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Advancement flaps When the sphincter complex is not too indurated and adequate intra-anal access can be obtained, an advancement flap tech nique can be employed; this aims to preserve both anatomy and function. Ideally sepsis and secondary tracks have healed, le...

Aetiology The cause of an anal fissure, and particularly the reason why the posterior midline is so frequently a ff ected, is not completely understood. The location in the posterior midline may relate to the shearing forces acting at that site at defecation, c...

Anal advancement flap An anal advancement flap to cover the anal fissure should be considered in those with an increased risk of altered conti nence following lateral internal sphincterotomy , especially in postpartum women and those with normal or low resting a...

Anal canal anatomy The anus is 3–4 /uni00A0 cm long in adults, being longer in the adult male than in the female. Posterior is the anococcygeal ligament, which separates it from the tip of the coccyx, while anteriorly it is separated by the perineal body from...

Anal sphincter surgery In situations where conservative treatment has failed, and where a discrete disruption of the sphincters exists, the ends of the divided muscle are found and reunited by an overlap repair (Parks) ( Figure 80.12 ). Short-term results are...

Biological agents The functional consequences of fistulotomy have led to a search for agents that seal the fistula track and allow ingrowth of healthy tissue to replace it. Intuitively , success must depend on the biomaterial itself and the environment into w...

CONDYLOMATA ACUMINATA (ANAL WARTS) There is increasing evidence that sexually transmitted infection with human papillomavirus (HPV) forms the aetiological basis of anal and perianal warts, anal intraepithelial neoplasia (AIN) and SCC of the anus. In areas of...

CONGENITAL ABNORMALITIES Early in embryonic life there is a common chamber – the cloaca – into which the hind gut and the allantois open. This endoderm-lined chamber is separated from the surface ecto derm of the embryo by the cloacal membrane. The cloaca bec...

Classification The most widely used classification of anal fistulae (Parks’) is based on anal gland sepsis in the intersphincteric space (the internal opening is at the dentate line); this results in a primary track whose relation to the external sphincter defines...

Clinical assessment A full medical (including obstetric, gastrointestinal, anal surgical and continence) history and proctosigmoidoscopy are necessary to gain information about sphincter strength and to exclude associated conditions. The key points to determin...

Clinical features Although superficial, acute anal fissures are characterised by severe anal pain during defecation (‘passing glass’ or ‘a knife cutting’), which usually resolves only to recur at the next evac uation. Frequently a trace of fresh blood is notice...

Diagnosis and management A high index of suspicion and targeted biopsy yields the diag nosis, whereas multiple (mapping) biopsies give an indication of the extent and overall severity of the disease. AIN /uni00A0 III should be regularly monitored clinically...

Differential diagnosis The only conditions with which an anorectal abscess is likely to be confused are abscesses connected with a pilonidal sinus, Bartholin’s gland or Cowper’s gland. Management of acute anorectal sepsis is primarily surgical, including care...

Digital examination with the index finger With an adequately lubricated index finger, the soft tissues around the anus are palpated for induration, tenderness and subcutaneous lesions. The index finger is then introduced gently into the anal canal along its poste...

EXAMINATION OF THE ANUS Careful clinical examination will be diagnostic in the vast majority of patients complaining of anal symptoms, but it requires a relaxed patient who is informed of what the examination will entail, a private environment, a chaperone ...

Endometriosis Endometriosis of the rectovaginal septum may present as a stricture. There is usually a history of frequent menstrual periods with severe pain during the first 2 days of the menstrual flow .

External haemorrhoids A thrombosed external haemorrhoid relates anatomically to the veins of the superficial or external haemorrhoidal plexus and is commonly termed a perianal haematoma. It presents as a sudden onset, olive-shaped, painful blue subcutaneous sw...

FISTULA- IN-ANO Aetiology A fistula- in - ano , or anal fistula, is a chronic abnormal commu nication extending from the anorectal lumen (the internal opening) to an external opening on the skin of the perineum or buttock (or rarely , in women, to the vagina). T...