important component in the evaluation of patients with 219

fecal incontinence. manual inflation of a cuff placed around the anus,

The evaluation of fecal incontinence should include increasing anal tone. This allows the patient to manually
a thorough history and physical examination, anal close off the anal canal until defecation is necessary.
manometry, pudendal nerve terminal motor latency Long-term results following overlapping sphinctero­
(PNTML), and endoanal ultrasound. Unfortunately, plasty show about a 50% failure rate over 5 years. Poorer
all of these investigations are user-dependent. Cen- outcome has been seen in patients with prolonged
ters that care for patients with fecal incontinence will PNTML. Long-term results for sacral stimulation have
have an anorectal physiology laboratory that uses stan- been promising; however, the indications for this proce­
dardized methods of evaluating anorectal physiology. dure are presently limited in the United States. Unfortu­
Anal manometry measures resting and squeeze pres- nately, the artificial bowel sphincter has been associated
sures within the anal canal using an intraluminal water- with a 30% infection rate.
perfused catheter. Pudendal nerve studies evaluate the
function of the nerves innervating the anal canal using a
finger electrode placed in the anal canal. Stretch injuries HEMORRHOIDAL DISEASE
to these nerves will result in a delayed response of the Incidence and epidemiology
sphincter muscle to a stimulus, indicating a prolonged

CHAPTER 19
latency. Finally, ultrasound will evaluate the extent Symptomatic hemorrhoids affect >1 million individu-
of the injury to the sphincter muscles before surgical als in the Western world per year. The prevalence of
repair. Only PNTML has been shown to consistently hemorrhoidal disease is not selective for age or sex.
predict outcome following surgical intervention. However, age is known to have a deleterious effect on
Rarely does a pelvic floor disorder exist alone. The the anal canal. The prevalence of hemorrhoidal disease
majority of patients with fecal incontinence will have a is less in underdeveloped countries. The typical low-
fiber, high-fat Western diet is associated with constipa-

Diverticular Disease and Common Anorectal Disorders

degree of urinary incontinence. Similarly, fecal inconti-
nence is a part of the spectrum of pelvic organ prolapse. tion and straining and the development of symptomatic
For this reason, patients may present with symptoms hemorrhoids.
of obstructed defecation as well as fecal incontinence.
Careful evaluation including cinedefecography should Anatomy and pathophysiology
be performed to search for other associated defects. Sur-
gical repair of incontinence without attention to other Hemorrhoidal cushions are a normal part of the anal
associated defects may decrease the success of the repair. canal. The vascular structures contained within this tis-
sue aid in continence by preventing damage to the
sphincter muscle. Three main hemorrhoidal complexes
TREATMENT Fecal Incontinence traverse the anal canal—the left lateral, the right ante-
rior, and the right posterior. Engorgement and strain-
The “gold standard” for the treatment of fecal inconti­ ing leads to prolapse of this tissue into the anal canal.
nence with an isolated sphincter defect is overlapping Over time, the anatomic support system of the hem-
sphincteroplasty. The external anal sphincter muscle and orrhoidal complex weakens, exposing this tissue to
scar tissue as well as any identifiable internal sphincter the outside of the anal canal where it is susceptible to
muscle are dissected free from the surrounding adipose injury. Hemorrhoids are commonly classified as internal
and connective tissue and then an overlapping repair or external. Although small external cushions do exist,
is performed in an attempt to rebuild the muscular the standard classification of hemorrhoidal disease is
ring and restore its function. Other newer approaches based on the progression of the disease from their nor-
include radio frequency therapy to the anal canal to mal internal location to the prolapsing external position
aid in the development of collagen fibers and provide (Table 19-5).
tensile strength to the sphincter muscles. Sacral nerve
stimulation and the artificial bowel sphincter are both Presentation and evaluation
adaptations of procedures developed for the manage­
ment of urinary incontinence. Sacral nerve stimulation Patients commonly present to a physician for two reasons:
is ideally suited for patients with intact but weak anal bleeding and protrusion. Pain is less common than with
sphincters. A temporary nerve stimulator is placed on fissures and, if present, is described as a dull ache from
the third sacral nerve. If there is at least a 50% improve­ engorgement of the hemorrhoidal tissue. Severe pain
ment in symptoms, a permanent nerve stimulator may indicate a thrombosed hemorrhoid. Hemorrhoidal
is placed under the skin. The artificial bowel sphinc­ bleeding is described as bright red blood seen either in
ter is a cuff and reservoir apparatus that allows for the toilet or upon wiping. Occasional patients can pres-
ent with significant bleeding, which may be a cause of
220 TABLE 19-5
an elliptical excision. Sitz baths, fiber, and stool softeners
THE STAGING AND TREATMENT OF HEMORRHOIDS
are prescribed. Additional therapy for bleeding hem­
DESCRIPTION OF orrhoids includes banding, sclerotherapy, excisional
STAGE CLASSIFICATION TREATMENT
hemorrhoidectomy, and stapled hemorrhoidectomy.
I Enlargement Fiber supplementation ­Sensation begins at the dentate line; therefore, banding
with bleeding Cortisone suppository or sclerotherapy can be performed without discomfort
Sclerotherapy in the office. Bands are placed around the engorged tis­
II Protrusion with Fiber supplementation sue, causing ischemia and fibrosis. This aids in fixing the
spontaneous Cortisone suppository tissue proximally in the anal canal. Patients may com­
reduction
plain of a dull ache for 24 h following band application.
III Protrusion Fiber supplementation During sclerotherapy, 1–2 mL of a sclerosant (usually
requiring Cortisone suppository sodium tetradecyl sulfate) is injected using a 25-gauge
manual Banding Operative
needle into the submucosa of the hemorrhoidal com­
reduction hemorrhoidectomy (stapled
or traditional)
plex. Care must be taken not to inject the anal canal
­circumferentially, or stenosis may occur. The sutured
IV Irreducible Fiber supplementation
and stapled hemorrhoidectomies are equally effective
protrusion Cortisone suppository
SECTION III

Operative hemorrhoidectomy in the treatment of symptomatic third- and fourth-

degree hemorrhoids. However, because the sutured
hemorrhoidectomy involves the removal of redundant
tissue down to the anal verge, unpleasant anal skin tags
anemia; however, the presence of a colonic neoplasm are removed as well. The stapled hemorrhoidectomy
must be ruled out. Patients who present with a protrud- is associated with less discomfort; however, this pro­
cedure does not remove anal skin tags. No procedures
Disorders of the Alimentary Tract

ing mass complain about inability to maintain perianal

hygiene and are often concerned about the presence of on hemorrhoids should be done in patients who are
a malignancy. immunocompromised or who have active proctitis. Fur­
The diagnosis of hemorrhoidal disease is made on thermore, emergent hemorrhoidectomy for bleeding
physical examination. Inspection of the perianal region hemorrhoids is associated with a higher complication
for evidence of thrombosis or excoriation is performed, rate.
followed by a careful digital examination. Anoscopy Acute complications associated with the treat­
is performed paying particular attention to the known ment of hemorrhoids include pain, infection, recurrent
position of hemorrhoidal disease. The patient is asked bleeding, and urinary retention. Care should be taken
to strain. If this is difficult for the patient, the maneuver to place bands properly and to avoid overhydration
can be performed while sitting on a toilet. The physi- in patients undergoing operative hemorrhoidectomy.
cian is notified when the tissue prolapses. It is impor- Late complications include fecal incontinence as a
tant to differentiate the circumferential appearance of a result of injury to the sphincter during the dissection.
full-thickness rectal prolapse from the radial nature of Anal stenosis may develop from overzealous excision,
prolapsing hemorrhoids (see “Rectal Prolapse,” above). with loss of mucosal skin bridges for reepithelialization.
The stage and location of the hemorrhoidal complexes Finally, an ectropion (prolapse of rectal mucosa from
are defined. the anal canal) may develop. Patients with an ectropion
complain of a “wet” anus as a result of inability to pre­
vent soiling once the rectal mucosa is exposed below
the dentate line.
TREATMENT Hemorrhoidal Disease

The treatment for bleeding hemorrhoids is based upon

the stage of the disease (Table 19-5). In all patients ANORECTAL ABSCESS
with bleeding, the possibility of other causes must be Incidence and epidemiology
­considered. In young patients without a family history
of colorectal cancer, the hemorrhoidal disease may be The development of a perianal abscess is more com-
treated first and a colonoscopic examination performed mon in men than women by a ratio of 3:1. The peak
if the bleeding continues. Older patients who have not incidence is in the third to fifth decade of life. Perianal
had colorectal cancer screening should undergo colo­ pain associated with the presence of an abscess accounts
noscopy or flexible sigmoidoscopy. for 15% of office visits to a colorectal surgeon. The dis-
With rare exceptions, the acutely thrombosed hemor­ ease is more prevalent in immunocompromised patients
rhoid can be excised within the first 72 h by performing such as those with diabetes, hematologic disorders, or
inflammatory bowel disease (IBD) and persons who are