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Operations to augment the anal sphincters If the degree of sphincter disruption or weakness is such that restoration of function cannot be achieved by direct means, the sphincter can be augmented by using muscle transposed from nearby (gluteus maximus or gr...

Operations Indications The indications for haemorrhoidectomy include: /uni25CF third- and fourth-degree haemorrhoids; /uni25CF second-degree haemorrhoids that have not been cured by non-operative treatments; /uni25CF ‘mixed’ haemorrhoids when the external haem...

Operative measures Anal sphincter dilatation has been used to reduce sphincter tone; however, this potentially disrupts the anal sphincters at multiple sites with an associated risk of incontinence such that it is rarely indicated.

Other anal malignancies Adenocarcinoma within the anal canal is usually an extension of a distal rectal cancer. Rarely , adenocarcinoma may arise from anal glandular epithelium or develop within a longstand - ing (usually complex) anal fistula, hence the need t...

Other techniques Video-assisted anal fistula treatment (V AAFT) involves the introduction of a rigid fistuloscope into the tract through the external opening. The scope has a channel to accommodate a forceps, brush or diathermy . The scope is passed into access...

PHYSIOLOGICAL ASPECTS OF THE ANAL SPHINCTERS AND PEL VIC FLOOR Anal continence and defecation are highly complex processes that necessitate the structural and functional integrity of the cerebral, autonomic and enteric nervous systems, the gastro - intestina...

PRURITUS ANI This is intractable itching around the anus, a common and embarrassing condition. Usually , the skin is reddened and hyperkeratotic and it may become cracked and moist. The causes are numerous but most commonly relate to poor or excessive hygiene,...

Pathology Occlusion of gland ducts leads to bacterial proliferation, gland rupture and the spread of infection and epithelial components into the surrounding soft tissue and to adjacent glands. Second - ary infection causes further local extension, skin damag...

Pilonidal sinus The term pilonidal sinus describes a condition found in the natal cleft overlying the coccyx, consisting of one or more, usually non-infected, midline openings, which communicate with a fibrous track lined by granulation tissue and containing h...

Postanal dermoid The space in front of the lower part of the sacrum and coccyx may be occupied by a soft, cystic swelling – a postanal dermoid - cyst. Hidden in the hollow of the sacrum it is unlikely to be discovered unless a sinus communicating with the ex...

Postoperative care In many countries, haemorrhoidectomy is performed on a day-case basis. The patient is instructed to take two warm baths each day and is given a bulk laxative to take twice daily , together with appropriate analgesia. A 5-day course of oral ...

Postoperative complications Postoperative complications may be early or late. Early complications include: /uni25CF Pain . Opiate analgesia, local anaesthetic agents, GTN and calcium channel blockers, together with botulinum toxin are useful postoperative adju...

Presentation A perianal abscess, confined by the terminal extensions of the longitudinal muscle, is usually associated with a short (2–3 day) history of increasingly severe, well-localised pain and a palpable tender lump at the anal margin. Examination reveals...

Principles of fistula surgery The aim of surgery is to keep the patient continent and comfortable and whenever possible to eradicate the fistula. John of Arderne , 1307–1390, was the first English surgeon of note. He practised at Newark-on-Trent, and, from 137...

Proctalgia fugax This problem is characterised by attacks of severe pain arising in the rectum, recurring at irregular intervals and apparently unrelated to organic disease. The pain is described as cramp-like, often occurring at night, lasting minutes and di...

Proctoscopy Proctoscopy , performed with the patient in the same position, allows a detailed inspection of the distal rectum and anal canal ( Figure 80.4 ). Minor procedures can also be carried out through this instrument, e.g. treatment of haemorrhoids by i...

Rectal examination The finger encounters a sharply defined shelf-like interruption of the lumen. If the calibre is large enough to admit the finger, it should be noted whether the stricture is annular or tubular. Sometimes this point can be determined only afte...

Sigmoidoscopy Although sigmoidoscopy is strictly an examination of the rectum, it should always be performed as rectal pathology is frequently associated with an anal lesion (e.g. anal fistula); not infrequently , rectal pathology is found independent of the ...