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Foreword
Education is never as expensive as ignorance.—Anon
It gives me great joy to write a foreword for this outstanding multidisciplinary book on anorectal disorders authored by Dr. Kamal Gupta, popularly
known as the “laser man” of India. So little is known about these hugely common conditions that often one can only share his/her ignorance in the eld;
this book stands out in terms of the latest information brought out with clarity
and brevity. The author has covered all aspects of these disorders ranging
from applied surgical anatomy and physiology to the latest management
modalities available. The surgical anatomy has been covered tastefully with
surgical aspects and relevance optimally addressed. Having known the author
for a long time as a very passionate student of medicine and a dedicated
teacher of the science and art of it, one can vouch for this masterpiece as
being among the best available in the eld.
Each chapter is oozing with information and instructions on the do’s and
don’ts in the eld. The diagrams, sketches, and photographs have been tastefully done to complement the rich text. A must-have book for all practicing
surgeons, residents, and other students training to be surgeons, especially the
budding colo-proctologists. I would recommend the book for all trainees
appearing for MS, MRCS, FRCS, and similar examinations. I would like to
congratulate the author for an outstanding effort and wish this masterpiece
great success.
Prof. (Dr.) Chintamani
Former Head of Department of Surgery
Safdarjang Hospital and VMMC
New Delhi, India
xiii
Foreword
Traditionally, perianal region is a poorly understood region. Modern advancements in the area are gradually taking the place of conventional surgical procedures. Numerous novel techniques have replaced traditional invasive
surgery, including band ligations, hemorrhoid artery ligations, foam sclerotherapy, and stapled hemorrhoidectomy. As a result, some severe complications are reported in centers of excellence from peripheral hospitals, which
underlines the requirement for postgraduates to have proper training.
Every good surgical textbook aims to convey concept clarity while teaching expertise in surgery. This book primarily aims to bring together all current
threads of pertinent knowledge. The book contains a very explicatory
explained anatomical features of the anal and perianal region.
The book Lasers in Proctology well explains laser hemorrhoidoplasty.
Laser hemorrhoidoplasty is a laser-based technique that is minimally invasive
and has the least number of complications. More comprehensive laser applications have been described in the treatment of stula-in-ano, pilonidal sinus,
and all the complications of hemorrhoids in this book. The hybrid technique
of combining video-assisted laser ablation of the stulous tract has been very
nicely explained.
Another valuable procedure in the book is laser lateral internal sphincterotomy, a minimally invasive technique for anal ssures. The chapters are
thorough without adding extraneous details. All the complicated procedures
have been very aptly described. Frequent queries, as well as some unusual
ones that present an intriguing method of treating individuals with anorectal
issues, have been addressed in this book. Once one begins reading the book,
one will discover new concepts of hybrid procedures that will enable one to
handle issues that may have previously been very difcult for one to handle.
With time, the widespread availability of these new procedures will add to the
armamentarium of training for young surgeons. However, I feel in years to
come, the forbidding costs of the equipment should also come down to make
these procedures more cost-effective.
To be precise, I strongly recommend this book as a must-read for young
and aspiring surgeons.
AbdulMajeedChaudhary
Professor and Chairman, Department of Surgery
Lahore Medical and Dental College
Lahore, Pakistan
xv
Preface
No teaching hospital will be considered complete unless it includes a proctologist
on its staff.—Lockhart Mummery, 1914
Lockhart Mummery's statement accurately emphasizes the importance of
proctology, a eld generally regarded as one of the neglected branches of
general surgery.
During my years in private practice, I was particularly intrigued and
moved by the reluctance patients with anorectal problems exhibit when
approaching a specialist. My desire to alleviate their suffering drew my attention to this eld and consequently drove me to relentlessly work in and pursue
the eld of proctology.
In my experience, surgeons typically receive a signicant part of their surgical training during residency. Later, in practice, they encounter situations
where the formal classroom training seems inadequate. Then, they realize the
importance of thinking outside the box and coming up with innovative solutions for the problems they encounter. The use of laser in surgery is one such
innovative element that has successfully provided better and more accessible
treatment. I am particularly reminded of a quote penned by Christian Lous
Lange: “Technology is a useful servant but a dangerous master.” This leads
me to conclude that technology can successfully present a solution when
appropriately applied. That is precisely what this book attempts to achieve.
I have constantly been asked why I decided to write this book. To my
mind, authors may write books for various reasons: Few may want to be
known as distinguished book authors; some may want to leave a legacy
behind; for others, writing and publishing may be the preferred method to
gain fame while imparting knowledge at the same time. While my humble
self cannot determine what truly motivates others, the reason I felt compelled
to write this book is that I wanted to share the concepts that had matured from
my pertinacious tiny mind, the myths behind laser surgery in proctology, and
my desire to dispel certain misconceptions about the use of lasers in surgery.
By striving to write this book, I have had the opportunity to pen down my
operative techniques as procedure protocols. I quote the famous quotation by
Toni Morrison that I fondly remember:
If there's a book you want to read, but it hasn't been written yet, then you must write it.
xvii
xviii
The book 'Lasers in proctology!' aims to provide a one-stop guide to the
basics of laser surgery for common anorectal disorders and provides information for aspiring surgeons who aim to build their reputation as specialists in
proctology. While writing this book, I have not only tried to nd answers to
my questions but also explored this from the perspective of what I would have
liked to learn or, more pertinently, what I would have liked to be taught during my residency days. I hope this book provides a practical guide for all
those practicing (or desirous of practicing) colorectal surgery.
The book contains 19 chapters that aim to guide surgical aspirants to practice lasers in proctology. The content is attempted to be written in a manner
that will hopefully provide practical insight into lasers. The endeavor has
been to ensure that the chapters are easy to understand with minimal need for
academic supervision. All the chapters have diagrammatic representations of
the procedures to understand the surgical approach. I have also shared my
experience and opinion with case studies in the various chapters to provide a
step-wise guide.
My persistence has yielded favorable results as I have managed to persuade some of the most esteemed and highly experienced anorectal surgeons
of national and international repute to review some of the chapters, and they
have been gracious to share with me (and you) their knowledge.
Since this book is targeted at and brought into existence for you, dear readers, I welcome suggestions, opinions, and criticism as learning is a continuous process.
Preface
Jalandhar, Punjab, India KamalGupta
Acknowledgments
Writing this book seemed daunting, but I was blessed to receive unwavering
support from my esteemed colleagues and family, which made this exercise
possible.
Foremost, I would like to thank my wife, Dr. Ruby, for demonstrating
inexplicable amounts of patience when I was in the middle of writing the
book. Reading various versions and providing feedback on every chapter so I
could make this book more insightful is, to my mind, one of the more formidable of her many talents.Without her constant support, positive criticism,
and encouragement, this book would not have seen the light of the day.
The term “Minimally Invasive Proctology” was rst introduced to me during my training in VAAFT at IMMAST, Mumbai, by my mentor and teacher,
Dr. Kushal Mital. I visited IMMAST twice as a student and was taught all
there is to know about minimally invasive procedures, except for lasers. Dr.
Mital asked me to join a faculty for lasers in Proctology at IMMAST (formerly known as CeMAST), and that, accompanied by my thirst for knowledge, is the genesis of this book. For this, I will always remain indebted to
him.
The chapter on laser hemorrhoidoplasty was written rst and sent for
review to Prof. Chintamani, President and Governor of the American College
of Surgeons (Indian Chapter). I am deeply thankful to him for providing
insight from a reader and an author’s perspective. With his constant encouragement and excellent suggestions, I could sail through and nish what I
started.
I am also incredibly grateful to Dr. Gulshan Jit Singh and Dr. Jas Kohli for
their contribution to the rst chapter on the introduction to lasers. Dr. Gulshan
Jit is the former head of the department of surgery, Vardhman Medical College
and Safdarjung Hospital, Delhi, India, and a well-known laser surgeon for
varicose veins. After his post-graduation in general surgery, he did his Ph.D.
in Biomedical Engineering from IIT Delhi. Dr. Jas Kohli is an M.Ch. in plastic surgery from Safdarjung Hospital, Delhi, India, and presently practices in
Ludhiana. He is a renowned cosmetic surgeon with a keen interest in lasers.
He is also a well-known humor writer.
I would like to express my deepest gratitude to Dr. Indru Kubhchandani
and Dr. Abdul Majeed Chaudhary for going through the anatomy of the anal
canal and the pathophysiology of hemorrhoids chapters and providing
insightful comments. Dr. Indru Kubhchandani, a colorectal surgeon, practices in Pennsylvania, USA. He has also served as the president of the
xix
xx
American Society of Colon and Rectal Surgeons. Dr. Abdul Majeed
Chaudhary is the principal and chairman of the department of surgery at
Lahore Medical College.
To be a co-author of the chapter on hemorrhoids, with my dear friend Dr.
Niranjan Agarwal, for the Colon and Rectal surgery textbook, by the
Association of Colon and Rectal Surgeons of India was a privilege and an
honor. He also reviewed chapters on anal abscesses and stula. Dr. Niranjan
Agarwal served as the president of the association. He is an esteemed academician and a member of the International Society University of Colon and
Rectal Surgeons executive board. The credit for individualizing the chapters
on conventional procedures from lasers goes to him. I found him to be a very
positive critic and a man with a golden heart.
I sincerely appreciate the feedback on the stulotomy chapter given by Dr.
Ajit Naniksingh Kukreja from Ahmedabad, India. He is the author of the
book Anorectal Surgery Made Easy.
I want to extend my sincere appreciation and gratitude to the surgeons at
St. Mark’s Hospital and Academic Institute, London, for allowing me to
undergo a traveling fellowship in colorectal surgery. This fellowship program
was granted to me as a scholarship by the Association of Colon and Rectal
Surgeons of India. St. Mark’s hospital is revered for surgical management of
anorectal disorders. Established in 1835 by Frederick Salmon, this academic
institute is known for its clinical excellence worldwide. This hospital stands
out as a temple of learning due to the experts who shaped it.
The most outstanding surgeons at St. Mark’s Hospital are recognized for
their advancements in surgical techniques in bowel diseases. They are E.T.
C. Milligan, Morgan, W. B. Gabriel, Park, Goligher, Goodsall, LockhartMummery, H.Graeme Anderson, and F.S. Edwards, to name a few. To reach
an unattainable level of competence, these outstanding surgeons have passed
on their knowledge from generation to generation. Modern techniques and
terminology of some important anatomical landmarks are based on the
ground-breaking research these surgeons accomplished.
My knowledge and surgical techniques in anal stula are primarily drawn
from the wealth of St. Mark’s literature. I think it was Park who rst introduced the idea of minimally invasive surgery for anal stula. He published an
article in 1961 about the importance of excision of the central source of infection and the core out procedure for the distal tract. This article, in my opinion,
was years ahead of its time. My surgical methods are based on Park’s justication for eliminating the internal opening and sphincter-saving during core
out. The degree of the sphincter to be cut during stulotomy has also been
followed as per Park.
I want to thank Dr. Phil Tozer and Dr. G.P Thomas for the valuable knowledge they have provided me during my fellowship at St. Mark’s. It was always
a pleasure to discuss the surgical procedures with them. During my talk on
“Lasers in Proctology,” in the grand rounds, it was an honor to have Dr. Tozer
as a chairperson.
A father gure whom I would like to thank the most is Prof. Ramakant,
former Head of Department of Surgery, King George Medical University,
Lucknow, India, and past president of the Association of Surgeons of India.
Acknowledgments
Acknowledgments
xxi
He taught me the technique of nger-guided hemorrhoidal artery ligation
(FGHAL) in a very informal way. Today, FGHAL is a well-accepted technique for the management of hemorrhoids. In 2018, I had the rst publication
on the FGHAL technique and compared it with Doppler-guided hemorrhoidal
artery ligation (DGHAL). Later, different authors published many papers on
this technique under different names.
This project would not have been possible without the help of my surgical
team. I would like to thank Dr. Neeru Sahni for collecting and compiling the
data. She had collected hundreds of publications on each topic before I started
to pen down the book. My rst surgical assistant, Ms. Harjeet, deserves a
special mention for her patience and assistance in modifying most laser procedures, especially stulas. Ms. Nupur, my ofce manager, was kind enough
to help me prepare rough digital sketches. My sincere thanks to Mr. Partap for
creating clear illustrations out of most of my concept diagrams and all other
members of my dedicated surgical team for their unwavering support.
I want to extend my gratitude to Dr. Suchitra Bindoria for believing in me
and giving me an opportunity to be a faculty at IMMAST, Mumbai. This is
the platform from where I have been able to share my knowledge with all the
young surgeons who come to learn Minimally Invasive Proctology.
Last but not least, I would like to express my gratitude to Dr. Vistasp
H.Edibam from Surat, India, and Dr. Chandan Juneja from Bengaluru, India,
for extending me unconditional support during my learning days. Both are
my batch mates and very dear friends.
A heartfelt thanks to the editors of Springer for publishing this book and
giving me a chance to convey to surgeons the right and safe way of using
lasers in proctology.
KamalGupta
Contents
1 Lasers in Surgery: From Past to Present . . . . . . . . . . . . . . . . . . . 1
1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 History of Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3 Classication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.4 Laser Light Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.5 Thermal Relaxation Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.6 Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.7 Laser and Tissue Interaction . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.7.1 Photothermal Interactions . . . . . . . . . . . . . . . . . . . . . . 4
1.7.2 Photochemical Interactions . . . . . . . . . . . . . . . . . . . . . 6
1.7.3 Photodisruption (Photoacoustic) Interactions . . . . . . . 6
1.7.4 Photoablation Interactions . . . . . . . . . . . . . . . . . . . . . . 6
1.7.5 Plasma-Induced Ablation . . . . . . . . . . . . . . . . . . . . . . . 6
1.8 Interaction Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.9 The Optical Fibers: Size, Structure, and Power Density . . . . . 7
1.10 Types of Fibers to Be Used in Proctology . . . . . . . . . . . . . . . . 7
1.11 A Comparative Study of the Various Wavelengths
of Diode Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.12 Tips Before Use of Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.13 Laser Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.13.1 Safety Measures While Using Laser Fibers . . . . . . . . . 9
1.13.2 Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.14 Laser Versus Cautery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.15 Your Queries! My Answers! . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.16 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.17 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 Surgical Anatomy of Anal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2 Anatomical Relations of Anal Canal . . . . . . . . . . . . . . . . . . . . 14
2.3 Urogenital Triangle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.4 Interior of Anal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.5 Upper Columnar Zone: Contents . . . . . . . . . . . . . . . . . . . . . . . 17
2.5.1 Morgagni Columns . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.5.2 Anal Valves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.5.3 Anal Crypts and Anal Glands . . . . . . . . . . . . . . . . . . . 17
xxiii
xxiv
2.5.4 Dentate Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.5.5 Anal Papillae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.5.6 Anal Cushions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.5.7 Anal Transitional Zone (ATZ) . . . . . . . . . . . . . . . . . . . 20
2.6 Intermediate Zone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.7 Lower Cutaneous Zone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.8 Internal Anal Sphincter (IAS) . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.8.1 Origin and Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.8.2 Thickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.8.3 Importance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.8.4 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.8.5 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.8.6 Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.8.7 Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.9 Conjoined Longitudinal Muscle (CLM) . . . . . . . . . . . . . . . . . 24
2.9.1 Thickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.9.2 Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.10 EAS (External Anal Sphincter) . . . . . . . . . . . . . . . . . . . . . . . . 24
2.10.1 Origin and Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.10.2 Thickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.10.3 Relations of External Anal Sphincter
with Muscles of Perineum . . . . . . . . . . . . . . . . . . . . . . 25
2.10.4 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.10.5 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.10.6 Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.10.7 Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.11 Blood Supply to Anal Canal . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.11.1 Arterial Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.11.2 Venous Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.12 Escape Valve Mechanism: A Signicant Finding . . . . . . . . . . 29
2.13 Anal Canal Lymphatic Drainage . . . . . . . . . . . . . . . . . . . . . . . 29
2.14 Anal Canal Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.14.1 Above Dentate Line . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.14.2 Below Dentate Line . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.15 Anal Canal Histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.16 Pelvic Floor Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.16.1 Levator Ani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
2.16.2 Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.16.3 Innervation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.16.4 Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.16.5 Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
2.17 Anorectal Ring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.18 Anorectal Triangle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.19 Anorectal Angle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.20 Physiology of Anal Canal and Defecation . . . . . . . . . . . . . . . . 34
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Contents
Contents
xxv
3 Anal Cushions and Pathophysiology of Hemorrhoids . . . . . . . . . 37
3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.2 Anatomy of Anal Cushions and Hemorrhoids . . . . . . . . . . . . . 38
3.2.1 Nonvascular Component of Anal Cushions . . . . . . . . . 38
3.2.2 Vascular Component of Hemorrhoids . . . . . . . . . . . . . 38
3.3 Functions of Anal Cushions . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
3.4 Superior Hemorrhoidal Artery (SHA) and Formation
of Corpus Cavernosum Recti (CCR) . . . . . . . . . . . . . . . . . . . . 39
3.5 Physiological Signicance of Anal Cushions
and Their Relation to Defecation . . . . . . . . . . . . . . . . . . . . . . . 42
3.6 Pathophysiology of Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . 43
3.6.1 Sliding Anal Cushion Theory . . . . . . . . . . . . . . . . . . . . 43
3.6.2 Hypervascularization Theory . . . . . . . . . . . . . . . . . . . . 43
3.6.3 Theory of Straining and Constipation . . . . . . . . . . . . . 44
3.7 Correlation Between Anal Tone and Formation
of Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.8 The Fate of Anal Cushions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.9 Classication of Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.9.1 Internal Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.9.2 External Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . 46
3.9.3 Mixed Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3.10 Rectal Varices and Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . 47
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4 Clinical Evaluation of Hemorrhoids . . . . . . . . . . . . . . . . . . . . . . . 49
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.2 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.2.1 Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.2.2 Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.2.3 Thrombosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4.2.4 Mucus Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4.2.5 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4.2.6 Pruritus Ani . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.2.7 Feeling of Lump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.3 History for Evaluation of Hemorrhoids . . . . . . . . . . . . . . . . . . 51
4.4 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.4.1 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.4.2 Palpation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.4.3 Digital Rectal Examination (DRE) . . . . . . . . . . . . . . . 52
4.4.4 Proctoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
4.4.5 Symptoms, Signs, Examination Findings
and Differential Diagnosis at a Glance . . . . . . . . . . . . 53
4.5 Evaluation and Clinical Correlation of Anorectal
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.5.1 Rectal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.5.2 Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.5.3 Perianal/Rectal Mass . . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.5.4 Mucus Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55