or anal tags) or has anal discharge that is associated with itching and is commonly associated with tumours, proctitis,and helminithic infestations. Perineal discharge, on the other hand, is usually due to fistula and is common in obese people.
A thorough examination of the patient with digital rectal examination are critical for identifying the cause of anal incontinence. The following have been associated with anal incontinence:
- Congenital abnormalities.
- Trauma to the sphincters and anorectal ring, injuring them(obstetric, operative, abuse and accidental).
- Neurological abnormalities (due to spinal cord disease).
- Anorectal disease(rectal prolapse, third degree haemorrhoids and anorectal
- Thoroughly examine the patient locally.
- Do a rectal examination using a proctoscope.
- Is that a predisposing condition?
- Management as per the primary cause.
- Refer to the appropriate level facility according to the primary pathology if not able to manage at the present level.
Rectal prolapse may be partial(mucosal) or complete(whole thickness of rectal wall). It is a common occurrence in children and the elderly(especially females, who form 85% of the affected adult population) but may occur at any age.
Clinically there are three types, categorized as follows:
- Primary prolapse with spontaneous reduction.
- Secondary prolapse with manual reduction
- Tertiary prolapse that is irreducible.
Most patients present with reducible prolapse, which often occurs during defecation and is associated with discomfort, bleeding, and mucus discharge.Prolapse may also be caused by mild exertion(e.g., through coughing or walking) and may also be associated with incontinence as flatus and feaces. When uterine prolapse compounds rectal prolapse, urinary incontinence may be a feature.
Rectal prolapse is also associated with bening prostatic hypertrophy,constipation,malnutrition, old age, and homosexuality/anal intercourse. Anorectal carcinomas should always be suspected if there are also ulcers, indurations, or masses in this area. During clinical examination it is important to check for patulous anus and for poor sphincter tone (on digital examination).
- Refer all suspected patients to levels 5 and 6 for appropriate management if at level 4.
- May be conservative or operative, depending on the patient. (Refer to surgical texts)
- Primary and secondary prolapse: conservative treatment with stool softeners, e.g., lactulose 15ml 12 hourly.
- Tertiary prolapse-Refer for definitive surgery.
- Complications include irreducibility of the prolapse with ulceration, bleeding, gangrene, and possible rapture of the bowel.
This is a common condition especially in males. Causal factors include skin conditions(psoriasis, lichen planus, contact eczema), infective conditions(candidiasis,threadworms), anal-rectal conditions(piles,fissures, fistula,proctatis, polyps), neoplastic disease, anal warts, GIT conditions(irritable bowel syndrome, ulcerative colitis, etc.), drugs (quidine, colchicine), and obesity.
- Treatment is that of the cause.
- Improved personal hygiene for those affected.
FISSURE IN ANO
This is an elongated longitudinal ulcer of the lower anal canal. The commonest site is the midline posteriorly, followed by midline anteriorly.
This condition occurs in children, but is more common in females in their midlife. It is uncommon in the eldrely. The affected individual experiences pain during defecation that is often intense, may last for an hour or more, but subsides only to come again during the next defecation. The patient is reluctant to open bowels because of the pain and tends to be constipated. The stool is frequently streaked with fresh blood and a slight discharge occurs in chronic cases. A sentinel tag is usually demonstrated, with a tightly closed puckered anus.
Digital rectal examination and proctoscopy are painful, and can be performed at examination under anaesthesia(EUA).
NB:It is important to consider carcinoma of the anus,anal chancre, tuberculosis ulcer(whose edges are undermined), and protalgia fugax as important differential diagnoses that must be ruled out.
- Anaesthetic+anti-inflammatory ointments(3-4 times a day) or suppositories may be tried. Avoid use of more than 1 week consecutively.
- Some heal spontaneously.
- Stool softeners, diet, saline sitz bath
- Operative treatment is recommended for cases refractory to conservative treatment.
These are varicosities of the haemorrhoidal plexus of ten complicated by inflammation, thrombosis, and bleeding. Haemorrhoids are not commonly associated with pregnancy.
There is painless rectal bleeding and prolapse or sensation of a mass in the anal area(especially during defecation). With mucous anal dicharge. Appropriate assessment is digital examination and proctoscopy(use good light). Haemorrhoids may be complicated by thrombosis, infection, and profuse bleeding, all of which require surgical intervention for appropriate management.
- Advise a high residue diet or bulk laxative to prevent constipation
- Specific treatment includes:
- Rubber-band ligation for 2-3 degrees haemorrhoids
- Manual anal dilatatioons
- Injection sclerotherapy.
- Haemorrhoidectomy (for 2-3 degrees piles) where other methods have failed
- Management of associated complications.
There are four types of abscess: submucosal, subcutaneous(perianal), ischiorectal, and high intramuscular. Usually there is no apparent cause, but certain underlying diseases such as Crohn’s disease, ulcerative colitis, rectal cancer, HIV disease, diabetes mellitus, and active tuberculosis may be present.
Presents as acute painful swelling with flactuation not always obvious and there is pain on defecation and blood-stained purulent anal discharge. Complications for anorectal abscesses include, fistula formation, recurrence of the abcess, and sinus formation.
- Give tabs diclofenac 50mg 8 hourly or ibuprofen 400mg 8 hourly for the appropriate duration.
- Incise and drain under general anaesthesia(de-roof by making a cruciate incision and excising the four triangles of the skin).
- Take a pus swab for culture and sensitivity.
- Advise saline sitz bath and stool softeners.
Rectal trauma may be caused by assault, road accidents, birth trauma, and sexual assault.
Patients present with pain, bleeding, and purulent rectal discharge. Critical findings include anal laceration, feature of peritonitis, and fever with or without foreign bodies in the rectum.
- Address the primary problem.
- For mild to moderate cases, manage conservatively, which includes:
- Administration of antibiotics like metronidazole 400mg 0rally 8 hourly and cefuroxime 750mg IV 8 hourly.
- Salin sitz bath and analgesics.
- Diclofenac 50mg orally 8 hourly or ibuprofen 400mg orally 8 hourly.
- For severe cases, carry out surgical interventions.
- Provide counseling and other support services of the patient as needed.
FISTULA IN ANO
This condition may complicate anorectal abcesses, crohn’s disease, ulcerative colitis, tuberculosis, colloid carcinoma of the rectum, LGV, and HIV infections.The types of fistula in ano are subcutenous(anus to skin), submucous, low anal(open below the anorectal ring),high anal, and pelvirectal.
There is persistent seropurulent discharge, periodic poain and pouting openings in the neighbourhood of the anal verge. Appropriate examination involvespalpating the anal inetrnal opening for a nodule on digital examination; confirmation is made at proctoscopy.
- Determine the primary pathology.
- Deal with the primary pathology as well as the fistula.
DISTAL COLON AND RECTAL CARCINOMA
Distal colon and rectal carcinoma is especially found in the elderly patients, presenting with rectal bleeding,change in bowel habits, and sometimes with abdominal or pelvic pain or even intestinal obstruction. It is important to rule out familiar conditions in the family history. Clinical examination for patients suspected to have distal colon and rectal carcinoma should include rectal examination.
- Proctoscopy, colonoscopy, and biopsy.
- Investigation for spread includes:
- Ultrasound scans and
- Where available laparoscopy.
- If at level 4, refer urgently to level 5 and 6 for appropriate management
- Carry out curative or palliative surgical intervention.
- An abscess formation is the culmination of an uncontrolled localized infection.
- There is tissue necrosis with liquefaction(pus formation).
Can be carried out at all levels with referral to higher level for more complicated abscesses or those requiring general anaesthesia. Caution should be exercised for special abscesses like mastoid abscess, as simple incision and drainage of these can result in severe injury or in chronic sinuses. Such sinuses should be referred to a higher level for appropriate management.
- Incision and drainage.
- Use anaesthesia lignocaine 2%
- An abscess needs incision and drainage. Fluctuation may be absent in deep abscess.
- Technique of incision and drainage involves:
- Prepare the area by cleaning and draping.
- Test using a needle to aspirate pus if not already done.
- Make an incision into the soft part of the abscess. Insert finger into the cavity and break all the loculi(pockets)of pus to leave a common cavity for drainage. Leave a wick of gauze(Vaseline)to facilitate drainage.
- Breast abscess may require counter incisions, leaving in a corrugated drain for about 24 hours.
- See(ENT section for management of mastoid abscesses).
- The wound(s) is/are allowed to heal by granulation.
- Hand and foot abscesses will require general anaesthesia. They require days to weeks of sitz baths before they heal. Ask the patients to add3 to 4 tablespoons of salt to the water.
- Recurrent perianal and ischiorectal abscesses necessitate proctosigmoidoscopy to rule ouit analfissures and fistulae. Recurrence may also be seen in patients with immune suppression, tuberculosis, inflammatory bowel diseases, and amongst homosexuals.
- Antibiotics are indicated in hand abscesses as per sensitivity and culture report. Other abscesses may or may not need antibiotics depending on the presence or absence of local cellulitis.
- Face abscesses require antibiotic cover. Flucloxacillin 250mg 8 hourly+metronidazole 500mg 8 hourly for 5 days.
- Always send specimens of pus(and where possible abscess wall) for culture and sensitivity and histological exam.