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18
R. Moonka and J. C. Carmichael
Conjoined Longitudinal Muscle
Possible functions of the conjoined longitudinal
muscle (CLM) include its role in attaching the
anorectum to the pelvis and acting as a skeleton
supporting and binding the rest of the internal
and external sphincter complex together [82].
Shak considers the CLM to play only a minimal
role in continence, potentiating the action of the
base loop in maintaining an anal seal [83]. He
ascribes its main role during defecation to shortening and widening of the anal canal and eversion of the anal orice and proposes the term
“evertor ani muscle”. Haas and Fox consider the
meshwork composed by the CLM may minimize
functional deterioration of the sphincters after its
surgical division; and acts as a support against
hemorrhoidal and rectal prolapse [11]. Finally
the CLM and its extensions to the intersphincteric plane divide the adjacent tissues into subspaces and may play a role in the containment of
sepsis [84].
The External Sphincter andSequence
ofDefecation
Defecation is a complex and incompletely understood phenomenon related to several integrated
mechanisms, all under the inuence of the central
nervous system. Defecation is triggered by lling
of the rectum from the sigmoid colon. Rectal distension is interpreted, via stretch receptors
located in the pelvic oor muscles, at a conscious
level as a desire to defecate. Rectal distension
also initiates the RAIR.The IAS relaxation, by
opening the upper anal canal, exposes the rectal
contents to the highly sensitive anal mucosa and
then differentiation between atus and stool can
be made. This “sampling” mechanism determines the urgency of defecation. Meanwhile, the
simultaneous EAS reex contraction maintains
continence. If defecation is to be deferred, conscious contraction of the EAS, assisted by the
mechanism of rectal compliance, yields time for
recuperation of the IAS function.
If the call to stool is answered, either the sitting
or squatting positions are assumed, and then the
anorectal angle is “opened”. Increase in both
intrarectal and intra-abdominal pressures result in
reex relaxation in EAS, IAS and puborectalis; at
this point, defecation may occur without straining. Contraction of the conjoint longitudinal muscle helps pull the vascular cushions out of the anal
canal and alongside the anal wall and shortens the
anal canal. Consequently, pelvic oor descending
and funneling occurs, and the rectal contents are
expelled by direct transmission of the increased
abdominal pressure through the relaxed pelvic
oor. Stool consistency will determine either
mass peristaltic emptying of the left colon or the
intermittent passing of stools. Transient EAS and
puborectalis contraction after completion of rectal
evacuation, the “closing reex”, restores IAS
tonus and closes the anal canal.
References
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1 Anorectal Anatomy andPhysiology
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Patient Evaluation
PasithornA.Suwanabol andJustinA.Maykel
2
Introduction
In general, any patient evaluation requires a
thorough history in conjunction with a careful
physical examination and additional directed
diagnostic studies. In order to correctly diagnose and effectively manage diseases of the
anus and rectum, symptoms are thoughtfully
considered in relation to the most likely underlying etiology. While common anorectal complaints are generally a result of benign disease,
more serious gastrointestinal pathology, such as
inammatory bowel disease and malignancy,
must always be considered in the differential.
Therefore, the combination of an accurate and
detailed history, focused physical examination,
and appropriate investigative testing should
result in proper diagnosis in both a timely and
cost-effective manner [1].
P. A. Suwanabol
Department of Surgery, Division of Colorectal
Surgery, University of Michigan,
Ann Arbor, MI, USA
J. A. Maykel (*)
Division of Colon and Rectal Surgery, Department of
Surgery, UMass Memorial Health Care,
Worcester, MA, USA
e-mail: justin.maykel@umassmemorial.org
Anatomy
In addition to sound clinical judgment, it is
essential that the clinician base their assessment on a thorough understanding of anorectal
anatomy. A comprehensive review of anorectal
anatomy and physiology is beyond the scope of
this chapter but it is important to consider the
critical points in relation to this discussion of
“patient evaluation.”
The rectum begins where the outer longitudinal taenia of the colon converge to form a conuent outer longitudinal muscle layer. The rectum is
approximately 12–15cm long with three intraluminal folds, the valves of Houston, with the middle valve typically corresponding to the level of
the anterior peritoneal reection. The anal canal
is approximately 4 cm long and begins at the
levator ani muscle and extends to the perianal
skin. The anal canal is encircled by the internal
anal sphincter (IAS) and the external anal sphincter (EAS). The IAS is the most distal extension of
the inner circular smooth muscle layer of the rectum and is innervated by the autonomic nervous
system. The IAS is therefore under involuntary
control and responsible for maintaining resting
anal tone. The EAS is formed by the puborectalis
muscle and innervated by somatic nerves. The
EAS is responsible for voluntary squeeze and
maintenance of continence [2, 3].
© Springer International Publishing AG, part of Springer Nature 2019
D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery,
https://doi.org/10.1007/978-3-319-65966-4_2
23
24
P. A. Suwanabol and J. A. Maykel
The anal canal contains columnar epithelium
proximally and transitional epithelium distally at
the level of the dentate line. The dentate line
denes the location of the anal crypts and glands
but also marks the change in neural innervation
from visceral proximally to somatic distally.
Finally, the most distal portion of the anal canal,
beyond the dentate line, is lined by squamous
epithelium and extends to the hair-bearing area of
the perianal skin (Fig.2.1) [2, 4].
The anus is also divided anatomically into the
anal canal and anal margin. The anal canal starts at
the top of the anal sphincter muscles and encompasses the distance from the anorectal junction to
the intersphincteric groove. The anal margin
begins at the intersphincteric groove and extends
to approximately 5cm onto the perineum. This is
important to distinguish for certain diagnoses such
as malignancies, as management differs between
anal canal and early anal margin cancers [5].
Finally, an understanding of this anatomy is
critical when classifying and describing anorectal
abscesses and stulas relative to the four potential spaces surrounding the anorectum: perianal,
intersphincteric, suprasphinteric, and ischiorectal
(Fig.2.2) [6]. Accurately categorizing abscesses
and stulas directs appropriate surgical management for abscesses (i.e. internal versus external
drainage) or approach to transsphincteric stulas.
Additional details on the anorectal anatomy can
be found in Chapter 1.
History
Chief Complaint
The critical nature of the patient history is highlighted by the fact that the ultimate diagnosis can
be suggested by the history alone. Patients are often
referred to a surgical specialist with a suspected
diagnosis that is inaccurate based on the patient’s
or referring doctor’s impression. For example,
“hemorrhoids” is frequently used as an umbrella
diagnosis for patients presenting with pain, bleeding, mass and itching yet the ultimate diagnosis is
unrelated to their asymptomatic hemorrhoids [7].
Patients often present with a complicated list
of symptoms, often struggling to focus on their
most signicant concern. Accordingly, it helps to
ask them to narrow their complaints to a single or
most pressing concern. With that focus, the surgeon can ask specic questions and lead the discussion towards a better understanding of their
issues: change in bowel habits, rectal discomfort,
tissue prolapse, mucous drainage, stool leakage.
The nature, duration and severity of such symptoms as well as the relationship to meals, alleviating and aggravating factors, medications, bowel
movement routines, and impact on sexual activity can then be elicited [8]. It is essential that the
clinician be aware of “alarm signs” that may signify a more ominous underlying pathology such
as unintended weight loss, change in stool cali-
Fig. 2.1 Anorectal
anatomy
2 Patient Evaluation
Fig. 2.2 Perirectal
abscess
25
ber, the presence of blood in stool, and personal
or family history of inammatory bowel disease
and gastrointestinal malignancies [9–11].
Bowel Habits
Bowel habits are always addressed, typically
through questioning as patients are not generally
willing to volunteer this information.
Characterization of stool with the aid of the
Bristol stool chart may be helpful; qualifying
stool from separate hard lumps (type 1) to watery
with no solid component (type 7) (Fig.2.3) [12].
Further characterization about incontinence and
constipation are necessary such as onset, frequency, and quantity. Details such as straining,
digitation either in the rectum or vagina, splinting, rectal sensation changes, and urgency should
be elicited [13–15]. For patients with complaints
of incontinence, recent changes in stool consistency may point to the underlying etiology and is
frequently overlooked. Additional recommendations for patients with complaints of incontinence
and constipation will be discussed further.
mitted disease [16–21]. Furthermore, it is important to elicit any incidents of obstetric or sexual
or physical trauma as these are not uncommon
for patients who present with anorectal complaints [22–25]. Additional helpful information
may include prolonged sitting on the commode,
lack of physical activity or conversely, extreme
activities that require sudden and signicant
increases of intraabdominal pressure such as
weight lifting [13].
Personal history of anorectal, obstetric and
gynecologic diseases, in addition to previous
anorectal, abdominal, gynecologic and urologic
surgery is an important and necessary adjunct to
the patient’s personal history [26–30]. Moreover,
a personal history of inammatory bowel disease, radiation, and baseline continence are
essential for both surgical planning and approach,
and managing patient expectations [28, 31, 32].
Obtaining a thorough history that includes specic details of bowel habits and prior surgery
cannot be overstated as this will certainly impact
decision for surgical intervention, surgical
approach, and postoperative management.
Personal History
Medication use and the use of supplementary
ber should be asked. It is important to specically inquire about sexual history including anoreceptive intercourse and high-risk behaviors that
make patients more susceptible to sexually trans-
Assessment forAmbulatory Surgery
Up to 90% of patients requiring operative interventions for anorectal diseases may be suitable for
ambulatory surgery. A comprehensive evaluation
will aid in determining eligibility and should
include general assessment of preoperative risk
prole [33–35]. A personal history of risk factors
26
Fig. 2.3 Bristol stool
chart. With permission
from [3] © Taylor and
Francis
P. A. Suwanabol and J. A. Maykel
that may impact the tness for ambulatory surgery
such as cardiopulmonary disease (including coronary artery disease, valvular heart disease, obstructive sleep apnea, chronic obstructive pulmonary
disease), cerebrovascular disease, liver or renal
dysfunction, diabetes mellitus, seizure disorder,
and bleeding disorders should be obtained [8].
Functional and nutritional assessment, and the use
of anticoagulant and antiplatelet medications as
well as immunosuppressants should be ascertained
[36]. American Society of Anesthesiology (ASA)
physical status, magnitude of proposed surgery,
type of anesthesia to be utilized, and patient factors such as airway, personal or family history of
malignant hyperthermia, and social factors such as
support at home and distance from surgery center
should also be considered when assessing a patient
for ambulatory surgery [36, 37]. Additional preop-
erative testing such as laboratory testing and electrocardiogram may be necessary; however, in
patients who are candidates for ambulatory surgery, routine screening tests have rarely been
found to impact the care provided [38–41].
Additional discussion is presented in Chapter 5.
Common Complaints
Bleeding
Bleeding is a distressing yet frequently encountered presenting symptom. Although internal
hemorrhoid irritation is the most common cause
of painless anorectal bleeding, it is critical to rule
out underlying malignancy particularly when the
bleeding does not resolve despite intervention.
Bleeding should be characterized by its color
(bright red versus dark or old blood), amount
2 Patient Evaluation
27
(streaks on toilet paper, dripping into the toilet or
clots), relationship to stool (blood on surface or
mixed within), and duration of bleeding over
time. Bleeding should be evaluated in its relationship to straining or activity, stool consistency,
change in bowel habits, and pain [8, 9].
Outlet bleeding, or bleeding originating from the
most distal rectum/anal canal, is characterized as
blood from that is usually bright red and seen on
toilet paper or in the toilet bowl. Most commonly,
when outlet bleeding is associated with pain or discomfort, it is a result of anal ssures whereas painless bleeding is caused by internal hemorrhoids or
proctitis. Concern for malignancy of the lower GI
tract is heightened when patients have a personal or
family history of colorectal malignancy, complain
of dark blood associated with mucous, blood mixed
with stool, or patients describe a change in bowel
habits [42, 43]. The blood may be episodic but tends
to persist over months. Malignancy causes discomfort or pain when the mass is distal in the rectum or
anal canal (Fig.2.4) [44]. Persistent bleeding should
be further assessed with a complete endoscopic
evaluation of the colon and rectum [45].
Pain
Pain is a unique symptom and tends to be seen in
the context of a limited differential. It should be
quantied in severity, duration, and its relation to
defecation. It is important to inquire whether pain
in the rectum is also associated with abdominal
pain, which may indicate a more serious underlying pathology such as inammatory bowel disease or malignancy [8]. Anal ssures are
characterized by sharp, knife-like or tearing anal
pain that occurs during and for variable time periods following a bowel movement. Pain can be
described as a spasm type of pain and is associated with bright red blood on the toilet paper or
dripping into the toilet bowl. Frequently patients
have difculty fully evacuating due to the associated sphincter spasm. Often a patient will recall
an episode of severe constipation or diarrhea at
the onset of the pain, and patients may complain
of a small “mass” due to the presence of a sentinel skin tag or prolapsing papilla, particularly in
the chronic setting [46]. Anorectal abscesses are
characterized by constant and gradually progressive anorectal pain associated with swelling and
fever (Fig.2.5) [47]. Systemic toxicity is rare but
can occur [44, 48]. Urinary dysfunction can occur
Fig. 2.4 Anal canal cancer Fig. 2.5 Perianal abscess
28
P. A. Suwanabol and J. A. Maykel
particularly with intersphincteric and supralevator abscesses [47]. Fistulas cause pain when the
tract closes and pus accumulates [44]. Patients
often recall a history of swelling and pain followed by drainage and subsequent relief of the
anorectal discomfort (Fig.2.6) [47].
In general, hemorrhoids do not cause pain, as
most patients present with bleeding and tissue
prolapse. Patients with symptomatic mixed hemorrhoids develop “ares” when the mixed hemorrhoids become edematous and swollen, often
taking days to settle and resolve. On rare occasions, patients can present acutely with an acute
“hemorrhoid crisis” which can require emergent
surgical intervention particularly in setting of
tissue necrosis (Fig.2.7). Sudden onset, excruciating pain associated with defecation and straining, and the presence of a grape-sized mass is
typically a thrombosed external hemorrhoid.
Bright red blood may be present as well [45].
Distinct from anorectal abscesses and stulae
are perianal suppurative diseases such as hidradenitis supurativa, skin furuncles, and skin infections from herpes, HIV, tuberculosis, and sexually
transmitted diseases such as syphilis. Moreover,
underlying Crohn’s disease is suspected in the
presence of multiple ssures, large skin tags, and
abnormal anorectal mucosa [49–51]. Deeper pelvic pain with sitting is often due to levator ani
syndrome whereas electric shock-like pain from
the levator muscle is attributed to proctalgia
fugax [52]. It is important to reiterate that low-
lying rectal and anal malignancies can cause pain
and must be ruled out. Pain from such malignancies is often associated with blood and mucous
discharge [42, 43].
Itching
Perianal itching is common and most often idiopathic but can cause signicant quality of life
issues. Patients may complain of associated
drainage or discharge, and mild bleeding can
occur due to perianal skin irritation and scratching. The presence of an associated mass should
help narrow down the differential. Patients should
be questioned about dermatologic conditions that
may also be present in locations outside of the
perineal skin such as psoriasis as well as atopic
conditions such as skin allergies and asthma.
Patients with pruritis ani typically admit to overzealous use of soaps, detergents, wipes and topical preparations while more liquid stool
consistency leads to skin irritating residue at the
anal verge [53, 54]. Specic foods may trigger
symptoms such as tomatoes, citrus fruits, coffee,
colas or alcohol [55]. A higher index of suspicion
for underlying malignancies should be made in
immunosuppressed patients, in patients with
open ulcers, masses or persistent symptoms
(Fig.2.8) [56]. Other conditions to consider with
complaints of itching are anal condyloma, Paget’s
disease, high-grade squamous intraepithelial
lesions, lichen sclerosis, and bacterial and fungal
infections (Fig.2.9) [57, 58].
Fig. 2.6 Anal stula Fig. 2.7 Hemorrhoid crisis