Professional Documents
Culture Documents
CHAPTER
Anus
Amit Merchea, David W. Larson
OUTLINE
Disorders of the Anal Canal
Pelvic Floor Disorders
Common Benign Anal Disorders
Less Common Benign Anal Disorders
Neoplastic Disorders
Anatomy
The anal canal extends from the anorectal ring at the most distal
aspect of the rectum to the skin of the anal verge and is approximately 4cm in length. The internal and external sphincter muscles
along with the pelvic floor structures contribute significantly to
the regulation of defecation and continence. The anus is bounded
by the coccyx posteriorly, the ischiorectal fossa bilaterally, and the
perineal body and either vagina or urethra anteriorly.
The sphincter apparatus of the anal canal consists of the internal and external sphincters and can be considered as two tubular
structures overlying each other. The circular muscle layer of the
rectum continues distally to form the thickened and rounded
internal sphincter, which terminates approximately 1.5cm below
the dentate line, just cephalad to the external sphincter (intersphincteric groove). The external sphincter is elliptical and surrounds the internal sphincter superiorly and is continuous with
the puborectalis and levator ani muscles (Fig. 52-1). The perineal
body is formed by the constitution of the external sphincter,
bulbospongiosus, and transverse perineal muscles anteriorly. The
paired levator ani muscles form the bulk of the pelvic floor, and
their fibers decussate medially with the contralateral side to fuse
with the perineal body around the prostate or vagina.
The internal sphincter is tonically contracted independent of
voluntary control. It receives innervation by the autonomic
nervous system. The external sphincter, under voluntary control,
Physiology
The process of defecation and maintenance of continence constitute the principal function of the anus. Various factors affect our
ability to effectively achieve these functionsthe coordinated
sensory and muscular activities of the anus and pelvic floor, the
compliance of the rectum, and the consistency, volume, and
timing of the fecal movements are all critical to avoidance of fecal
incontinence or defecatory disorders.
As the external sphincter contracts, the anal canal lengthens.
With straining, it shortens. The internal anal sphincter imparts
the resting pressure (~90cm H2O). Squeeze pressure, generated
by external sphincter contraction, more than doubles resting pressure. The pressure differential between the rectum and anal canal
(low to high) is the principal mechanism that provides continence.
The anorectal angle is the angle between the anal canal and the
rectum. This angle is approximately 75 to 90 degrees at rest and
becomes more obtuse, straightening with straining and evacuation. The ability of the puborectalis to relax and to allow this
straightening of the angle facilitates defecation.
1394
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CHAPTER 52 Anus
Conjoined
longitudinal
muscle
1395
Levator ani
muscle
Rectum
External
sphincter
muscle
Deep
Puborectalis
muscle
Superficial
Subcutaneous
Anal transition
zone
Anoderm
Internal
sphincter muscle
Anal
margin
Anal
verge
FIGURE 52-1 The anal canal musculature and pelvic floor muscles are depicted.
History
It is important to elicit symptoms of pain, bleeding, discharge
(purulent or fecal), and any alteration of bowel habits (frequency,
consistency). Other past medical, social (including sexual), and
family history may be relevant in diagnosing anorectal disease.
Bleeding is among the most common presenting symptoms
of diseases of the anus and large bowel. Specific details about the
nature of the bleeding can help localize the source in the alimentary tract. Blood that drips, is separate from stools, and is bright
red is usually seen with rectal outlet bleeding, as from internal
hemorrhoids. Blood on toilet tissue may be associated with
minor hemorrhoidal disease but also with anal fissure, although
anal fissure is typically accompanied by severe pain at defecation.
Passage of clots or melena may indicate a more proximal source
of bleeding. One must always give consideration to evaluation
of the more proximal bowel to exclude serious conditions, such
as cancer. This should be of prime importance when initial
anorectal examination cannot confirm a bleeding source, when
the patient has greater than average risk of cancer, or when bleeding does not resolve promptly after initiation of appropriate
treatment.
Anal or rectal pain occurring during or immediately after stooling is another common presenting complaint. Severe pain during
defecation, often described by patients as passing glass, is usually
associated with anal fissure. Pain, either with or without defecation, that is throbbing in nature is most often seen with an abscess
or poorly draining fistula. Patients may also complain of purulent,
mucoid, or feculent discharge. A deep-seated rectal pain unrelated
to defecation often characterizes proctalgia fugax or levator ani
syndrome. This is characterized by painful episodes of short duration (<20 to 30 minutes) that are often relieved by walking, warm
baths, or other maneuvers.
Physical Examination
Adequate visualization of the external anal anatomy and the anal
canal by anoscopy requires appropriate positioning of the patient
(either left lateral or, more commonly, prone jackknife) and good
lighting. Skin tags, excoriations, scars, and any changes in color
or appearance of perianal skin should be easily recognized. A
patulous anus may indicate incontinence and possibly prolapse.
Inspection while straining (even with the patient on the commode)
may help differentiate the presence of hemorrhoids from rectal
prolapse. A careful and systematic digital examination allows the
identification of any palpable abnormalities of the anal canal.
Finally, the resting tone and strength of the squeeze pressure of
the anal sphincter can be assessed.
Anoscopy or proctosigmoidoscopy (flexible or rigid) after
enema preparation enables visualization of the anus, rectum, and
left colon. Mucosal inflammation is identified by loss of the
normal vascular pattern with erythema, granularity, friability, and
even ulcerations. Gross lesions (polyps or carcinoma) should be
readily identifiable. Biopsy specimens of any suspicious findings
should be obtained for histologic diagnosis.
Other investigations, such as stool culture, specialized imaging
(ultrasound, magnetic resonance imaging [MRI], defecography),
and specialized physiologic testing, may be helpful adjuncts and
should be obtained as clinically appropriate.
1396
SECTION X Abdomen
occur in 2% to 15% of noninstitutionalized adults.1 Fecal incontinence can have a significant impact on peoples lives, causing
physical discomfort, embarrassment, and social isolation. Furthermore, the financial costs and caregiver burden are substantial with
real risk of underreporting.
Clinical Evaluation
Obtaining a complete medical history and thorough physical
examination is imperative in determining the cause of the fecal
incontinence, which will ultimately guide therapy. Defining the
extent of the incontinence can be accomplished by a simple
historymajor incontinence represented by complete loss of solid
stool, and minor incontinence by occasional staining or seepage.
Mucus seepage from prolapsing hemorrhoids or large secretory
villous polyp, urgency from colitis or proctitis, and overflow
incontinence from fecal impaction may be inappropriately confused with true incontinence. The severity of the incontinence
should be established by assessing the patients control of flatus
and liquid and solid stool and by the impact of symptoms on
quality of life. Numerous scoring systems for fecal incontinence
exist and can help quantify the problem objectively (Table 52-1).
The cause of fecal incontinence is often multifactorial with
combinations of both anatomic and physiologic dysfunctions.
Anatomic defects in the sphincter may be the result of trauma
from previous surgical procedures, impalement, or obstetric injuries. Moreover, physiologic changes may occur from these anatomic changes, over time or directly, that may lead to sphincter
dysfunction, decreased rectal compliance, or decreased sensation.
All of these issues may contribute to or have an impact on the
degree of incontinence even years after the inciting events.
The most common nonanatomic causes of fecal incontinence
should include associated gastrointestinal disorders, such as diarrhea, which can aggravate continence.2 A physical examination
may reveal anatomic abnormalities that account for the incontinence, such as the presence of prolapse, hemorrhoids, or abscess/
fistula. A proper digital rectal examination can highlight a weak
resting tone and squeeze pressure or a patulous anus and the presence of scars, defects, deformities, or keyhole abnormalities.
Endoscopy remains critical to exclude proctitis, impaction, neoplasia, or other rectal mucosal abnormalities that may be contributing factors.
To confirm physical examination findings, the use of focused
diagnostic tests may be required. Anorectal manometry confirms
the extent of impairment of the internal and external sphincters.
Manometry may identify asymmetry, suggesting anatomic defects
amenable to repair. Balloon expulsion testing during manometry
may demonstrate impairments in rectal sensation. Endoanal ultrasound or MRI may also be employed to detect structural defects
of the anal sphincters, rectal wall, and puborectalis muscle.
Treatment
Medical management. Medical management is the initial
option for patients with mild incontinence that may not significantly affect quality of life in patients without a reparable anatomic abnormality. Medications to slow transit, to decrease
frequency, and to increase stool consistency can be used. Biofeedback training uses noninvasive methods to strengthen the anal
musculature and to improve sensation. Nearly 90% of patients
note improvement in quality of life.3 A bowel management
program, including antidiarrheal medications (loperamide),
bulking agents (methylcellulose), and anticholinergic agents
(hyoscyamine), has been successful for some patients.4 Medical
management can also be complementary to surgical therapy and
may be carried out before or after surgery to optimize surgical
results.
Surgical repair. Surgical options range from the traditional
anatomic approaches, such as sphincter repair, to newer techniques like sacral nerve stimulation and the artificial bowel
sphincter. For patients with intractable symptoms or failure of
other therapeutic measures, colostomy remains a definitive cure.
For defined anatomic defects, the most common surgical approach
is the sphincteroplasty, in which the separated muscle ends are
dissected, reapproximated, and sutured. This can be done in an
overlapping fashion or by simply reapproximating the sphincter
(Fig. 52-2).5 The overlapping sphincteroplasty is associated with
low rates of morbidity and mortality and reasonable rates of shortterm success, with good to excellent results achieved in 55% to
68% of patients.6 Long-term results of sphincteroplasty have demonstrated a deterioration of continence over time, with only 40%
having good to excellent control at a median follow-up of 10
years.7
The use of injectable materials for the treatment of fecal incontinence has recently gained attention. In this procedure, a bulking
agent (silicone, collagen, carbon microbeads, or dextranomer
hyaluronic acid) is injected into the intersphincteric space to
augment the internal anal sphincter. There are limited data for
these approaches; however, a single randomized controlled trial
did demonstrate short-term improvement in 50% of patients
undergoing injection with dextranomerhyaluronic acid (Solesta;
Salix Pharmaceuticals, Raleigh, NC).8
More complex approaches to treatment of fecal incontinence
include the dynamic graciloplasty, sacral nerve stimulator, and
artificial bowel sphincter. The use of the gracilis muscle as a flap
encircling the anal canal is reserved for patients in whom the bulk
of the anal sphincter is missing and requires complete reconstruction. Results of graciloplasty have been favorable, with the majority of patients maintaining continence and the ability to defer
defecation at 5 years.9 Sacral nerve stimulation has been traditionally used in patients in whom the anal sphincter is intact but there
NEVER
RARELY
SOMETIMES
USUALLY
ALWAYS
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
From Jorge JM, Wexner SD: Etiology and management of fecal incontinence. Dis Colon Rectum 36:7797, 1993.
Responses are scored and summed. A score of 0 indicates perfect continence, 20 is complete incontinence; rarely, <1/month; sometimes, >1/
month; usually, >1/week; always, >1/day.
CHAPTER 52 Anus
1397
FIGURE 52-2 Overlapping Sphincteroplasty. A, An anterior curvilinear incision is made on the perineum
between the anus and vagina. The disrupted ends of the external sphincter are dissected free, and the
muscle ends are overlapped and reapproximated with suture. A levatorplasty is also concurrently performed.
B, Digital rectal examination can judge for appropriate tightness of the repair. C, The incision is then reapproximated. Some surgeons may leave drains or a small gap in the closure to allow drainage.
is an associated neurologic injury or poor innervation. A prospective multicenter trial demonstrated success rates of up to 85% at
2 years with a decrease in the number of incontinent episodes per
week by approximately 70%.10 More recent investigation has been
conducted to determine its effectiveness in the setting of a defined
anal sphincter defect (<180 degrees); many patients have noted
significant improvement in these settings.11 With increasing use
of sacral nerve stimulation, the use of an artificial bowel sphincter
has been limited. Complications associated with its use are erosion,
infection, and obstruction. A review had demonstrated little
change in the rate of device explantation or infection in spite of
novel surgical techniques and approaches to placement.12 An
algorithm for the treatment of fecal incontinence is presented
(Fig. 52-3).
1398
SECTION X Abdomen
Clinical evaluation
including digital rectal
examination
Mild Incontinence
Nonoperative
Treatment
Severe Incontinence
Biofeedback
Sphincter Defect?
If no improvement,
consider injectables or
SECCA Procedure
Yes
Overlapping
Sphincteroplasty
No
Sacral Nerve
Stimulator
Artificial Bowel
Sphincter
Fecal Diversion
CHAPTER 52 Anus
1399
FIGURE 52-5 Delorme Repair. Mucosal sleeve resection is performed and followed by muscle plication,
anastomosing the proximal mucosal resection site to the distal mucosa, proximal to the dentate. (Courtesy
Mayo Foundation for Medical Education and Research, Rochester, Minn.)
Rectocele
Clinical Evaluation
Rectocele, like sigmoidocele and enterocele, is associated with a
posterior vaginal defect. Symptoms include a vaginal bulge or
prolapse of the anterior rectal wall into the vagina, obstructed
defecation, and, in many cases, the need to digitally compress the
vagina or to digitize the rectum or perineum to evacuate. The
cause of rectocele is likely to be multifactorial as it is often associated with a number of other pelvic floor disorders, including
constipation, paradoxical muscle contraction, and neuropathies
or anatomic disorders from vaginal childbirth.22 A careful rectovaginal examination will reveal the size of the defect where the
rectum prolapse extends to the vagina.
1400
SECTION X Abdomen
Defecography (fluoroscopic or magnetic resonance) can demonstrate dynamic information on rectal emptying. A rectocele is
diagnosed if the distance between the line of the anterior border
of the anal canal and the maximal point of bulge of the anterior
rectal wall into the posterior vaginal wall is more than 2cm. It is
the most useful test for understanding the relevance of the rectocele in the defecation process and for identification of additional
pelvic floor abnormalities.
Treatment
Treatment, when the rectocele is symptomatic, initially involves
the optimization of bowel function through diet, fiber supplementation, and good bowel habits. Nonsurgical therapies include
the use of pessaries and biofeedback. A pessary has been associated
with resolution of prolapse symptoms, but many of these patients
are older and have less severe prolapse. Biofeedback has met with
limited success, providing only partial relief in most patients.23
Surgical treatment. Patients should be considered for surgical
correction if the rectocele is larger than 2cm or the patient has
to digitize the vagina or rectum to assist with defecation. Approach
to surgical repair is through a transvaginal, transperineal, or transanal technique. All repairs can be completed with or without mesh
and may include a levatorplasty. Symptomatic improvement has
been observed in 73% to 79% of properly selected patients. A
newer technique, the stapled transanal rectal resection, has been
investigated for treatment of rectocele associated with internal
rectal prolapse causing obstructed defecation. This procedure uses
two circular staplers, one anteriorly to resect the rectocele and a
second posteriorly to resect the mucosal prolapse. Whereas many
patients note improvement in their symptoms, this has been associated with a high rate of fecal urgency and potential for anal
stenosis.24
First degree
Second degree
Third degree
Fourth degree
Bleeding; no prolapse
Prolapse with spontaneous reduction
Prolapse requiring manual reduction
Prolapsed, cannot be reduced
CHAPTER 52 Anus
1401
E
FIGURE 52-6 Hemorrhoids. A, Thrombosed external. B, Internal, first-degree internal as seen through
anoscope. C, Internal prolapsed and reduced spontaneously, second degree. D, Internal prolapsed, requiring
manual reduction, third degree. E, Inability to be reduced, strangulated, fourth degree. (Courtesy Mayo
Foundation for Medical Education and Research, Rochester, Minn.)
1402
SECTION X Abdomen
FIGURE 52-7 Rubber Band Ligation. The internal hemorrhoid is identified proximal to the dentate line;
the area of proposed banding should be pinched to test for sensation before banding. The hemorrhoid is
drawn into the ligator by use of either forceps or the suction device of a suction ligator. The band is then
placed. (Courtesy Mayo Foundation for Medical Education and Research, Rochester, Minn.)
Anal Fissures
CHAPTER 52 Anus
1403
C
FIGURE 52-9 Closed Hemorrhoidectomy. A, An elliptical incision is made surrounding the hemorrhoidal
tissues, and these are excised from distal to proximal. B, Care is taken to preserve the sphincter muscle.
C, The feeding vascular pedicle at the proximal point is sutured and the defect closed with a running absorbable suture. In the open technique, this excision site is not closed with suture. (Courtesy Mayo Foundation
for Medical Education and Research, Rochester, Minn.)
C
FIGURE 52-10 Procedure for Prolapsed Hemorrhoids. A, Circumferential grade IV hemorrhoids.
B, The stapling device has an obturator that is placed in the internal canal to aid in reduction of tissue and
placement of purse-string suture in the mucosa above the dentate line. C, Stapling device demonstrating
circumferential excision of anal canal and hemorrhoid mucosa.
1404
SECTION X Abdomen
Hemorrhoids
External
Thrombosed
>72 hours
Nonthrombosed
<72 hours
Dietary
modification,
pain control,
sitz baths
Internal
Consider
surgical
excision
Dietary
modification
Grade I
Grade II
1. Diet
2. Banding
1. Diet
2. Banding
3. Excision
Grade III
Grade IV
1. Excision/PPH
2. Banding
1. Excision/PPH
Consider excision
if: large, poor
hygiene, painful
FIGURE 52-11 Algorithm for the treatment of hemorrhoids. PPH, procedure for prolapse and
hemorrhoids.
FIGURE 52-12 Posterior midline anal fissure. (Courtesy Mayo Foundation for Medical Education and Research, Rochester, Minn.)
CHAPTER 52 Anus
1405
Location of
Fissure?
Lateral
Midline
Operative
treatment
Nonoperative
treatment
Topical nitrates,
calcium channel
blockers
Consider, Crohns
disease, TB, syphilis,
HIV/AIDS, cancer, etc
Lateral internal
sphincterotomy
Botulinum toxin
injection
Failure to heal?
Perform examination
under anesthesia,
consider biopsy and
evaluation of sphincter
Hypotonic
sphincter
Consider fissurectomy
with advancement flap
Hypertonic
sphincter
Consider repeated
sphincterotomy
Internal sphincter
External sphincter
1406
SECTION X Abdomen
Supralevator
Intersphincteric
Ischioanal
Submucosal
Perianal
Anorectal Suppuration
The most common cause of anorectal suppuration is nonspecific
cryptoglandular infection. Other less common although not necessarily rare causes include Crohns disease and hidradenitis suppurativa. The abscess represents the acute manifestation and the
fistula the chronic sequela.32
Anorectal abscesses generally originate in the intersphincteric
space. The infectious process may remain isolated within the
intersphincteric space, or it may extend vertically upward or
downward, horizontally, or circumferentially. Abscesses are generally classified into perianal, ischiorectal, intersphincteric, and
supralevator (Fig. 52-15).
Clinical Presentations of Various Types of Abscesses
An intersphincteric abscess is limited to the primary site of origin.
These abscesses may be asymptomatic; however, classically, the
patient will present with pain out of proportion to physical examination findings. Downward extension results in a perianal abscess,
exhibited by a tender swelling at the anal margin.
Upward extension may result in a supralevator abscess. These
abscesses may be difficult to diagnose because the patient may
complain of vague pelvic or anorectal discomfort, and there is a
lack of external manifestations. Supralevator abscesses may also
result from pelvic infectious processes, such as diverticulitis. In
rare instances, these may extend downward into the ischiorectal
or intersphincteric space.
Horizontal spread may traverse the internal sphincter internally into the anal canal or externally across the external sphincter
into the ischiorectal fossa, forming an ischiorectal abscess. These
abscesses may become large as external physical examination findings may be subtle, and the infection may initially or insufficiently
CHAPTER 52 Anus
1407
in Ano
NO!
NO!
45%
30%
Type 1
Type 2
20%
5%
Type 3
Type 4
Counterdrainage
Counterdrainage
External
sphincter muscle
Dentate line
Internal sphincter
muscle (cut)
may result in a devastating and sometimes lethal necrotizing infection of the perineum. In these situations, wide dbridement of
infectious and necrotic tissue is necessary, often combined with
broad-spectrum antibiotics.
Recurrent abscesses may result if there has been inadequate
drainage, presence of a fistula, or underlying immunosuppression.
In this setting, examination under anesthesia may be warranted
after imaging studies of the abdomen or pelvis (e.g., MRI or
computed tomography [CT]) have been obtained. Horseshoe
abscesses result from circumferential spread of the infectious
process. A modified Hanley procedure that drains the deep postanal space and lateral extensions of the abscess should be performed. A posterior midline incision is made extending from the
subcutaneous portion of the external sphincter over the abscess to
the tip of the coccyx, separating the superficial external sphincter
and unroofing the deep postanal space and its lateral extension
(Fig. 52-17). Lateral incisions can be made and setons placed to
drain any anterior extensions of the abscess.
FIGURE 52-18 Fistulas and their relationship to the sphincter apparatus: type 1, intersphincteric; type 2, trans-sphincteric; type 3, suprasphincteric; type 4, extrasphincteric. (From Parks AG, Gordon PH,
Hardcastle JD: A classification of fistula-in-ano. Br J Surg 63:112,
1976.)
Antibiotics and abscess culture have a limited role in the treatment of uncomplicated anal suppuration but should be considered in patients with immunosuppression, systemic illness, or a
history of prolonged and frequent antibiotic use.
Ancillary imaging studies (CT scan, MRI, endoanal ultrasound, fistulography) may have some utility in select cases, but
treatment is generally based on clinical findings. These studies
may be helpful to guide management in patients with complex or
recurrent disease.
Fistula in Ano
Fistula in ano can develop in approximately 40% of patients
during the acute phase of sepsis or even be discovered within 6
months of initial therapy. Fistulas are categorized by the Parks
classification (Box 52-1 and Fig. 52-18).
Clinical Presentations
The most common anal fistula is an intersphincteric fistula. Most
frequently, the fistula traverses directly downward to the anal
margin. In some cases, however, the track may travel upward in
the rectal wall (high blind track), with or without a perineal
opening.
1408
SECTION X Abdomen
Posterior
Transverse
anal
line
A
Anterior
Long. ant. fistula
FIGURE 52-19 Goodsalls Rule. The predicted relationship of internal and external fistula orifices is depicted. The internal opening is
marked A. The long anterior fistula is often an exception to the rule.
(From Schrock TR: Benign and malignant disease of the anorectum. In
Fromm O, editor: Gastrointestinal surgery, New York, 1985, Churchill
Livingstone, p 612.)
track starting from the internal opening and filling the track from
internal to external. A comprehensive review of the literature has
reported that successful fibrin glue injection results are varied and
range from 14% to 60%.32
A bioprosthetic fistula plug is also available to serve as a matrix
for tissue ingrowth and to obliterate the fistula track. It is inserted
into the fistula and then secured at the internal opening. The
external opening is widened and left open to allow drainage. Over
time, tissue will grow into the plug and replace the matrix, obliterating the fistula track. There are limited data about the success
of this approach, but its low morbidity and low risk make it an
attractive option in patients with complex fistulas.
High fistulas or other persistent fistulas may be treated by a
sliding advancement flap made of mucosa, submucosa, and circular muscle to cover the internal opening. Success rates are again
variable, ranging from 13% to 56%, and some patients still report
changes in continence, even though the sphincter is not
violated.32
Finally, a newer technique, ligation of the intersphincteric
fistula track, has been developed (Fig. 52-20). This involves dissection in the intersphincteric plane for identification of the fistula
track and ligation of it to obliterate the communication with the
anal canal. This approach limits risk to the sphincter mechanism
and has shown promise with success rates of 60% to 94%.32
Pilonidal Disease
Pilonidal infections and chronic pilonidal sinuses are usually
found in the midline of the sacrococcygeal region of young hirsute
men. The incidence of disease is approximately 26 per 100,000
population. The presence of hair in the gluteal cleft seems to play
a central role in the pathogenesis of this disease. This is consistent
with the observation that pilonidal disease rarely occurs in those
with less body hair. Other risk factors include obesity, local
trauma, sedentary lifestyle, deep natal cleft, and family history.
Diagnosis is generally a clinical one; patients may present with a
CHAPTER 52 Anus
1409
FIGURE 52-20 Ligation of intersphincteric fistula track. This procedure preserves the sphincter and minimizes any risk of incontinence.
Treatment
Rectovaginal Fistula
Surgical Repair
Before embarking on surgical repair of rectovaginal fistulas, it is
important to consider the underlying disease, size of the fistula,
presence of active inflammation, and severity of symptoms. Small,
low-output fistulas may close spontaneously. However, those associated with inflammatory bowel disease, radiation therapy, or
underlying infection may resolve only with medical or surgical
therapy. High rectovaginal fistulas (upper third of the vagina)
generally require a transabdominal approach, whereas low rectovaginal fistulas can be repaired transvaginally, transrectally, or
transperineally.
An endorectal advancement flap, sphincteroplasty, and transperineal procedures can all be employed for the repair of a truly
low-lying fistula (anovaginal fistula).35 An endorectal advancement
flap consists of a flap of rectal mucosa, submucosa, and underlying
internal anal sphincter muscle that is advanced to cover the primary
opening in the rectum or anus. The flap is best suited for the
initial repair or for patients without an underlying sphincter defect.
The transperineal approach (perineoproctotomy) converts the rectovaginal fistula into a fourth-degree tear. The tissues are then
reapproximated in a normal anatomic fashion with the internal,
external, and levator muscles in discrete layers. This should be
reserved for patients with preexisting sphincter defects for whom
other more conservative approaches have failed.35
For high rectovaginal fistulas, a transabdominal approach is
often required. This approach requires mobilization of the rectovaginal septum, division of the fistula, and subsequent closure of
1410
SECTION X Abdomen
Hidradenitis Suppurativa
Hidradenitis suppurativa primarily involves the intertriginous
skin regions of the axilla, inframammary, groin, perianal, and
perineal areas. Hidradenitis has traditionally been considered the
result of occlusion of apocrine glands by keratotic debris. This
occlusion leads to bacterial proliferation, suppuration, and spread
of inflammation to surrounding subcutaneous tissues. Subcutaneous tracks and pits develop; the infected tissues ultimately become
fibrotic and thickened. Many bacterial organisms have been identified, including Streptococcus milleri, Staphylococcus aureus, Staphylococcus epidermidis, and Staphylococcus hominis.
Clinical Presentation
Perianal hidradenitis can be manifested as early acute or late
chronic, severe form; the condition most commonly is first manifested with an inflammatory, painful nodule. The nodules may
spontaneously regress and then recur or rupture and drain. Fistulas or sinus tracks may ultimately develop that intermittently
release purulent debris. After repeated interventions, dense scarring and fibrosis may develop. The appearance is classic (Fig.
52-21). In rare cases, squamous malignant neoplasms may also be
Organisms
Bacterial
Neisseria gonorrhoeae
Treponema pallidum
Haemophilus ducreyi
Chlamydia spp.
Shigella flexneri
Campylobacter spp.
Viral
Herpes simplex
Human papillomavirus
Molluscum contagiosum
Parasitic
Entamoeba histolytica
Giardia lamblia
Cryptococcus spp.
Isospora belli
CHAPTER 52 Anus
1411
FIGURE 52-22 Perineal Crohns disease. A, Crohns disease fissures demonstrate deep and shaggy edges,
significant ulceration, and abundant granulation tissue. B, Perianal Crohns disease can be complicated by
multiple fistulas and abscesses, complicating treatment and requiring combination surgical and medical
therapy. (Courtesy Mayo Foundation for Medical Education and Research, Rochester, Minn.)
Clinical Presentation
Perianal complications of Crohns disease can affect approximately
40% of patients. In these patients, the presence of perianal disease
is often predicted by the location and activity of more proximal
gastrointestinal disease. The majority (>90%) of patients with
rectal disease will have perianal disease. This is compared with
approximately 40% of patients with isolated colonic disease,
whereas up to 5% of patients with perianal disease will have no
disease in the proximal gastrointestinal tract.38 Those patients
younger than 40 years and nonwhites are also more likely to
1412
SECTION X Abdomen
Clinical Evaluation
Activity Index
ELEMENTS
SCORE
Discharge
None
Minimal mucous
Moderate mucous or purulent
Substantial
Gross fecal soiling
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
Degree of Induration
None
Minimal
Moderate
Substantial
Gross fluctuance/abscess
0
1
2
3
4
NEOPLASTIC DISORDERS
There is a wide spectrum of benign and malignant neoplastic
lesions of the anus. Defining the anatomy of the anal canal is
important in differentiating the appropriate treatment modalities
for various lesions.
The American Joint Commission on Cancer (AJCC) has
defined three anatomic regions in which anal or perianal squamous cell cancer may be manifested: anal canal, perianal, or skin.
Anal canal lesions are defined as those lesions that cannot be
visualized or are incompletely visualized by gentle traction of the
buttocks. Perianal lesions are completely visible and arise within
5cm of the anal opening when the buttocks are gently spread.
Skin lesions are outside of the 5-cm radius.42
Initial assessment should begin with a complete history and physical examination. The extent and duration of the symptoms, such
as bleeding, pain, changes in continence, and weight loss, should
be documented. The perianal area should be closely examined for
changes in the normal skin. Digital rectal examination establishes
tumor location, fixation, and function of the sphincter muscles.
Anoscopy or rigid proctosigmoidoscopy can help determine the
size and relation of the tumor to the dentate line, anal verge, or
anorectal ring. One should also examine for any pathologic
lymphadenopathy. Staging studies investigating for distant disease
include chest, abdominal, and pelvic CT. Pelvic MRI for staging
purposes is encouraged to determine exact tumor size and nodal
involvement. A positron emission tomography scan should be
considered in those with T2 or greater tumors or those with positive nodal involvement.
CHAPTER 52 Anus
1413
FIGURE 52-23 A, Perianal condyloma acuminatum. B, Sharp excision of condyloma. (Courtesy Mayo Foundation for Medical Education and Research, Rochester, Minn.)
1414
SECTION X Abdomen
CHAPTER 52 Anus
TABLE 52-4 TNM Staging Classifications
N0
N0
N0
N0
N1
N1
N1
N0
N1
N2
N3
Any N
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M0
M1
radiation therapy promised to preserve continence, to avoid colostomy, and to offer similar or improved survival.
Nigro was the first to promote radiation therapy with chemotherapy as definitive treatment for squamous cell cancers of the
anal canal. The current protocol includes infusional 5-FU with
mitomycin C and external beam radiation to the pelvis with a
minimum dose of 45 Gy. The inguinal nodes, pelvis, anus, and
perineum should be included in the radiation fields. Patients with
T2 lesions and residual disease after 45 Gy, T3 or T4 tumors, or
node-positive disease are usually treated with an additional 9 to
14 Gy for a total dose of 54 to 59 Gy. In patients treated with
APR for persistent or locally recurrent disease, 5-year actuarial
survival is reported at 57%.46
Despite high success rates with definitive chemoradiotherapy,
15% to 30% of patients will have recurrence or fail to respond
1415
SELECTED REFERENCES
Madoff RD, Mellgren A: One hundred years of rectal prolapse
surgery. Dis Colon Rectum 42:441450, 1999.
A historical perspective of surgery to repair rectal prolapse,
summarizing much of the relevant data.
Nelson RL, Chattopadhyay A, Brooks W, etal: Operative procedures for fissure in ano. Cochrane Database Syst Rev (11):CD002199,
2011.
An evidence-based review of the data on different surgical
approaches to chronic anal fissure.
1416
SECTION X Abdomen
Parks AG, Gordon PH, Hardcastle JD: A classification of fistulain-ano. Br J Surg 63:112, 1976.
A classic description of the anatomy, data, and classification
of anorectal suppurative disease, including abscesses and
fistulas.
Steele SR, Varma MG, Melton GB, etal: Practice parameters for
anal squamous neoplasms. Dis Colon Rectum 55:735749, 2012.
A comprehensive review of diagnostic and treatment issues
pertinent to anal squamous neoplasms.
Tou S, Brown SR, Malik AI, etal: Surgery for complete rectal
prolapse in adults. Cochrane Database Syst Rev (4):CD001758,
2008.
A comprehensive review of the varying techniques for rectal
prolapse repair.
REFERENCES
1. Whitehead WE, Borrud L, Goode PS, etal: Fecal incontinence in US adults: Epidemiology and risk factors. Gastroenterology 137:512517, 517.e1517.e2, 2009.
2. Whitehead WE, Bharucha AE: Diagnosis and treatment of
pelvic floor disorders: Whats new and what to do. Gastroenterology 138:12311235, 1235.e11235.e4, 2010.
3. Heymen S, Scarlett Y, Jones K, etal: Randomized controlled
trial shows biofeedback to be superior to pelvic floor exercises
for fecal incontinence. Dis Colon Rectum 52:17301737,
2009.
4. Omar MI, Alexander CE: Drug treatment for faecal incontinence in adults. Cochrane Database Syst Rev (6):CD002116,
2013.
5. Galandiuk S, Roth LA, Greene QJ: Anal incontinence
sphincter ani repair: Indications, techniques, outcome. Langenbecks Arch Surg 394:425433, 2009.
6. Malouf AJ, Norton CS, Engel AF, etal: Long-term results of
overlapping anterior anal-sphincter repair for obstetric
trauma. Lancet 355:260265, 2000.
7. Oom DM, Gosselink MP, Schouten WR: Anterior sphincteroplasty for fecal incontinence: A single center experience
in the era of sacral neuromodulation. Dis Colon Rectum
52:16811687, 2009.
8. Maeda Y, Laurberg S, Norton C: Perianal injectable bulking
agents as treatment for faecal incontinence in adults. Cochrane
Database Syst Rev (2):CD007959, 2013.
9. Murphy J, Chan CL, Scott SM, etal: Rectal augmentation:
Short- and mid-term evaluation of a novel procedure for
CHAPTER 52 Anus
28. Giordano P, Gravante G, Sorge R, etal: Long-term outcomes
of stapled hemorrhoidopexy vs conventional hemorrhoidectomy: A meta-analysis of randomized controlled trials. Arch
Surg 144:266272, 2009.
29. Nelson RL, Thomas K, Morgan J, etal: Nonsurgical therapy
for anal fissure. Cochrane Database Syst Rev (2):CD003431,
2012.
30. Nelson RL, Chattopadhyay A, Brooks W, etal: Operative
procedures for fissure in ano. Cochrane Database Syst Rev
(11):CD002199, 2011.
31. Garg P, Garg M, Menon GR: Long-term continence disturbance after lateral internal sphincterotomy for chronic anal
fissure: A systematic review and meta-analysis. Colorectal Dis
15:e104e117, 2013.
32. Steele SR, Kumar R, Feingold DL, etal: Practice parameters
for the management of perianal abscess and fistula-in-ano.
Dis Colon Rectum 54:14651474, 2011.
33. Steele SR, Perry WB, Mills S, etal: Practice parameters for
the management of pilonidal disease. Dis Colon Rectum
56:10211027, 2013.
34. Al-Khamis A, McCallum I, King PM, etal: Healing by
primary versus secondary intention after surgical treatment
for pilonidal sinus. Cochrane Database Syst Rev (1):CD006213,
2010.
35. Saclarides TJ: Rectovaginal fistula. Surg Clin North Am
82:12611272, 2002.
36. El-Attar SM, Evans DV: Anal warts, sexually transmitted
diseases, and anorectal conditions associated with human
immunodeficiency virus. Prim Care 26:81100, 1999.
37. Simard EP, Pfeiffer RM, Engels EA: Cumulative incidence of
cancer among individuals with acquired immunodeficiency
syndrome in the United States. Cancer 117:10891096,
2011.
38. Fry RD, Shemesh EI, Kodner IJ, etal: Techniques and results
in the management of anal and perianal Crohns disease. Surg
Gynecol Obstet 168:4248, 1989.
39. Irvine EJ: Usual therapy improves perianal Crohns disease as
measured by a new disease activity index. McMaster IBD
Study Group. J Clin Gastroenterol 20:2732, 1995.
1417
40. Poupardin C, Lemann M, Gendre JP, etal: Efficacy of infliximab in Crohns disease. Results of a retrospective multicenter
study with a 15-month follow-up. Gastroenterol Clin Biol
30:247252, 2006.
41. Schwartz DA, Pemberton JH, Sandborn WJ: Diagnosis and
treatment of perianal fistulas in Crohn disease. Ann Intern
Med 135:906918, 2001.
42. Edge SB, Compton CC: The American Joint Committee on
Cancer: The 7th edition of the AJCC cancer staging manual
and the future of TNM. Ann Surg Oncol 17:14711474,
2010.
43. Steele SR, Varma MG, Melton GB, etal: Practice parameters
for anal squamous neoplasms. Dis Colon Rectum 55:735749,
2012.
44. Margenthaler JA, Dietz DW, Mutch MG, etal: Outcomes,
risk of other malignancies, and need for formal mapping
procedures in patients with perianal Bowens disease. Dis
Colon Rectum 47:16551660, discussion 16601661,
2004.
45. McCarter MD, Quan SH, Busam K, etal: Long-term
outcome of perianal Pagets disease. Dis Colon Rectum 46:
612616, 2003.
46. Mariani P, Ghanneme A, De la Rochefordiere A, etal:
Abdominoperineal resection for anal cancer. Dis Colon
Rectum 51:14951501, 2008.
47. Gunderson LL, Winter KA, Ajani JA, etal: Long-term
update of US GI intergroup RTOG 98-11 phase III trial for
anal carcinoma: Survival, relapse, and colostomy failure with
concurrent chemoradiation involving fluorouracil/mitomycin
versus fluorouracil/cisplatin. J Clin Oncol 30:43444351,
2012.
48. Gervaz P, Buchs N, Morel P: Diagnosis and management of
anal cancer. Curr Gastroenterol Rep 10:502506, 2008.
49. Podnos YD, Tsai NC, Smith D, etal: Factors affecting survival in patients with anal melanoma. Am Surg 72:917920,
2006.
50. Chang GJ, Gonzalez RJ, Skibber JM, etal: A twenty-year
experience with adenocarcinoma of the anal canal. Dis Colon
Rectum 52:13751380, 2009.