Dr Sandhya Pillai - GP CME
Transcript of Dr Sandhya Pillai - GP CME
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Dr Sandhya PillaiGeneral & Oncoplastic Breast Surgeon
Shorewest Surgical Care
16:30 - 17:25 WS #181: Perinanal Conditions and Pilonidal Disease
17:35 - 18:30 WS #193: Perinanal Conditions and Pilonidal Disease
(Repeated)
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PERIANAL CONDITIONS &
Dr Sandhya Pillai
General and Oncoplastic Breast Surgeon
CMDHB
Shorewest Surgical Care
Auckland Breast Centre
PILONIDAL DISEASE
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• Can take a long time to fix
PERIANAL CONDITIONS
• Take a long time to present
• Set expectations early
• Lifestyle modification to prevent recurrence/ allow healing
• Take a good history – lots of clues
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6 o’clock back
THE ANAL CLOCK
12 o’clock front
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• Spot diagnoses
PERIANAL CONDITIONS
12 important perianal conditions
• What to say to your patient
• What to do for your patient
• When to refer
• What the specialist does
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WHAT IS IT?Perianal
hematomaa) Prolapsed haemorrhoid
b) Perianal hematoma
c) Abscess
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CONFUSION CLEARED!
Perianal hematoma
(external haemorrhoids)
Prolapsed Internal
haemorrhoids
“Bunch of grapes” “Perianal bruise”
Thrombosis inferior haemorrhoidal
venous plexusProlapsed swelling of anal cushions
(superior haemorrhoidal venous plexus)
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ANATOMY
Dentate
line
Superior
haemorrhoidal venous
plexus
Inferior haemorrhoidal
venous plexus
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PERIANAL HAEMATOMA
(EXTERNAL HAEMORRHOID)
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PERIANAL HEMATOMA – WHAT TO LOOK FOR?
• Raised
• blue tinged
• painful lump
• just under skin
• Coloured perianal area
• Sudden pain and swelling
• Anal margin
• With straining or heavy lifting
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PERIANAL HEMATOMA – WHAT TO TELL PATIENT?
• It will go away over 1-4 weeks
• It will get less painful gradually
• Take pain relief
• Sitz baths helpful for comfort
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PERIANAL HEMATOMA – WHEN TO REFER?
REFER ACUTELY
If skin necrotic or infected
FOR DEROOFING and EVACUATION HEMATOMA
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WHAT IS IT?
Haemorrhoids(a)Worms
(b)Prolapsed haemorrhoids
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INTERNAL HAEMORRHOIDS
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WHY DO HAEMORRHOIDS OCCUR?
Increased intraluminal pressure
Obstruction and dilatation
Of venous plexus
loss of elasticity of the fibrous scaffolding
around submucosal venous plexus
Shearing forces
Swollen prolapsing haemorrhoids
+ shearing forces (constipation)
CONSTIPATION
bleeding
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CLASSIFICATION
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WHAT TO LOOK FOR?
• Painful prolapsed/ thrombosed
• Necrotic skin/infection
mass
• Painless Bleeding
• Outlet type bleeding
• Itch
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WHO NEEDS A COLONOSCOPY?
• age >50y
• Red flag symptoms – pain on defecation, change in BH, PR mass
• Significant family history
• Ongoing bleeding despite adequate treatment of haemorrhoid
not everyone with haemorrhoids needs a colonoscopy
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ACUTE THROMBOSED PAINFUL - WHAT TO TELL PATIENT?
• It will take 1-2weeks to settle completely
• Topical: proctosedyl, ultraproct, voltaren
• Oral: paracetamol, Voltaren
• sitz baths, ice, glucose syrup soaked gauze
• Banding or surgery can help once it settles
• Prevention of recurrence – fix constipation
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LIFESTYLE CHANGE: WHAT TO TELL PATIENT?
MODIFIABLE FACTORS
The Four “F”s
• Fruit
• Fibre
• Fluid
• Fitness
& Routine
RECUR
UNLESS WE
FIX
CONSTIPATION
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HAEMORRHOIDS – WHEN TO REFER?
REFER ACUTELY
• necrotic skin
• infection
• acute symptoms can’t be managed in community
REFER ELECTIVELY
• Ongoing bleeding – needs banding or surgery
• Red flags
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ELECTIVE SURGICAL MANAGEMENT
1st/2nd degree
More than once
5% phenol in almond oil
Into submucosa around plexus
Prostatitis
Impotence
Mucosal ulceration
Pelvic sepsis
Rectovaginal fistula
• Banding/infrared coagulation
• Sclerotherapy
• Single pedicle haemorrhoidectomy
• Stapled haemorrhoidectomyCircumferential
Less pain and faster recovery
More stricture and prolapse
USS guided ligation
Less bleeding and pain
For high risk patients• HAL-RAR
Care to leave skin bridges
Grade 3-4
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WHAT TO TELL PATIENTS AFTER TREATMENT
POST BANDING:
• Sensation of fullness for ≥ 5 days
• Do not strain
• Bleed 1-2 days now normal
• 7-10day bleed normal
• Repeatable
• Lifestyle change
POST HAEMORRHOIDECTOMY :
• Take regular pain relief
• Avoid constipation – laxatives
• Sitz bath
• Shower/wet wipes after BM
• Takes 6-12 weeks to heal
• Needs 2weeks off work
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(a) Fistula in ano
(b) Pilonidal disease
WHAT IS IT?
Pilonidal sinus
disease
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WHY DO I HAVE PILONIDAL SINUS - WHAT TO TELL PATIENT
Combination of factors:
• deep cleft
• ingrown hairs
• Friction/shearing forces
• Hygiene
• Occupations
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Pilonidal sinus
Pilonidal cyst Pilonidal abscess
PILONIDAL SINUS – WHEN TO REFER
Incidental, asymptomatic
leave it alone
REFER elective surgery
Symptomatic discharging
REFER elective surgery
Lateral swelling & pits
No inflammation
REFER acute surgery
Swelling with
inflammation
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PILONIDAL SINUS – ELECTIVE SURGERYPurpose of surgery
• decrease the depth of the cleft
• take the cleft off the midline
Karydakis
Off-midline closure
Limberg rotation flap
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PILONIDAL SINUS - AFTER ELECTIVE SURGERY
• It is skin surgery
• BUT IT IS NOT MINOR SURGERY
• Time of work/school – minimum 2 weeks
• Recovery can take 2-12 weeks
• Drains can be in for a while
• 50% wound breakdown risk – variable extent
• Recurrence prevention – hygiene and epilation once healed
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• Pilonidal sinus
FIRST QUARTER TAKE HOME MESSAGES
• Acute referral - necrotic/infected/unmanageable
• Red flags
• Lifestyle modification for recurrence prevention
• Perianal hematoma
& haemorrhoids
• Risk factor elimination – hairs, hygiene
• Don’t treat asymptomatic
• Surgery – cleft off midline and decrease depth
• Acute – abscess only
• Set expectations early – recoperation, complications
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(a) Fistula in ano
(b) Pilonidal sinus
(c) Abscess
WHAT IS IT?
Fistula in ano
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An abnormal chronic granulation tissue lined tract between the anorectal
mucosa and skin
FISTULA IN ANO – WHAT IS IT?
2ndary causes: Crohns, tb, malignancy, trauma, foreign body, iatrogenic, HIV
CRYPTOGLANDULAR THEORY
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• Recurrent discharge/fistula only
• perianal or ischioanal abscesses
• Assess risk factors for secondary causes
• Pruritis
FISTULA IN ANO - WHAT TO LOOK FOR?
small hole perianal – base of scrotum
Inflammation/abscess
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Perianal
• Coloured area perianal
• Painful fluctuant lump
• Few systemic symptoms
• Earlier presentation 1-2d
FISTULA IN ANO – ABSCESS – PERIANAL VS ISCHIOANAL?
Ischioanal
• Further from anal verge
• Between Ischial tuberosity
and anal verge
• Induration and pain- days
• High fevers
• Fluctuance is a late sign
• Later presentation 5-7d
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Antibiotics do not get rid of perianal abscesses – they need drainage
FISTULA IN ANO – WHAT TO DO?
REFER ACUTELY IF ABSCESS
Do not drain under local anaesthetic in clinic – severe vagal responses
REFER ELECTIVELY
TO A COLORECTAL SURGEON
IF FISTULA
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SURGICAL TREATMENT PRINCIPLES
DEFINE THE ANATOMY • EUA
• MRI
MANAGE THE SYMPTOMS • Analgesia
• Sitz bath
DRAIN THE SEPSIS • Antibiotics
• Drainage
• Seton
ERADICATE THE SURGICAL
TRACT & PRESERVE SPHINCTERS
• Surgical
techniques
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• Recurrent problems
• Multiple fistulae
• History red flags for secondary causes
WHO NEEDS COLONOSCOPY
MOST DO NOT NEED COLONOSCOPY
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All have only average of 50% success
SURGICAL OPTIONS
Method Success Incontinence
Laying open 45-80% 20-30%
Cutting seton (no longer
used)
30% 50%
Painful and no better
than non cutting
Non cutting seton Low fistula 50%
High fistula 30%
Low fistula 30%
High fistula 50%
Mucosal advancement flap
45-80% 20-35%
Surgissis plug 50% Nil significant
3% sepsis
Ligation Intersphincteric
Fistula Tract (LIFT)
Low fistula
50-80%
10-15%
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(a)Perianal wart
(b)Perianal tag
(c)Thrombosed haemorrhoid
WHAT IS IT?
Perianal tag
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PERIANAL TAG – WHAT TO TELL PATIENT
• Cause : Scar tissue from attempts at healing
• Need to check for & treat underlying cause if any
• Not a cancer
• Can leave it alone unless it causes problems
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PERIANAL TAG – WHAT TO DO
• Look for underlying cause
• Treat underlying cause
• Reassure patient
• fissure
• haemorrhoids• previous surgery
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PERIANAL TAG – WHEN TO REFER
REFER ELECTIVELY:
• Hygiene issue
• Swelling and irritation
• Underlying cause requires specialist input
• Patient wants it excised
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WHAT IS IT?
Anal fissure
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ANAL FISSURE – WHAT TO LOOK FOR?
• Constipation
• burning pain on defectation
Splay to see
Not always possible – pain/muscle spasm
PR exam – often not feasible
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SPOTTED AN ANAL FISSURE – WHAT TO DO?
Constipation
Tear in skin of anus
Muscle spasm
• Fruit
• Fibre
• Fluid
• Fitness
• Routine
• Laxatives
• Rectogesic 0.2%
• Diltiazem 2%
Haemorrhoid topical agents don’t help
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ANAL FISSURE – WHEN TO REFER?
REFER ELECTIVELY
• 6 weeks diltiazem has not worked
• Recurrent problem
• Red flags
• Can’t spot a fissure & history not classical or older patient
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SURGICAL TREATMENT – RELAX THE SPHINCTER
• Intersphincteric
• Muscle relaxation
• Lasts 3 months
• Fix constipation in interim
• Fissure heals
• Can be repeated
• Upto ½ length of int sphincter men
• Upto 1/3 length of sphincter women
• Very rarely done in women
• Permanent
• Incontinence it weak sphincter already
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• Perianal tag
SECOND QUARTER TAKE HOME MESSAGES
• Look for red flags – secondary causes
• Set expectations early 15% recurrence, 50% success
• Distinguish perianal and ischioanal abscesses
• Antibiotics and drainage in clinic can’t fix perianal abscesses
• Fistula in ano
• Treat underlying cases
• Refer if symptomatic
• Anal fissure • Rule out red flags
• BREAK THE VISCIOUS CYCLE for resolution
• Lifestyle modification
• Diltiazem ointment
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WHAT IS IT?
Pruritis ani
(a)Pruritis ani
(b)Skin lesions
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PRURITIS ANI – WHAT TO LOOK FOR?
Look for underlying cause
• SCC ANUS
• Bowen’s disease (SCC insitu) anus
• Fissure
• Fistula
• Haemorrhoids
• Warts
• Tags
• Incontinence
• Worms
• Fungal infection
• Dermatitis
Ask about
• Toileting behaviours
• Hygiene practices
• Topical medications
• Recent antibiotics
Perianal and PR
examination
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PRURITIS ANI– WHAT TO DO?
Treat any underlying
cause
Advise
Refer
• Sensitisation of local receptors
• Stop itching
• Cut nails
• Firm up BM
• Keep dry
• Zinc oxide barrier cream
• Don’t overly clean
• 5days 1% hydrocortisone
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PRURITIS ANI – WHEN TO REFER?
Elective referral to Colorectal surgeon
• Skin protection - Berwicks dye + tincture of benzoin
• Desensitisation - 0.006% capsaicin; Methylene blue with LA
• Underlying cause
• Severe skin changes
• Symptoms not manageable
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WHAT IS IT?
Rectal prolapse
(a)Prolapsed haemorrhoids
(b)Anal cancer
(c)Rectal prolapse
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RECTAL PROLAPSE–WHAT TO TELL PATIENTS?
• Rare condition
• Over 50y
• female
• Developmental delay
• psychiatric problems
• multiple meds
• Multifactorial - rectum loses scaffolding
• The longer without treatment the more other problems – incontinence
• Not everyone needs surgery
• Surgery is the only definitive treatment
• Avoid constipation
• Use bulking agents for stool
• Supportive garments
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RECTAL PROLAPSE – WHAT TO LOOK FOR?
Rectal mucosal
prolapseFull thickness
rectal prolapse
Prolapsed
haemorrhoids
Internal rectal
prolapse
History – circumferential lump, mucous, soiling, lump falling out, sitting on a ball,
obstructed defecation, incomplete emptying, encore defecation
Examination – circumferential not bunch of grapes
PR with straining, strain while squatting (not always seen lying down)
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RECTAL PROLAPSE – WHAT TO DO?
REFER TO A COLORECTAL SURGEON
• If well enough to have surgery
• Surgery is the only available definitive treatment
• The longer it is left the more other problems like incontinence ensue
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RECTAL PROLAPSE– SURGICAL TREATMENT?
Specialist Colorectal Surgeon
Perineal approachLaparoscopic/Open
Abdominal rectopexy
Perineal mucosal sleeve
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RECTAL PROLAPSE– PERIANAL VS SURGICAL?
Perineal approaches Abdominal approaches
• Less sexual dysfunction
• young males, older
• Spinal anaesthesia
• Less pain
• 10% recurrence
• 50% continence improvement
• 1-2% sexual dysfunction
• 2-5% recurrence
• GA
• More effective for bigger prolapse
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WHAT IS IT?
Proctalgia
fugax
MY BUTT
HURTS
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PROCTALGIA FUGAX–WHAT TO TELL PATIENTS?
• Can be exacerbated by
• Stress
• Intercourse
• Menstruation
• Constipation
• Defecation
• Severe muscle spasms around the anus of unknown cause
• Diagnosis of exclusion
• Can’t necessarily cure – functional disorder
• Can help to manage the pain
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PROCTALGIA FUGAX– WHAT TO LOOK FOR?
• Painful spasms minutes to hours
• Can wake them at night
• Associated triggers
• Recent surgery
• Red flags
Exclude other causes:
Fistula
Abscess
Fissure
Haemorrhoids
Cancer
IBD
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PROCTALGIA FUGAX – WHAT TO DO?
• Rule out other causes - Colonoscopy
• Reassurance
• Warm bath
• Diltiazem ointment 2%
• Salbutamol 200mcg tds/prn
• Stress counselling
Low level evidence – case series
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PROCTALGIA FUGAX – WHEN TO REFER?
REFER TO COLORECTAL PELVIC FLOOR CLINIC
• Red flags
• No organic cause found & Symptoms not settling after 3 months
• MRI
• Colonoscopy
• Manometry
• Clonidine 150mcg bd
• Local anaesthetic injection
• Botox
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• Rectal prolapse
THIRD QUARTER TAKE HOME MESSAGES
• Treat any underlying causes
• Advise patients – lifestyle modification – toileting, hygiene, itching
• Set expectations early
• Pruritis ani
• IT is circumferential NOT a bunch of grapes
• Surgery is the only definitive treatment
• Can manage symptoms with non surgical means
• Proctalgia
fugax
• Look for red flags – if could be cancer
• Diltiazem/salbutamol/stress management
• Set expectations early
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WHAT IS IT?
Fecal
incontinence
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FECAL INCONTINENCE – WHAT TO LOOK FOR?
SEVERITY OF SYMPTOMS • Frequency
• Obstructed defecation, encore defecation
• Type – urge, stress, awareness, flatus/faeces
• Social impact
SPHINCTER INJURY • Obstetrics – multiple pregnancies,
episiotomy, forceps, big babies
• Perianal surgery
• Trauma
• Neurological disease
ASSOCIATED SYMPTOMS • Urinary incontinence
• PR bleeding or mucus
• Change in BH
IBD
Cancer
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FECAL INCONTINENCE– WHAT TO LOOK FOR?
Perianal examination: Is the anus level with the ischial tuberosities
PR examination: bulge touches finger on straining
Pelvic floor
issues
PR examination: Is the sphincter deficient anywhere Anatomical
sphincter issue
PR examination: Does the sphincter clench tightlySphincter
dysfunction
PR examination: Is there a bulge into the vagina rectocele
prolapse
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FECAL INCONTINENCE – WHAT TO DO?
• Colonoscopy to rule out other causes if red flags
• Constipating medications
• Dietary change – alcohol, caffeine
• Bulking agents
• Pelvic floor exercises
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FECAL INCONTINENCE– WHEN TO REFER?
REFER TO COLRECTAL PELVIC FLOOR CLINIC AND PHYSIOTHERAPIST
• Red flags for further investigation
• No organic cause and symptoms not settling after 3 months and
are debilitating
• Endoanal ultrasound – sphincter anatomical integrity
• Mamometry – sphincter function
• Defecating proctogram – prolapse/rectocele
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FECAL INCONTINENCE – TREATMENT?
• Management – nappies, hygeine
• Biofeedback/ Bowel retraining
• Pelvic floor exercises
• Sphincter repair
• Sacral Nerve stimulator implantation
• Surgery for rectocele or prolapse
• Anal bulking agents – lipofilling, microspheres, collagen
• Colostomy – last resort for quality of life50%
success
Dependant on the underlying cause for the incontinence
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WHAT IS IT?
Anal warts
condylomata
accuminata
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ANAL WARTS – WHAT TO ASK/LOOK FOR?
CONTRIBUTORY FACTORS • Sexual history
• HIV status
• Immunosuppressants
EXAMINATION • Perianal
• Perineum
• PR – mass
• proctoscopy
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ANAL WARTS– WHAT TO DO?
• HPV vaccination – decrease recurrence – not funded in adults for this
• Advise on safe sexual practices
• Treat – symptomatic or dysplasia - Topical treatments +/- surgery
Colorectal referral
• Internal or difficult to treat
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ANAL WART – TOPICAL TREATMENT?
• Podophyllotoxin
• Imiquimod tds 16 weeks – 48% response; 34% partial response; 34% recur
• 5-fluorouracil 9-16weeks bd– 90% response; 50% recurrence
• Photodynamic therapy
• Targeted treatment – infrared, electrocautery, crytotherapy
• Surgical excision – best if combined with cautery
Imiquimod +
surgery highest
clearance rates
Lowest recurrence
Warts are LSIL
Yearly
surveillance
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WHAT IS IT?
Anal SCC
(a)Non healing fistula
(b)Anal SCC
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ANAL IN SITU NEOPLASIA (AIN) – SCREENING?
• asymptomatic
• Conflicting evidence
• AIN can progress to anal cancer – rates are low
• Some high risk groups may have a higher risk of progression
• Spontaneous regression can occur in some groups
LSIL to HSIL 12-24%
HSIl to SCC 8-11%
No evidence for population based screening – low rate of conversion
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ANAL IN SITU NEOPLASIA (AIN) – REFER?
REFER HIGH RISK GROUPS
LSIL – 12 monthly review
HSIL – 3 to 6 monthly review
• History & Examination
• Pap smear – high false positives - anoscopy
• Anoscopy (acetic acid and lugols iodine)
• Biopsy new or suspicious lesions
• for progression to HSIL• treat for symptoms not preventing progression
• Control of dysplasia
• Preservation of function
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ANAL IN SITU NEOPLASIA (AIN) – TREATMENT?
• Topical treatments – imiquimod/5-fu
• Surgery
• SurveillenceCombination best
Iradication
function
preservation
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ANAL SCC – WHAT TO DO?
• Risk factors assessment – HPV, AIN, smoking, high risk sexual
behavior, HIV, immunosuppression, crohns, females, chronic
inflammation
High index of suspicion
REFER EARLY
Ulcer or mass - +/- bleeding/pain/tenesmus/pruritis
Investigations:
• Endoanal USS
• MRI
• CT staging
• PET staging
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ANAL SCC – SURGICAL TREATMENT?
Purpose of treatment:
• Ablate the cancer
• Preserve sphincter function
• Most can be treated with radiation and chemotherapy 70%
success & 75% 5y survival
• Dermatitis, sexual dysfunction, proctitis, tenesmus, stenosis, bladder
dysfunction, DVT
• 30% need surgery – non responsive/recurrence
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• Anal warts
FOURTH QUARTER TAKE HOME MESSAGES
• Detailed history vital
• Red flag identification – Cancer/IBD
• Thorough exam
• Fecal
incontinence
• HPV infection
• Ascertain risk
• thorough examination
• Refer if difficult to treat or internal or symptomatic
• AIN & SCC• LSIL – yearly review; treat for symptoms
• HSIL – 3 to6 monthly review; treat to control dysplasia
and preserve function
• Anal SCC – high index of suspicion; aim of treatment is
cancer ablation and sphincter preservation; most get
chemoradiation
• Anus to tuberosity
• Sphncter thickness
• Squeeze
• Bulge into vagina
• Prolapse
• mass
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PERIANAL CONDITIONS
Pilonidal sinus & abcess
Perianal tag
Perianal
hematoma
Anal
fissure
Fistula in ano
Rectal
prolapse Pruritis
Ani
Proctalgia
fugax
Fecal
incontinence
Anal
SCC
Anal Warts
Haemorrhoids
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PERIANAL CONDITIONS TAKE HOME MESSAGE
• Spot recognition
• Look for red flags and refer early
• Set patient expectations early
• Advise about lifestyle modification
• Refer if symptoms not manageable in primary care or if red flags
or need surgical intervention
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