Pilonidal Disease
Pilonidal means “nest of hair”. Pilonidal disease refers to an abscess, cyst or sinus in the intergluteal cleft, often containing hair or other debris. They commonly occur along the posterior supreior gluteal cleft. Caused by hair becoming entrapped in the follicle triggering an inflammatory response (by sitting and moving around). Diagnosis is clinical.
Common between puberty and 35 years of age. More common in men. Rare after 40 years of age.
- Signs and symptoms
- Painful fluctuant mass in the sacrococcygeal region
- Local erythema and cellulitis
- Visible sinus tract moving upwards that drains pus
- Treatment
- Hair control around the area: weekly shaving or other hair removal techniques
- Incision and Drainage
- Short term antibiotic for residual skin infection (1st gen cephalosporin, or something to cover gram positives)
- Treat sinus tracts with further surgery: wide excision, curettage, marsupialization, excisions with rotational flaps
Hidradenitis supprurativa
Disease of the apocrine galnds. Painful infection of apocrine glands (axilla in women and groin in men). Predilection to intertriginous regions (perineum, scrotum, labia, inframammary fold). Diagnosis is clinical.
- Signs and symptoms
- Painful, pea-sized or marble-sized comedone(s) that bridge together
- Breaks open releasing pus
- Persists for years
- Local itching and burning
- Worsened by obesity, stress, horomonal chages, smoking, and sweating
- Management
- Surgical therapy: ultimate therapy
- Weight loss
- Lifestyle changes to reduce future problems
- Axillary hidradenitis suppurative
- Perianal hidradenitis suppurativa
- Hidradenitis supprativa, vlvuar, perianal roin status post-removal and contracture
Anorectal abscess
An anorectal abscess is a pus-filled cavity that most commonly develops from an infected anal crypt gland (cryptoglandular infection) following obstruction and bacterial overgrowth**.** The infection begins in the intersphincteris space and may spread upward, downward, and laterally to involve other spaces around the anus and lower rectum. About 50% of anorectal abscesses heal within several weeks after drainage and do not recur. The remainder can form a fistula in ano. If anorectal abscesses remain undrained, necrotizing soft-tissue infection can occur. These carry a 50% mortality.
More common in men than women. Mean age of onset is 40 years (20 – 60 years range). 50% of abscesses develop into fistulas.
Anatomical locations of anorectal abscess
| Anorectal abscess | Location |
|---|---|
| Ischiorectal abscess (most common) | Abscess beneath the levator ani, traverses the external sphincter into the ischiorectal space. Spreads laterally from the crypts, through the external sphincter and into fatty tissue of ischiorectal space |
| Perianal abscess | Abscess beneath the perianal skin, does not traverse the external sphincter. Extends distally from the crypts to skin surrounding anal verge |
| Intersphincteric abscess | Abscess between the internal and external sphincter. Confined to crypts and glands. |
| Supralevator abscess (least common) | Abscess above the levator ani, extension of intersphincteric abscess OR suppurative abdominal condition (appendicitis, complicated diverticulitis). Extends proximally from crypts past the levator ani muscles into the supralevator space. |
- Risk factors for anorectal abscess
- Flow obstruction and infection of anal crypt glands (MCC, 90%)
- Inflammatory bowel disease (chron’s, ulcerative colitis)
- Acute appendicitis, Complicated diverticulitis
- Radiation-induced proctitis (secondary to radiotherapy for ca prostate)
- Iatrogenic (post-hemorrhoidectomy via iatrogenic sinuses or fistulas)
- Foreign bodies (ingested toothpick or bones; stuff in anus >.<)
- Colorectal cancer
- Immunosuppression (may present with leukopenia or perianal pain without noticeable swelling or signs of infection)
- Pathophysiology
- Obstruction of anal glands by debris → stasis and bacterial overgrowth → Abscess
- Extension of abscess into perirectal spaces (intersphincteric, transphincteric, suprasphincteric, extrasphincteric) → fistula formation, bacteremia, sepsis
- Signs and symptoms
- Constant anorectal pain not associated or worsened with defecation
- Swelling at or around the rectum/anus
- Fever and chills
- Apparent cellulitis or abscess on buttock
- Area of focal tenderness on DRE
- Erythematous, subcutaneous mass near the anus = perianal abscess
- Rectal or perirectal drainage (bloody, purulent, mucoid) = perirectal abscess
- Purulent drainage from the anal canal or anoderm = Fistula
- DRE findings for anorectal abscess
- Fluctuant, indurated mass
- Pain with pressure
- Investigations
- CT or MRI scan: confirm location of deep abscess
- Anal ultrasound: confirm deep abscess
- Proctosigmoidoscopy or anoscopy: rule out other comorbidities (IBD, Malignancy)
- Fistula probe with methylene blue: identify possible fistulae and comorbidities (IBD, Malignancy)
- Treatment
- Incision and drainage: stops further infection and tissue damage (can lead to sphincter damage, promote fistula formation, and lead to sepsis)
- Sitz bath
- Analgesics and stool softeners
- Post-op antibiotics: ciprofloxaxin and metronidazole to cover gram-negatives and anerobes.
- Indications for post-operative antibiotics
- Immunocompromised patients
- Diabetic patients
- Patients with valvular heart disease
Fistula in Ano
A Fistula in Ano is a communication between the anal canal and perianal skin. They are a notorious complication of perianal abscess and Crohn’s disease. It can occur where a drain was placed or the incision made to drain the abscess was made. Fistula in ano can result in recurrent abscesses. Patients are often bothered by purulent or feculent drainage from the external opening. The location of the internal opening can be determined using Goodsall’s rule. Diagnosis is clinical.
Goodsall’s rule for fistula in ano
| Opening in relation to transverse anal line | Tract |
|---|---|
| Anterior opening | Travels in a radial (straight) path to the anal canal |
| Posterior opening | Travels in a curved tract to the anal canal. PC = Posterior opening takes a Convoluted course |
| Opening more than 3 cm from the anus | May travel in a curved tract to the anal canal |
Classification of fistula in ano (Park’s)
| Classification | Description |
|---|---|
| Intersphincteric | Penetrates internal sphincter to intersphincteric space |
| Transsphincteric | Penetrates internal and external sphincters to ischiorectal fossa |
| Suprasphincteric | Penetrates levator ani |
| Extrasphincteric | From the rectum above the dentate line through the levator ani |
- Signs and symptoms
- Feculent or purulent peri-anal discharge
- Perianal or rectal pain
- Swelling
- Bleeding
- External opening visible
- Investigations
- Proctosigmoidoscopy or anoscopy under anaesthesia: for formal diagnosis
- Treatment
- Fistulotomy: cut along the length of the fistula to open it. Leave to heal by secondary intention.
- Seton placement (cutting or draining): placed to keep the fistula tract open, ensure adequate drainage and fibrosis (healing). Cutting setons slowly divide the fistula while maintaining continence
- Fibrin glue or fistula plug: provides scaffolding for collagen deposition,
- Treat the underlying cause e.g. crohn’s disease
- Antibiotics
- Indications for fistulotomy
- Intersphincteric and low transphincteric fistulas
- Indications for seton placement
- High transsphincteric, suprasphincteric and extrasphincteric fistula
Genital warts
This is an STD caused by HPV. Transmitted via anal intercause. HPV-6 and HPV-11 cause warts. Also exposed to HPV-16 and HPV-18 and are likely to develop cancer.
- Signs and symptoms
- Itching and burning
- Sessile or peducnulous0like masses, 1-5 mm
- Variable in color, painless, rarely bleed
- Found on the penis, vulva, vagina, cervix, perianal skin, perianal canal
- Investigations
- Biopsy
- Differentials
- Molluscum contagiosum: smaller, not always STD, umbilicated or “dimpled” center
- Medical treatment
- Bichloroacetic acid
- Podophylin
- Imiquimod
- Surgical treatment
- Cryotherapy
- Local excision with electrocoagulation
