Page 177 - Medicine and Surgery

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Chapter 4: Disorders of the rectum and anus 173

Management lapsed segment. Weakness in the surrounding muscula-
Small asymptomatic piles are managed conservatively, ture may cause irregular bowel motions, faecal incon-
a high-fibre diet may reduce constipation. First-degree tinence may occur. The prolapse may only be demon-
piles can be treated by sclerosing injection into the pedi- strated on straining.
cle. More severe haemorrhoids may be treated by follow-
ing: Management
Ligation: The pile is pulled down through a procto- Children are often managed conservatively, it is rare

scope and a rubber band is applied to the pedicle. One for the prolapse to persist beyond the age of 5. Con-
pile is treated at a time with intervals of 3 weeks be- stipation should be avoided by dietary intervention.
tween treatments. Partial prolapsing mucosa is excised by dissection
Infrared photocoagulation causes necrosis within the and ligation. If the sphincter control is poor, surgery

haemorrhoid and hence shrinkage. will not affect bowel habit which may improve with
Haemorrhoidectomy requires ligation and excision. sphincter exercises.

Post-operative pain is common especially on defeca- Complete prolapse requires a pelvic repair procedure
tion. Complications include haemorrhage and rarely including mobilisation of the rectum, fixation to the
anal stenosis, abscesses, fissures or fistulas. sacrum and suture of the levator ani muscles to the
frontoftherectum.Ifincontinencepersistssuturingof
thesphinctersmayhelp.Colostomymaybeconsidered
Rectal prolapse
in frail elderly patients.
Definition
Prolapse of the rectum through the anal canal. Rec- Fissure-in-ano
tal prolapses may be incompletely through the anus
(Type I), complete prolapse by intussusception of the Definition
rectum (Type II) or complete prolapse due to a sliding An anal fissure is a tear in the skin lining the lower anal
hernia of the pouch of Douglas (Type III). canal.

Incidence Aetiology
Type I is more common in children, type II and III in 1 Primary fissure-in-ano are idiopathic, they are gener-
adults, 85% female. ally posterior. Patients often report the onset of symp-
toms when passing hard, constipated stool.
Aetiology 2 Secondary fissure-in-ano are seen in inflammatory
Partial prolapse is more likely when there is a shallow bowel disease when they are often multiple and may
sacral curve such that the rectum is directly above the occur anywhere around the anal circumference.
anus. Complete prolapse results from poor pelvic floor
muscle tone, which may follow gynaecological surgery. Pathophysiology
10% of children with cystic fibrosis present with rectal Fissures are longitudinal tears, which develop into canoe
prolapse. shaped ulcers involving the lower third of the internal
sphincter. Swelling and inflammation at the anal verge
Pathophysiology may form a sentinel pile (haemorrhoid).
Initially prolapse only occurs on defecation with sponta-
neous return; however, with time the prolapse becomes Clinical features
more permanent. Severeburningpainondefecationthatmaylastforhours
sothatdefecationisavoided.Thesentinelpilemaybevis-
Clinical features ible on examination, rectal examination is very painful
There is often discomfort on passing stool possibly with and often impossible. Examination under anaesthesia
bleeding and mucus due to inflammation of the pro- (proctoscopy/sigmoidoscopy) allows diagnosis.