Rectal Disorders Victor Politi, M.D., FACP Medical Director, SVCMC School of Allied Health Physician Assistant Program

Anatomy The rectum is the lower 10 to 15 cm of the large intestine. The anatomic anal canal is the outlet of the digestive system. It is a tube about 3.8 cm long running from the perianal skin of the buttocks to the mucosal lining of the rectum.

Anatomy Its external opening is the anus, which is tightly shut except during stool evacuation by two strong but sensitive rings of muscles: the internal sphincter and external sphincter.

The action of the internal sphincter is controlled subconsciously (it is always contracted to prevent accidental loss of stool), whereas the action of the external sphincter is voluntary. Anatomy

The sphincters are well supplied with blood vessels and nerves. Where the anal canal meets the rectum there is a ring of folds called the dentate line. Among these folds are the anal crypts, small tube-like depressions opening into the anal canal. Anatomy

The dentate line delineates where nerve fibers end. Above this line, this area is relatively insensitive to pain. Below the dentate line, the anal canal and anus are extremely sensitive. Anatomy

The veins from the rectum and anus drain into the portal vein, which leads to the liver, and then into the general circulation. The lymph vessels of the rectum drain into lymph nodes in the lower abdomen; those of the anus drain into the lymph nodes in the groin.

Rectal Exam Inspect the skin around the anus for any abnormality. With a gloved finger, probe the rectum. For women, this is often done along with a manual examination of the vagina.

Rectal Exam An anoscope or proctoscope (a 3- to 10-inch rigid viewing tube) can also be used. A sigmoidoscope (a longer, flexible tube) can observe as much as 2 or more feet of the large intestine. An anoscopy or sigmoidoscopy is generally uncomfortable but not painful; however, if the area in or around the anus proves to be painful because of an abnormal condition, a local, regional, or even general anesthetic may be given before examination proceeds.

Rectal Exam Sometimes a cleansing enema to rid the lower part of the large intestine of stool is given before sigmoidoscopy. Tissue and stool samples for microscopic examination and cultures may be obtained during sigmoidoscopy. A barium enema x-ray may also be performed.

The Lower Digestive Tract

Hemorrhoids Hemorrhoids are dilated, twisted (varicose) veins located in the wall of the rectum and anus.

Hemorrhoids occur when the veins in the rectum or anus become enlarged; they may eventually bleed. Hemorrhoids may also become inflamed or may develop a blood clot (thrombus).

Hemorrhoids that form above the boundary between the rectum and anus (anorectal junction) are called internal hemorrhoids. Those that form below the anorectal junction are called external hemorrhoids. Both internal and external hemorrhoids may remain in the anus or protrude outside the anus.

Hemorrhoids Cushions of vascular tissue found within the anal canal - when examined microscopically, lack a muscular wall The lack of muscular wall characterizes these vascular structures more as sinusoids and not veins

Hemorrhoidal bleeding is actually arterial - although many still call it venous bleeding Hemorrhage from disrupted hemorrhoids occurs from presinusoidal arterioles Hemorrhoidal tissue is thought to contribute to anal continence and functions as a compressible lining that provides complete closure of the anus

The main cushions are primarily found anatomically in the left lateral, right anterolateral, and right posterolateral positions, with smaller accessory cushions in other quadrants

Etiology Most common cause - constipation Prolonged straining Pregnancy Heredity Increased intra-abdominal pressure Aging (due to thinning of supportive tissue)

The Liver and Hemorrhoids Look at the venous return for the external and internal hemorrhoidal veins External - systemic Internal - portal

Classification Internal Hemorrhoid –Whenever the internal hemorrhoidal plexus is enlarged, there is associated increase in supporting tissue mass with resultant venous swelling External Hemorrhoid –The veins in the external hemorrhoidal plexus become enlarged or thrombosed, the resultant bluish mass is called an external hemorrhoid

Internal / External Hemorrhoid

Classification Both types of hemorrhoids are very common and are associated with increased hydrostatic pressure in the portal venous system such as during pregnancy, straining at stool, or with cirrhosis

Classification Internal vs. external External are distal to the dentate line Internal are proximal to the dentate line –Internal hemorrhoids are further sub-classified by their physical characteristics

Classification of Internal Hemorrhoids Grade I –Seen on anoscopy, may bulge a short way into anal canal; does not extend below dentate line Grade II –Prolapses out of anal canal with straining or defecation; reduces spontaneously Grade III –Prolapses out of anal canal with straining or defecation; reduces manually Grade IV –Irreducible;may strangulate

Generalized Symptoms Bleeding on stool or in toilet Mucosal protrusion Discharge Soiled underwear - due to internal Sensation of incomplete evacuation

Generalized Symptoms Hemorrhoids are painless unless thrombosed Bleeding from internal hemorrhoids is bright red - from external - darker

Symptoms - Internal Hemorrhoids When internal hemorrhoids enlarge pain is not a usual feature until complicated by thrombosis, infection, or erosion of the overlying mucosal surface Most persons complain of bright red blood on the toilet tissue, or coating the stool, with a feeling of vague anal discomfort

Symptoms - Internal Hemorrhoids The discomfort is increased when the hemorrhoid enlarges or prolapses through the anus Prolapse is often accompanied by edema and sphincteric spasm Prolapse, if not treated, usually becomes chronic as the muscularis stays stretched - the patient c/o constant soiling of underwear and very little pain

Symptoms - Internal Hemorrhoids Prolapsed hemorrhoids may become infected or thrombosed; the overlying mucous membrane may bleed profusely as the result of trauma of defecation

Prolapsed Hemorrhoid

Symptoms - external hemorrhoids External hemorrhoids, because they lie under the skin are usually very painful Result in tender blue swelling at the anal verge due to thrombosis of a vein in the external plexus - need not be associated with enlargement of the internal veins Spasm often occurs since the thrombus usually lies at the level of the sphincteric muscles

Diagnosis The diagnosis of internal or external hemorrhoids is made by –inspection –digital exam –direct vision through the anoscope & proctosocpe

Diagnosis Exam- –Prone, jack-knife position or lateral Sims position –Location of the hemorrhoids should be described according to their anatomic position –Visual inspection –DRE- digital rectal exam

Diagnosis Since hemorrhoids are very common, they must not be regarded as the cause of rectal bleeding or chronic hypochromic anemia until a through investigation has been made of the more proximal GI tract Acute blood loss can occasionally be attributed to internal hemorrhoids Chronic anemia in the presence of a large but not bleeding hemorrhoid should provoke a search for a poly, cancer or ulcer

Treatment Treatment includes medical as well as surgical modalities With medical therapy, bleeding and pain usually improve over a 6 week period

Treatment Most hemorrhoids respond to conservative therapy such as sitz baths or other forms of moist heat, suppositories, stool softeners, and bed rest

Medical Therapy Stool bulking agent –Psyllium –Methylcellulose Sitz baths –probably most effective topical treatment for relief of symptoms

Treatment Internal hemorrhoids that remain permanently prolapsed are best treated surgically; milder degrees of prolapse or enlargement with pruritus ani or intermittent bleeding can be successfully handled by banding or injection of sclerosing solutions

Treatment External hemorrhoids which become acutely thrombosed are treated by incision, extraction of the clot, and compression of the incised area following clot removal No surgical procedure should be carried out in the presence of acute inflammation of the anus, ulcerative proctitis, or ulcerative colitis

Treatment Both proctoscopy and barium enema should always be performed before a patient is subjected to hemorrhoidectomy

Surgical Therapy Rubber Band Ligation –One of most widely used techniques –Approximately 5-7 days after procedure the banded tissue sloughs-off Infrared Photocoagulation –Laser not often used Sclerotherapy –Phenol 5% –Sodium tetradecyl sulfate

Surgical Therapy Operative hemorrhoidectomy –Indicated for patients with symptomatic combined internal and external hemorrhoids

Anal Inflammation Perianal inflammatory lesions may be primary or may be associated with inflammatory bowel disease or diverticular disease Anal fissures are superficial erosions of the anal canal which usually heal rapidly with conservative therapy

Anal Inflammation Anal ulcers are more chronic and deep and give symptoms largely as the result of painful spasm of the external anal sphincter during and after defecation Bleeding may occur with either fissure or ulcer Healing of the ulcer is often associated with a hypertrophied anal papilla and some degrees of anal contracture

Anal Inflammation Fistula in ano, a tract leading from the rectal lumen to the perianal skin, usually results from local crypt abscesses –fewer than 5% of these lesions found in the US are due to TB or cancer –The fistula is a chronically inflamed canal made up of fibrous tissue surrounding granulation tissue

Anal Inflammation Perirectal abscesses often represent the tracking down of purulent material escaping form the rectosigmoid; diverticulitis, Crohns disease, ulcerative colitis, or previous surgery may be the underlying cause

Anal Inflammation Fistulas between the rectum and vagina or rectum and the bladder represent serious complications of granulomatous, septic, or malignant disorders and require the patient to be hospitalized for definitive diagnostic and therapeutic procedures

Anal Fissures A tear in the anoderm below the mucocutaneous junction (dentate line) In most cases, the fissure is located over the posterior midline –however, it can occur over the anterior midline, particularly in females

Diagnosis Best made by careful history and gentle examination Most distinctive symptom - pain - associated with bowel evacuation, described as sharp or knifelike, lasting minutes or hours afterward Bleeding is minor

Pathogenesis Repeated trauma to the anal canal (including, but not limited to, large stools) Theory of ischemia to posterior commissure

Physical Exam Lateral decubitus position Gentle spreading of the buttocks show the characteristic tear –Telltale sign - is that the mere spreading of the buttocks causes a great deal of discomfort, accompanied by obvious anal spasm Sentinel tag is often indicative of a chronic anal fissure

Three Types of Fissures 1st Type (most benign) –Healthy individual –First time –No internal sphincter hypertrophy 2nd Type –Pain with defecation –Deep –History of bowel irregularily –High-strung personality

Three Types of Fissures 3rd Type –Long history of recurrent anorectal discomfort –Fibrotic sentinel tag and hypertrophied anal papilla, posterior midline scarring, and anal stenosis In the 2nd and 3rd types, patients are typically afraid to go to the bathroom

Medical Treatment Fiber Water Sitz baths 0.2% nitroglycerin paste on peri-anal area 3-4 times a day

Medical Treatment For patients with recurrent fissure with marked internal sphincter hypertrophy and spams, as well as chronic changes such as sentinel tag, hypertrophied anal papilla, posterior midline anal scarring or even anal stenosis, medial management is unlikely to succeed.

Surgical Treatment Lateral internal sphincterotomy –the most important complication to avoid is incontinence. The rate has been quoted to be as high as 36%

Anal Itching Itchy skin around the anus (pruritus ani) can have many causes, including skin disorders such as psoriasis and atopic dermatitis, diseases such as diabetes or liver disease, anal disorders such as skin tags or draining fistulas, and cancers such as Bowen's disease.

Allergic reactions such as contact dermatitis caused by anesthetic preparations applied to the skin, various ointments, or chemicals used in soap are another cause. Infections with fungi, bacteria, or parasites (such as pinworms and, less commonly, scabies or lice) can produce anal itching. Itching can also be a side effect of antibiotics, especially tetracycline. Anal Itching

Spices, citrus fruits, coffee, beer, and cola as well as vitamin C tablets can cause irritation of the anus when they are expelled in feces, causing itching. Anal Itching

Poor hygiene that leaves stool residue (especially in people with large external hemorrhoids) or overly meticulous hygiene with excessive rubbing and use of soap can also lead to irritation and itching. Anal Itching

Excessive sweating because of pantyhose, tight underwear (especially non-cotton underwear), obesity, or hot weather may be a factor. Anal Itching

Anal Itching - Tx After bowel movements, the anal area should be cleaned with absorbent cotton or soft, plain toilet or facial tissue, which may be moistened with warm water. Dusting with cornstarch or a small amount of talc may combat moisture.

Corticosteroid creams, antifungal creams such as miconazole, or soothing suppositories may be used. Anal Itching - Tx

Anorectal Abscess An anorectal abscess is a pus-filled cavity caused by bacteria invading a mucus- secreting gland in the anus and rectum

An abscess may be deep in the rectum or close to the opening of the anus. An abscess develops when bacteria invade a mucus-secreting gland in the anus or rectum, where they multiply Anorectal Abscess

Although the anus is an area that is rich in bacteria, infection generally does not occur because the internal sphincter acts as a barrier and blood flow to the area is rich. Anorectal Abscess

When infection does occur, it usually is caused by a combination of different types of bacteria. An abscess can cause substantial damage to nearby tissues and may lead to incontinence of stool. Anorectal Abscess

Abscesses just under the skin can be swollen, red, tender, and very painful. Abscesses higher in the rectum often cause fewer symptoms but may produce fever and pain in the lower abdomen. Anorectal Abscess

If an abscess is in the skin around the anus it can be directly visualized. When no external swelling or redness is seen, diagnosis is made by DRE. A tender swelling in the rectum indicates an abscess. Anorectal Abscess

Antibiotics have limited value except for people who have a fever, diabetes, or an infection elsewhere in the body. Usually, treatment consists of if I/D after a local anesthetic has been given. Anorectal Abscess

Even with proper treatment, in about 2/3 of people, an abscess leads to the formation of an anorectal fistula. Anorectal Abscess

Anal Cancer Anal cancers occur most commonly in individuals with a prior history of chronic anal irritation. Such irritation may result from condylomata acuminata (ie, viral lesions thought to be caused by papilloma virus infection), perianal fissures and/or fistulas, chronic hemorrhoids, and leukoplakia

Anal Cancer Occurs most commonly in middle aged individuals Develops more frequently in women than men Most often associated with bleeding,pain, the sensation of a perianal mass, and perianal pruritus at the time of diagnosis

Anal Cancer Increased risk - homosexual males, presumably due to trauma from anal intercourse No data to indicate that anal cancers are AIDS-related tumors associated with infection by the human immunodeficiency virus

Anal Cancer Until recently, radical surgery was tx of choice with poor result Now, alternative therapeutic approach combining external beam radiation with concomitant chemotherapy has resulted in biopsy-proven disappearance of all tumor in more than 80% of patients whose initial lesion was less than 5cm in size –More than 80% of patients with anal cancers can be cured with nonoperative treatment

Proctitis Proctitis is inflammation of the lining of the rectum (rectal mucosa).

Proctitis has several causes. –Crohn's disease or ulcerative colitis. –STDs (gonorrhea, syphilis, Chlamydia trachomatis infection, herpes simplex virus infection, or cytomegalovirus infection). –May also be caused by bacteria not transmitted sexually, such as Salmonella. –Antibiotics that destroy normal intestinal bacteria. –Radiation therapy directed at or near the rectum, which is commonly used to treat prostate and rectal cancer. Proctitis

Proctitis typically causes painless bleeding or the passage of mucus from the rectum. When the cause is gonorrhea, herpes simplex virus, or cytomegalovirus, the anus and rectum may be intensely painful. Proctitis

DRE Anoscope or sigmoidoscope Tissue sample of rectal lining -the bacterium, fungus, or virus that may be causing the Proctitis can be identified. Colonoscopy or barium enema x-rays. Proctitis- Exam/Diagnosis

Proctitis Antibiotics are the best treatment for Proctitis caused by a specific bacterial infection. Metronidazole (Flagyl) or vancomycin (Vancocin) when proctitis is caused by use of an antibiotic that destroys normal intestinal bacteria

When the cause is radiation therapy or is unknown, anti-inflammatory drugs such as hydrocortisone or may provide relief. Both hydrocortisone and mesalamine can be administered as either an enema or a suppository. Proctitis

Mesalamine and other anti-inflammatory drugs, such as sulfasalazine, and olsalazine, may be taken by mouth at the same time that drugs are administered rectally, for added benefit. Proctitis

If these forms of treatment do not relieve the inflammation, formalin can be applied directly to the area or oral corticosteroids may be used. Laser or Argon plasma coagulation has also been used. Procitis

Pilonidal Disease Pilonidal disease is an infection caused by a hair that injures the skin at the top of the cleft between the buttocks. A pilonidal abscess is a collection of pus at the infection site; a pilonidal sinus is a chronic draining wound at the site.

Pilonidal disease usually occurs in young, hairy white men but can also occur in women. A pilonidal sinus can cause pain and swelling. Pilonidal Disease

To distinguish pilonidal disease from other infections, look for pitstiny holes in or next to the infected area. Treatment for a pilonidal abscess consists of I/D. Usually, a pilonidal sinus must be removed surgically. Pilonidal Disease

Rectal Prolapse Rectal prolapse is protrusion of the rectum through the anus.

Rectal prolapse causes the rectum to turn inside out, so that the rectal lining is visible as a dark red, moist fingerlike projection from the anus. Less commonly, the rectum protrudes into the vagina Rectal Prolapse

A temporary prolapse of only the rectal lining (mucosa) often occurs in otherwise healthy infants, probably when the infant strains during a bowel movement, and is rarely serious. Rectal Prolapse

In adults, prolapse of the rectal lining tends to persist and may worsen, so that more of the rectum protrudes. A complete prolapse of the rectum is called procidentia; this occurs most often in women older than age 60. Rectal Prolapse

To determine the extent of a prolapse, a DRE is done after the patient strains. By examining the anal sphincter, diminished muscle tone is often detected. A sigmoidoscopy and barium enema x-rays may reveal underlying disease. Rectal Prolapse

In infants and children, a stool softener eliminates the urge to strain. Strapping the buttocks together between bowel movements usually helps the prolapse heal on its own. Rectal Prolapse

In adults, surgery is usually needed to correct the problem. Surgery often cures procidentia. During one kind of abdominal operation, the entire rectum is lifted, pulled back, and attached to the sacral bone in the pelvis. In another, a segment of the rectum is removed, and the remainder of the rectum is stitched to the sacral bone. Rectal Prolapse

For people who are too weak to undergo surgery because of extreme old age or poor health, surgery to the rectum is preferred to surgery to the abdomen. One type of surgery to the rectum is performed by inserting a wire or plastic loop to encircle the sphincter in a technique called the Thiersch procedure. Alternatively, a segment of the rectum or the excess lining of the rectum may be excised. Rectal Prolapse

Fecal Incontinence Fecal incontinence is the accidental loss of stool. Causes of fecal incontinence in adults include back trauma, sphincter disruption as a result of accidents, anorectal surgery, or obstetrical trauma, and medical illness such as multiple sclerosis and diabetes mellitus. Many women have suffered nerve or muscle injury to the anal sphincter caused by forceps- assisted delivery, prolonged second stage of labor, or delivery of large baby, and this can contribute to fecal incontinence.

Visualize the anorectal area to see if there are any changes, scarring, fissures, or prolapse (protrusion) of the rectum. DRE should be performed to determine if there is an impaction of stool, to assess muscle tone at rest and with squeeze effort, and to exclude a rectal mass. Fecal Incontinence

Anal manometry is a specialized test that can measure the pressures generated by the anal sphincter muscles at rest and with maximal squeeze effort. X-rays may identify physical abnormalities of muscle function. This examination involves the placement of barium paste simulating stool into the rectum and asking the patient to defecate, strain, or squeeze while taking x-ray pictures. Ultrasound can be used to evaluate the muscles and other structures of the anal area. Fecal Incontinence

Treatments for incontinence include dietary modification, medicines, biofeedback, and surgery. Avoidance of foods that promote production of gas, and foods containing ingredients such as lactose, fructose, and sorbitol. Fecal Incontinence

Fiber supplements can increase bulk and add form to the bowel movement and result in improved control. Kegel exercises to strengthen the pelvic floor muscles may improve anorectal control. Loperamide HCl, Imodium, or diphenoxylate HCl, Lomotil may decrease stool volume and frequency, improve stool consistency, or perhaps directly affect the sphincter muscles. Fecal Incontinence

Swallowed objects, such as toothpicks, chicken bones, or fish bones, may become lodged at the junction between the rectum and anus. Also, enema tips, thermometers, and objects used for sexual stimulation may become lodged unintentionally in the rectum after being passed through the anus. Foreign Objects

Sudden, excruciating pain during bowel movements suggests that a foreign object, usually at the anorectal junction, is penetrating the lining of the anus or rectum. Foreign Objects

Other symptoms depend on the size and shape of the object, how long it has been there, and whether it has perforated the anus or rectum or caused an infection. Foreign Objects

A DRE, abdominal examination, sigmoidoscopy, and x-rays may be needed to make sure the wall of the large intestine has not been perforated. Foreign Objects

If the object can be felt, a local anesthetic is usually injected under the skin and lining of the anus to numb the area. The anus can then be spread wider with a rectal retractor, and the object can be grasped and removed. Natural movements of the wall of the large intestine (peristalsis) generally bring higher foreign objects down, making removal possible. Foreign Objects

If the object cannot be felt or cannot be removed through the anus, exploratory surgery is needed. The patient is given a regional or general anesthetic so that the object can be gently moved toward the anus or so that the rectum can be cut open to remove the object. After the object is removed, the doctor performs a sigmoidoscopy to determine whether the rectum has been perforated. Foreign Objects

Questions