Anorectal refers to conditions related to the anus or rectum. These conditions are mainly caused due to some sort of overgrowth or abnormal growth of tissues in the anus and rectum region. While discussing these issues might be embarrassing, living with them can be painful. The common anorectal problems are:
- Anal Fistula
A. Anal Fistula
An anal fistula, commonly known as fistula-in-ano, is a small channel that can develop between the end of the rectum/anal canal and the skin near the anus. It can pain and cause bleeding when passing stools. A fistula usually occurs after surgery to drain a perianal abscess.
Causes of Anal Fistula
The most common cause of an anal fissure is injury to the skin at the anal opening primarily due to a hard, dry bowel movement. Other causes include Digital insertion (during examination), Foreign body insertion or Anal intercourse. Pregnant women may also develop a fissure during childbirth.
Treatment Options for Fistula
To manage an anal fistula, surgery is performed by a specialist to assess the depth and extent of fistula tract. The following types of surgery are commonly used for the treatment:
Minimally Invasive Fistula Treatment (MAFT): It is a minimally invasive laparoscopic technique.
Fistulotomy/Fistulectomy: Most fistulas are treated with a fistulotomy, in which the skin and muscle over the tunnel are cut open,converting it into an open groove. This allows the fistula tract to heal from inside out.
What is Minimally Invasive Anal Fistula Treatment (MAFT)?
MAFT (VAAFT) is a major breakthrough treatment option for complex fistulas. VAAFT (The Video assisted Anal Fistula Treatment) or MAFT (Minimally Invasive Fistula Treatment) are alternatively used terms.
This technique involves examination of fistula path using an endoscope to determine the point of internal opening of fistula. This is followed by closing the internal opening of the fistula using a stapler and the entire fistula tract is destroyed under direct telescopic vision by electrocautery.
Advantages of MAFT(VAAFT)
- No surgical wounds on the buttocks or in the perianal region
- No damage to the anal sphincters
- Less pre-operative investigations to ascertain type of fistula
- Early recovery and return to work and normal actions.
- Can be done as a Day-Care procedure
- Possibilities of localization of the internal fistula opening (key point in all fistula surgical treatments) is much higher
- Fistulous tract can be completely destroyed from within, without damaging any other tissues
Piles are also called haemorrhoids. Hemorrhoids are masses, clumps, cushions of tissue in the anal canal and are full of blood vessels, support tissue, muscle and elastic fibers. They are classified into two general categories: Internal and External.
Internal Haemorrhoids lie far deep inside the rectum where you can't see or feel them. Due to the pain-sensing nerves in the rectum, they usually do not hurt. However, bleeding is the only sign of their existence.
External Haemorrhoids lie within the anus and are often uncomfortable. If an external haemorrhoid prolapses outside (usually in the course of passing a stool), you can see and feel it.
Causes of Piles
Piles develop due to chronic constipation that leads to excessive straining, resulting in swelling of veins in the rectal area. Pregnant women may also develop piles due to increased pressure on the veins in the pelvic area.
Treatment Options for Piles
Physical examination and proctoscopy are done to diagnose piles. In the early stages, piles resolve on their own and do not require any treatment. However, right treatment can significantly reduce the discomfort and itching that many patients experience. The treatment options available are as follows:
- Depending on the diagnosis, the doctor advises whether you require home treatment or further intervention. Lifestyle and dietary modifications such as regular physical exercise, plenty of fluids and a high fibre diet can provide symptomatic relief.
- Surgery: Surgery is used for particularly large piles. Generally, surgery is used when conservative treatment/management is not effective. Sometimes surgery is done on an outpatient basis - the patient goes home after the procedure.
Different Surgeries for Piles
Haemorrhoidectomy (open surgery of the piles): In this procedure, the excess tissue that is causing bleeding is surgically removed. It may involve a combination of a local anesthetic and sedation, a spinal anesthetic, or a general anesthetic. This type of surgery is effective in completely removing piles, but can cause pain for few days.
Minimally Invasive Procedure for Hemorrhoids (MIPH): This technique uses stapler for performing surgery. It is relatively painless and be done as a day care surgery.
What is Minimally Invasive Procedure for Hemorrhoids (MIPH)?
In this procedure, the vessels at the base of hemorrhoids or piles are stapled and divided high up in the anal canal. The external piles get pulled inside. Few of its advantages are:
- Minimal postoperative pain
- Shorter hospital stay
- Quicker recovery and return to normal activities
- Excellent cosmetic outcomes
An anal fissure is a small tear in the skin lining on opening of anus. They are developed by hard or difficult bowel movements, causing severe pain or bleeding. Your doctor may recommend few changes in diet for soft stools, and topical anesthetics to reduce pain. In case, surgery is required, your surgeon will work to relax the anal area so that there is less anal pain.
Causes of Fissures
The most common cause of an anal fissure is injury to the skin at the anal opening due to a hard, dry bowel movement. Other causes include Digital insertion (during examination), Foreign body insertion or Anal intercourse. Pregnant women may also develop a fissure during childbirth. They may be acute (recent onset) or chronic. Chronic fissures recur frequently or are present for a long time and are often associated with a small external lump called a skin tag or sentinel pile.
Treatment Options for Fissures
Anal fissures often heal within a few weeks if you take steps to keep your stool soft, such as increasing your intake of fiber and fluids. Bathing in warm water for 10 to 20 minutes several times a day, especially after bowel movements, can help relax the sphincter and promote healing.
Conservative management : Atleast 50% of anal fissures are healed by medical management, which includes topical ointments, sitz baths, dietary modifications (i.e. incorporating a high fibre diet and avoiding foods that are not well digested like maida, popcorn, chips), drinking plenty of fluids, and using stool softeners/ laxatives.
Surgery : Surgery is used for treatment when fissures do not respond to other treatment. The two options available are:
Chemical Internal Sphincterotomy : A minimally invasive approach to relax the anal muscle by injecting chemicals in the anal sphincter muscle and partially paralyzing it.
Lateral Internal Sphincterotomy : In this surgery, a portion of the anal sphincter muscle is divided which helps the fissure to heal and decrease the pain and spasm. If a sentinel pile is present, it is removed to promote healing. It is a quick surgical process and can also be performed as a short outpatient procedure. The chances of recurrence are almost nil. It is the most effective treatment option for non healing fissures.
A rectal prolapse occurs when the rectum protrudes out of the anal opening primarily due to stretching or disruption of its attachments to the abdominal wall.
Causes of Prolapse
The exact cause remains unclear. However, the predisposing factors include:
- Prolonged straining during bowel movement,
- Multiple pregnancies,
- Neurological illnesses causing muscular weakness or connective tissue disorders.
- Weakness of the anal sphincter muscle is often associated with rectal prolapse, resulting in leakage of stool and mucus discharge. This condition is more common in the elderly
Treatment Options of Prolapse
The treatment of prolapse depends on the history of symptoms and physical examination. In case of an internal rectal prolapse, defecography is required. In some cases of very minor, early prolapse, treatment can begin at home with the use of stool softeners and by pushing the fallen tissue back into the anus by hand. There are several surgical approaches to repair prolapse. The surgeon will decide surgery depending on patient’s age, other existing health problems, extent of the prolapse, results of the examination and other tests, and his experience with certain techniques.
1. Rectal (perineal) Repair Approaches
It includes three different methods that are used depending on the nature of the prolapse.
Minimally Invasive Procedure for Hemorrhoids (MIPH) : This process is indicated only in cases of partial or mucosal prolapse.
Altemeier procedure (also called a proctosigmoidectomy): This involves removal of the prolapsed part of the rectum and suturing together the cut edges.
Thiersch wiring: It is a temporary procedure wherein the anal verge is wired to narrow the opening. The procedure is poorly tolerated.
The perineal approach being minimally invasive has various advantages such as:
- Decreased operative time
- Less blood loss
- Faster recovery
- Less post-operative pain
2. Abdominal repair approaches
Abdominal procedure requires making an incision in the abdominal muscles to view and operate in abdominal cavity. This approach is performed under general anesthesia most often on healthy adults. The two most common types of abdominal repair are:
Rectopexy (fixation [reattachment] of the rectum). Rectopexy can also be performed laparoscopically through small key-hole incisions.
Resection (removal of a segment of intestine) is followed by rectopexy and is preferred for patients with severe constipation. This can be performed laparoscopically as well.