Anorectal surgery is performed for many disorders that affect the anus and rectum. Procedures are commonly performed for internal hemorrhoids, external hemorrhoids, abscesses, fistulas, anal fissure, and rectal prolapse. In addition, various malignant conditions may require operative intervention.
Symptoms of anorectal disease are variable, but include pain, bleeding, itching, and burning. Often, anorectal conditions produce no symptoms. The first step in diagnosis is a history and physical examination. Other aspects of the examination that may be employed include endoscopy, ultrasound, and imaging (such as CT scan and MRI).
Hemorrhoids are abnormally dilated tissue consisting of blood vessels, connective tissue, and smooth muscle. Symptoms include bleeding, itching, burning, pain, and no symptoms at all. The initial treatment of hemorrhoids includes dietary modification (increase fiber and liquid intake), stool softeners, and sitz baths (sitting in a warm tub of water). For internal hemorrhoids, rubber band ligation (often an office-based procedure) or infra-red coagulation may be options. For more advanced internal hemorrhoids, excisional hemorrhoidectomy may be offered. For external hemorrhoids, dietary modification may be recommended initially. If surgery is recommended, excisional hemorrhoidectomy is commonly performed.
Perianal Abscess and Fistula
A perianal abscess is a collection of infected fluid (pus) surrounding the anus. Symptoms include pain, fevers, and the presence of a mass around the anus. The treatment is incision and drainage, which may be performed in the office or in the operating room at the hospital. Following abscess drainage, 50 percent of patients will develop a fistula. A fistula is an abnormal connection between the inside of the anus or rectum (primary opening) and the skin (secondary opening). There are many treatments for a perianal fistula, including a fistulotomy (incision of the fistula tract), closure with fibrin glue or a fistula plug, and closure with an anorectal advancement flap. In addition, initial treatment may include placement of a seton (rubber band that allows for drainage of residual infected fluid), followed by closure of the tract with one of the procedures listed above.
An anal fissure is a tear in the lining of the anal canal. Symptoms include pain that is worse during and after bowel movements and bleeding. The cause of an anal fissure is likely the passage of a hard stool combined with a tight internal anal sphincter muscle. The initial treatment includes dietary modifications (increase fiber and liquid in the diet) and stool softeners. Topical smooth muscle relaxants (such as Nitroglycerin and Diltiazem) may be used. Another treatment option consists of injection of Botulinum toxin (BoTox) into the muscle surrounding the fissure. Also, a procedure called a lateral internal sphincterotomy (in which a portion of the anal sphincter muscle is divided) may be recommended.
Rectal prolapse is protrusion of the rectum through the anus. Symptoms include incontinence, fecal and mucus soiling, and a sensation of fullness and tissue protruding from the anus. Surgery is often recommended as a treatment. There are many options available to treat rectal prolapse. In properly selected patients, a colon resection and rectopexy is recommended. In this procedure the redundant colon is remove and the two ends reconnected. The rectum is then suture to the bony sacrum to prevent recurrent prolapse. A colon resection and rectopexy is an abdominal surgery. In select patients, it may be performed laparoscopically.
In some cases an abdominal surgery is not recommended. For these patients, the surgery is performed through the anus. A commonly performed procedure is call a perineal rectosigmoidectomy (also known as an Altemeier procedure). In this surgery, the prolapsed rectum is surgically excised through the anus. After removal of the prolapsed segment, the two ends are sutured together. Your surgeon will discuss the options for treatment with you during your consultation.