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How toDiagnose andManage
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Anorectal Disorders inLowandMiddle-Income Countries
ConnieHong-HungKeung
A good leader inspires people to have condence in the leader, a great leader inspires
people to have condence in themselves.
– Eleanor Roosevelt
28
Abbreviations
AIN Anal intraepithelial neoplasia
DRE Digital rectal exam
HIV Human immunodeciency virus
IBD Inammatory bowel disease
LMICs Low- and middle-income countries
SCC Squamous cell carcinoma
TB Tuberculosis
Introduction/Background
Anorectal problems, while not often discussed
due to their location, can often seriously affect
patients and cause severe pain and discomfort.
They can be debilitating for patients as they often
do not know where to seek help. The breadth of
issues can range from benign pathology to malignancies and from an anal itch to life-threatening
disease. A good understanding of the anatomy
C. H.-H. Keung (*)
Indiana University School of Medicine, Department
of Surgery, Indianapolis, IN, USA
and common problems will allow a surgeon to
bring comfort, healing, and recovery for these
patients.
Principles ofDiagnosis
With experience, a surgeon will be able to formulate and narrow the differential diagnosis by
obtaining a focused history and asking pertinent
questions about the patient’s symptoms. While
there are many additional tests that can be performed, the diagnosis and treatment algorithm
can be initiated soon after obtaining a complete
history and performing a complete physical
examination, not conned only to the anus and
rectum. A good history supplemented by a conrmatory physical examination is essential to diagnose anorectal issues [1].
History andPhysical Examination
The patients’ histories of their anorectal symptoms are very important and the highlights are
outlined below.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_28
339
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C. H.-H. Keung
Pain: Its important characteristics are (1) dull vs.
sharp, (2) associated with bowel movement,
and (3) persistent or intermittent.
Bowel habits: (1) Constipation vs. diarrhea, (2)
straining, (3) duration on the toilet.
Mass: (1) Fixed vs. mobile, (2) location, (3)
bleeding.
Protrusion: (1) Piles vs. circumferential protru-
sion, (2) reduction (spontaneous, manual,
persistent).
Bleeding: (1) Copious vs. smear, (2) bright red
vs. melena, (3) with bowel movement vs.
spontaneous.
Mucus or discharge: (1) Continuous or inter-
mittent, (2) foul smelling, clear, or
purulent.
Pruritus: (1) Certain time of day/night, (2) asso-
ciated with BM, (3) associated with specic
foods.
Physical Examination may be foreign to a
patient and needs to be proposed and approached
carefully. Assurances and explanation of the
examination is very important so that the patient
can anticipate all the steps of the investigation.
There are three potential positions for the examination of the anorectum: prone, knee-chest or
jackknife, or left lateral decubitus positions
(Fig. 28.1). The ideal exposure is in one of the
prone positions as that provides optimal exposure. However, this position may be limited by
the patient’s comorbidities, specically joint
issues limiting pressure on the knees. It is also
not desirable in elderly patients with cardiac or
pulmonary problems. Aside from assurance,
careful explanation of each step of the examination must be done as part of the consent process.
The examination includes (1) external inspection,
(2) digital rectal exam (DRE), and (3) anoscopy.
Fig. 28.1 Positions for anoscopy and for colonoscopy.
Source: Corman’s Colon and Rectal Surgery, online at
https://abdominalkey.com/evaluation- and- diagnostic-
techniquesby Abdominal Key- Fastest abdominal insight
engine. Evaluation and Diagnostic Techniques. Denoya
PT and Corman ML
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Principles ofManagement
Hemorrhoids
Patients often blame all anorectal problems on
hemorrhoids (Fig. 28.2). While there are other
pathologies, hemorrhoids do account for one of
the most common surgical problems of the anorectum. Hemorrhoids are normal anatomic structures. They are vascular cushions that assist with
continence. They are often located in standard
locations: left lateral, right posterior, and right
anterior positions. The blood supply is the superior hemorrhoidal artery and drainage is through
the inferior, middle, and superior hemorrhoidal
veins. There have been many postulations as to
why hemorrhoidal disease arises; often cited are
excessive straining (as with persistent constipation) or pressure from above (as in portal hypertension in cirrhosis). A study in northwest Ethiopia
found that constipation and obesity contributed to
increased odds of having hemorrhoidal problems
requiring surgical attention [2]. Hemorrhoidal
pathologies can be divided between external hemorrhoids and internal hemorrhoids. External hemorrhoids often cause pain, discomfort, and an
acute bulge at the anal verge. These are located
Internal
hemorrhoids
External hemorrhoids
Fig. 28.2 Locations of internal and external hemorrhoids. Source: GOGRAPH 370 Hemorrhoid. Clip Art |
Royalty Free
Bleeding
Table 28.1 Hemorrhoids/piles—“Goligher grading”
Stage I No protrusion of hemorrhoids which
remain above the dentate line
Stage II Protruding hemorrhoids below the dentate
line that spontaneously reduce
Stage III Protruding hemorrhoids, possible to push
back in manually
Stage IV Protruding hemorrhoids that cannot be
pushed back in manually anymore
below the dentate line. Although internal hemorrhoids often protrude on straining and bleed, they
originate above the dentate line. Internal hemorrhoids are classied in four stages (see Table28.1).
Physical examination begins with inspection, then
DRE, and anoscopy.
External hemorrhoids can be detected on
external examination. The small mass (generally
not larger than 1–2 cm) must be differentiated
between acute vs. resolving thrombosis. Acute
thrombosed hemorrhoids are extremely tender
and examination should be concluded at this
point. Patients can often have patulous tags
around the anal verge, indicating history of
thrombosis in the past, and these should not be
operated on. In the case of a thrombosed hemorrhoid, patient level of discomfort and pain as well
as the duration of symptoms will dictate the type
of intervention. Perianal pain is worst about
72 hrs following thrombosis, and will begin to
improve after that, especially if sitz baths are
instituted. Before 72hours, excision of the clot is
recommended as long as the patient does not
have portal hypertension. Therefore, if the
patient’s symptoms are improving after 3days, it
is advisable to allow spontaneous resolution with
no intervention other than sitz baths for comfort.
If an excision is indicated, it can be performed in
the ofce under local anesthesia. Incision of the
overlying skin of the thrombosed hemorrhoid
permits evacuation of the clot. The skin should
not be reapproximated. Pressure can be applied
to the area to control oozing and application of
Monsel’s solution or silver nitrate [3].
Internal hemorrhoids can sometimes be palpated on DRE; however this is not reliable as
even pathologically enlarged hemorrhoids are
vascular cushions which can be easily compressed by nger pressure and may feel “normal”
on DRE.It is still important to perform DRE as
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C. H.-H. Keung
other pathological ndings can mimic hemorrhoidal ndings and need to be ruled out.
Anoscopy is the dening test for internal hemorrhoids with the assurance that the anal canal is
examined circumferentially. Depending on the
skill of the anoscopist and the tolerance of the
patient, this maneuver may require insertion of
the anoscope a few times. Internal hemorrhoids
above the dentate line should be examined for
their size and documented for their mucosal irritation or bleeding. It is also important to determine
the extent of any prolapse after asking the patient
to Valsalva during anoscopy. This may provide an
improved sense of the severity of the disease.
Rectal bleeding can often be attributed to
hemorrhoids, but in addition the patient may harbor a more concerning diagnosis while presenting with concomitant hemorrhoids. A complete
family history and careful review of systems may
help to indicate the need for further testing, such
as a colonoscopy, to rule out more proximal
colonic and rectal pathologies such as a malignancy. In 2017 health-seeking behaviors were
evaluated in Nigeria, and many physicians attributed rectal bleeding to hemorrhoids and failed to
refer patients for colonoscopy which suggested a
need for stronger educational programs about
colorectal cancers [4].
Management of hemorrhoids should rst
begin with careful review of lifestyle habits and
recommendations for modications to decrease
strain in the anorectum. Optimizing stool bulk
and consistency with ber supplementation is
essential. Careful discussion on ber amount
(25 to 30g a day) and type of diet is important.
In addition, patients should be advised to spend
as little time sitting on the toilet as possible (no
sitting and reading). For discomfort, sitz baths
2–3 times/day for 10–15min may alleviate any
acute pain. Trial of these lifestyle modications
can be done for 2–3months, followed by discussion of any symptom improvements.
If patients remain symptomatic, then other
options may be pursued. There are numerous
approaches available for further interventions to
manage internal hemorrhoids. These include
sclerotherapy, infrared photocoagulation, rubber
band ligation, or excisional hemorrhoidectomy.
Rubber or plastic band ligation can be done in
the ofce and is suggested for grade I to grade III
hemorrhoids. This should be performed in a
patient who is awake. The patient is placed in
position, and the hemorrhoid is either grasped or
suctioned through an anoscope; then a device will
deploy a rubber band to noose the internal hemorrhoid (Fig.28.3). The patient may feel pressure or
dull discomfort, but should not experience any
sharp pain. If there is pain, the rubber band is
below the dentate line and the band should be
removed. It is recommended to place no more
than 3 bands in one sitting so as to avoid anal stenosis [3]. The delivery instrument metal or plastic
(Fig.28.4) is reusable and affordable and the rubber or plastic bands are very inexpensive.
Operative excisional hemorrhoidectomy can
be performed by using several different techniques. Most commonly used presently are either
the open (Milligan-Morgan) technique or the
closed (Ferguson) technique. Both techniques
follow the same principles of excision. An elliptical incision is made starting in the perianal margin; the hemorrhoidal tissue is then dissected off
the underlying internal sphincter muscles. The
internal apex is then suture ligated. In a closed
technique, the ligating suture is then used to
approximate the edges of the excision. In an open
technique, suture ligation alone is done and the
edges of the excision are not reapproximated.
Anal Fissures
An anal ssure is a tear in the epithelium of the
distal anal canal. This is often the result of anal
trauma secondary to a large hard bowel movement. The tear, or the ssure, persists due to
sphincter hypertonicity. The most common position of an anal ssure is in the posterior location.
Vascular studies have demonstrated relative ischemia in this location, and supports postulations
that there is relative ischemia in the posterior
midline location of the anus.
28 How toDiagnose andManage Anorectal Disorders inLow- andMiddle-Income Countries
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Fig. 28.3 Application
of a plastic band to an
internal hemorrhoid.
Source: Sabiston
Textbook of Surgery,
17th Ed. Nelson, H,
Chapter 49, p.1493,
Fig.7 (Elsevier)
343
Fig. 28.4 Disposable ligators for application of the rubber band (photo courtesy of MA Hardy)
History of a ssure usually includes an initial
sharp pain on defecation that can last a few hours
after toileting. This is the most characteristic
complaint of a patient with an anal ssure and is
diagnostic. The pain has also been described as
burning or tearing of the skin, followed by muscle spasm in the region. Due to the tear in the
epithelium, there can be some bleeding from the
region of the ssure. Patients can report fear can
report fear or anxiety about going to the bathroom to pass the next bowel movement due to the
anticipated severity of pain.
Physical examination is often limited only to
the external inspection, as the pain from the ssure limits a useful DRE or anoscopy unless the
patient is anesthetized. Frequently external
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C. H.-H. Keung
inspection with gentle spreading of the anal verge
will reveal a disruption in the anal epithelium
conrming the diagnosis of an anal ssure. At
this point the exam is complete and focus should
be geared towards several treatment options.
After the healing of the ssure, it is important to
conduct a full examination, including DRE and
anoscopy, to ensure that there are no other pathologic lesions that may contribute to the patient’s
symptoms and presentation. If this is not possible, then an examination under anesthesia is warranted to complete the evaluation. Chronic
ssures have a sentinel skin tag that can be readily seen during the external examination in the
ofce. There is often an anal papilla that can also
be visualized on anoscopy [3].
Typical presentations for ssures include the
anterior or posterior positions. If a ssure is
located in the lateral position, either right or left
anus, suspicion should be raised for other pathologies. Fissures can be divided into acute ssures
(<6weeks) and chronic ssures (>6weeks). Most
acute ssures heal with lifestyle modications
such as ber supplementation and sitz baths.
Chronic ssures generally do not heal spontaneously, and therefore treatment is geared towards
addressing hypertonicity of the sphincter muscles.
Topical ointment to the perianal region of nitroglycerin, diltiazem, or nifedipine has been shown
to be effective in the treatment of chronic ssures.
Due to the vasodilatory effects of these drugs,
patients should be cautioned about headaches
and/or dizziness after their application. These
drugs may be used only with caution in patients
with cardiac or valvular diseases.
After the failure of lifestyle modications and
of the use of topical vasodilators, options include
the use of Botox injection or sphincterotomy.
Botox injections may be prohibitively expensive
and therefore not appropriate for use in low- and
middle-income countries (LMICs). Recurrence
rates with Botox injections are higher than the
successes of complete healing achieved with
sphincterotomy. Sphincterotomy, which involves
cutting of the internal sphincter, results in >90%
resolution of ssures depending on the technique.
This method may, however, result in incontinence
in up to 30% of patients. Sphincterotomy should
be approached with caution, especially in women
who may have experienced peripartum trauma
from vaginal delivery [3].
Anorectal Abscess andFistulas
Prevalence of stula-in-ano was the leading
cause of perianal admission at a referral hospital
in Addis Ababa, accounting for 43% of admissions [5].
While abscesses may seem like a basic surgical
issue, thorough understanding of the anal anatomy
(Fig. 28.5) will allow a surgeon to successfully
drain perianal and perirectal abscesses. The majority of such abscesses originates from cryptoglandular tissues. These glands are located at the
dentate line, and their obstruction leads to abscess
formation in the potential spaces that surround the
anorectum. These spaces include perianal, ischiorectal, intersphincteric, and supralevator locations
(Fig.28.5). The most common site of infection is
the perianal space while the supralevator space
abscesses are relatively rare. When the abscess
spreads circumferentially, it results in a horseshoe
abscess located in the deep post anal space [1].
Patients usually present with fever, perianal
pain, and swelling in the perianal region. It is
Fig. 28.5 Various perianal spaces for abscesses and
stulas
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important to note that supralevator and intersphincteric abscess may not have external manifestations on physical examination and are more
difcult to diagnose. A digital rectal exam for
tenderness is important to rule out these locations
for potential abscesses although at times, this
may cause signicant discomfort and even
extreme tenderness. Ischiorectal and perianal
abscesses will often present as a swelling with
uctuance adjacent to the anal verge or within the
anal margin [1].
The urgent treatment for an anorectal abscess
is incision and drainage. After preparation of the
area with a betadine scrub, local anesthesia is
injected circumferentially around the abscess.
After the apex of the abscess is identied, a cruciate incision may be made and then the edges are
removed to create adequate opening for drainage.
In order for the wound edges not to coapt, resulting potentially in recurrence or inappropriate
drainage, the edges must be kept wide apart. For
ischiorectal abscesses which can be a few centimeters from the anal verge, the center of the incision should be placed as close to the anal verge as
possible. This will then decrease the potential
length and tortuous nature of a subsequent stula.
Horseshoe abscesses require drainage of the post
anal space since the origin of this type of abscess
is an intersphincteric infection. In those cases,
the internal sphincter muscle often needs to be
divided and separate counter incisions need to be
made over each ischiorectal fossa.
Fistulotomy is often discouraged at the
same time as incision and drainage. This is
due to the acute inflammation in the potential
operative field, and fear that attempts to find a
fistula will create false passages and more
trauma to the perianal region. Therefore localization of fistulas should be delayed till after
the acute inflammation and infection has been
controlled [1].
Severe necrotizing soft tissue infections are
relatively rare, but progression of an undiagnosed
and untreated anorectal abscess may frequently
lead to generalized septicemia, including
Fournier’s gangrene which may be fatal. Such
patients often present with sepsis and even shock.
They must be aggressively resuscitated while ini-
tial surgical treatment must focus on wide local
debridement to excise all necrotic tissue and to
limit the spread of infection.
Fistulas usually form following an anal gland
infection or abscess which burrows to the outside
of the skin as it communicates with the inside of
the rectum. Fistulas are classied based on their
relationship to the anal sphincter complex and
result because of an abnormal connection
between two distant epithelial surfaces
(Fig. 28.6). The majority of anorectal stulas
result from cryptoglandular pathology while less
than 10% originate from inammatory bowel
disease (IBD), anal ssures, and tuberculosis
(TB).
The diagnosis of stulas is made by physical
examination. Sometimes this may have to be
done under sedation in order to nd the internal
opening with the aid of probes. Goodsall’s rule
(Fig. 28.7) while not always predictive, can
help guide location of the internal opening. The
rule suggests that if an imaginary transverse
line was drawn to divide the anus, external os
found anteriorly will tract radially internally.
External openings posteriorly will drain to the
posterior midline. Careful DRE may lead to the
internal defect by careful palpation of the anoderm. Examination under anesthesia will help
to denitively locate the stula tract and permit
to make decisions on next treatment steps. If no
stula is found, then MRI and stulography
may be useful diagnostic adjuncts if they are
available; if not, repeat examination may be
informative.
Treatment of stulas has two goals. First, control of inammation/sepsis. Second, closure of
the tract while preserving continence and muscle
integrity. This is frequently a two-step process
with the rst step being frequently done at the
rst examination which results in the denite
diagnosis. At the time of the anorectal examination under anesthesia, after the stula tract has
been identied, a seton (heavy silk, #2) or preferably a vessel loop (thin rubber) can be placed
through and through the stula tract (Fig.28.8).
This should be loosely tied to itself in order to
remain in place without cutting through the tract.
Placement of the seton prevents recurrence of the
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Fig. 28.6 Classication
of stulas. 1.
Intersphincteric; 2.
Transsphincteric; 3.
Suprasphincteric; 4.
Extrasphincteric.
Source: Sneider EB &
Maykel JA.Anal abscess
and stula. Gastroent.
Clin. Of NA, 2013
(Figs.2 & 3), Publ.
Elsevier
C. H.-H. Keung
abscess and permits appropriate brosis of the
tract. Approximately 8 weeks are allowed for
brosis to occur and then the stula is reevaluated for the second step procedure. In the second
step, three options are available to the surgeon to
obliterate the stula tract: (1) stulotomy, (2)
ligation of intersphincteric tract, or (3) rectal
mucosal advancement ap [3].
Fistulotomy should be reserved for those who
have minimal muscle involvement. The tract is
then opened widely, the edges are marsupialized,
and the tract is allowed to granulate and heal by
secondary intention.
In ligation of intersphincteric stula tract,
the intersphincteric groove is identied and a
3–4cm incision made over this plane. A probe
is passed through the stula. Dissection is then
carried down toward the stula with the probe
assisting in the identication of the tract along
its whole length. A right angle clamp is then
Posterior: curved tracts
ior fistula
Anterior: straight tracts
Tr
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347
used to circumferentially isolate the stula
within the groove. The probe is removed and
ligation of the tract is done with 2-0 vicryl
sutures on both sides (ends) and the stula is
then sharply divided between the suture ligatures. The intersphincteric plane is then approximated, rst at the muscular layer and then at
the skin level.
Endorectal advancement ap is coverage of
the internal opening with healthy anorectal
mucosa. The stula tract is identied with a
probe. Dissection is initiated 1cm distal to the
ansverse anal line
Fig. 28.7 Goodsall’s rule. Source: Feingold, D.L.,
Kiely, J.M. (2019). Cannot Find Internal Opening of
Fistula-in- Ano. In: Lee, S., Steele, S., Feingold, D.,
Ross, H., Rivadeneira, D. (eds) Colorectal Surgery
Consultation. Springer, Cham. https://doi.
org/10.1007/978- 3- 030- 11181- 6_27
Anus
3 cm
Long anter
internal os and a curvilinear broad based ap
partial or full thickness is raised about 3–4cm.
Once the ap is made, the opening within the
muscle layer is closed with a 3-0 suture. The distal portion of the ap is then trimmed including
the internal opening. The ap is then sutured to
the distal wound edge. This procedure should be
performed primarily by those who have done
this before and are already familiar with the
technique and should be reserved for stulas
which have recurred.
Complex stulas can become recurrent despite
multiple attempts at closure. Such recurrent stulas and those related to specic etiologies, such
as rectourethral, rectovaginal, or malignant stulas, may require a transabdominal approach to
resolve. In those cases, occasionally a more proximal stoma may be needed to divert the ow of
stool to control the stula and allow appropriate
repair and healing [3].
Anorectal Infections
Anorectal infections are frequent in LMICs and
can be unfamiliar to physicians in HICs. There
are infectious etiologies that may cause colitis
and extend distally into the rectum or others
that are specic pathogens associated with
proctitis. The infectious colitis specic pathogens are covered separately in Chap. 27 about
Fig. 28.8 Seton
placement using a soft
vessel loop. Source:
www.drmaherabbas.
com, courtesy of Maher
A.Abbas, MD, FACS,
FASCRS, Post Anorectal
Surgery Care
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C. H.-H. Keung
the acute abdomen. Focusing on proctitis-specic pathogens, one must be alert to a patient’s
sexual history and risk factors for transmission.
Treatment of potential contacts must be considered. Other potential anorectal infections
include HPV, HIV/AIDS, molluscum, lice, scabies, or TB.
Proctitis is the inammation of the rectum.
Patients will complain of anorectal pain, tenesmus, and discharge. This can often be confused
with inammatory bowel disease so a careful history must be obtained including a sexual history.
Please see Table28.2 for the list of pathogens and
their recommended treatment. The exact diagnosis is frequently unclear so workup must begin
with anal swabs for culture (HSV, chlamydia, and
gonorrhea). This should be done prior to lubrication or DRE. Treatment is started empirically
with broad antiviral drugs and antibiotics. This
can be narrowed as culture results return
(Fig.28.9).
Table 28.2 Anorectal bacterial pathogens, presentation, and treatment
Pathogen Presentation Testing Treatment Notes
Syphilis Papules RPR, Darkeld
examination
HSV Vesicles NAAT, culture,
serologic testing
Chancroid Deep painful ulcer
with
lymphadenopathy
Donovanosis Painless nodules that
develop into ulcer
Lymphogranuloma
venereum (LGV)
Anal pain, discharge,
tenesmus
NAAT, culture Azithromycin 1g
Difcult to culture,
Donovan bodies on
tissue crush biopsy
NA AT Doxycycline 100mg
Human papillomavirus (HPV) (condylomas)
has approximately 40 subtypes with only some
that cause condylomas (type 6 and 11) and others
that are associated with possible precursors to anal
malignancies (type 16 and 18). Many of these
patients have a sexual history of anal receptive
intercourse. HPV is also frequently associated
with HIV so HPV proctitis should trigger further
investigations for HIV since both are found in the
same high-risk groups. The goal of treatment of
HPV is primarily to treat the symptoms of HPV
since the warts can often self- resolve. Treatment
options for warts include home-based treatment
regimens or surgical management. Home-based
regimens include applications of podolox,
imiquimod, or sinecatechins. Surgical treatments
are usually reserved for those with extensive burden of warts. Options include excision/cautery,
cryotherapy, or provider application of trichloroacetic or bichloroacetic acid. HPV is closely associated with precursor lesions to squamous cell
PCN 2.4million units
IM×1
Valganciclovir 1g po
bid×10days
po×1
Azithromycin 1g po
>3weeks
bid×21days
Latent syphilis has
systemic presentation
Counsel, educate, and
treat partner
Counsel, educate, and
treat partner
Treat till all lesions are
healed
Retest in 3months
after treatment; all
partners within
60days should be
treated as well
Proctitis
Anorectal pain/discharge/tenesmus
Fig. 28.9 Proctitis management
Testing:
NAAT-gonorrhea/chlamydia
HSV-PCR testing
Treat empirically:
Doxycycline 100mg bid x 21 days (Chlamydia)
Ceftriaxone 250mg IM (Gonarrhea)
Valgancyclovir1g orally bid (HSV)
If testing comes back back positive, can narrow
treatment regimen
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