Anus and anal canal
objectives
To understand the anatomy of the anus and anal canaland their relationship to surgical disease and its treatment
To understand the pathology ,clinical presentation ,investigationand treatment of anal canal
To appreciate that anal disaese is common and its treatment tend to be conservative
To understand that too aggresive or inappropriate surgery my render the patient permanently disabled
Surgical anatomy
Anal canal,extend from pelvic floor to the anal verge Internal sphincter .white in color ,and transverse fiber
External sphincter it is a voluntary muscle red fiber
Mucous membrane above dentate line is columnar epithelium ,while below it ,is squamous epithelium, Lymphatic drainage above line drains to post rectal LN while below drains to inguinal LN
Anal fissure
It is an longitudinal ulcer located extend from anal verge to dentate line It associated with skin tag and sentinel papillae Posteriorly located in more than 90% Affect female more than male etiology
Trauma Ischemia Stricture after haemorrhoidectomy Inflammatory bowel disease (crohns disease) Sexually transmitted disease
Clinical features it is common in young age group , it is not rare in children Pain is sharp ,agonizing ,during the act of defecation Bleeding, it is slight,& may appear as streaks might be slight discharge On Ex,we find longitudinal ulcer with skin tage&santenil papillae, PR .Exam,is very painful better to be avoided unless there is special indication
treatment The aim ;is to relax the internal sphincter 1- conservative a-glyceryl trinitrate ointment b-diltiazem )ca channel blocker) c-laxatives
Surgical treatment Lateral sphinctrotomy Anal advancement flap
Pilonidal sinus
It is acquired disease ,due to the act of friction ,the broken hairs accumulate at natal cleft with moisture will induce boil ,this will open a sinus ,for accumulation of hair The negative pressure will suck more hair All these will induce infection
Clinical feature Affect male >female ,at the 3rd decade of life but it is not rare in children Discharging sinus at level of coccyx ,with one or more opening Contains hair tuft in the opening Might be associated infection (abscess)
Treatment 1- CONSERVATIVE a-cleaning of the track and remove hair b- frequent washing c-avoid long period sitting Surgical treatment Acute stage : rest ,antibiotics,wash ,antiseptics, If these doesn t control the condition ,drainage of abscess done Operations 1-open the tracks and suture the skin to the edge of tracks (marsupialization) 2-excise the tracks (sinus area ),homeostasis ,drain and direct closure 3-excise sinus area and packing and followed by daily change dressing &bath till closure by granulation tissue