Anorectal Potpurri Fissures, Pilonidal, Condyloma

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Anorectal PotpurriFissures, Pilonidal, Condyloma
No aromatherapy here

• 26 March 2008
• Thomas Garofalo, MD, FACS
• Cleveland Clinic East Region

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Disclosure

• No affiliations

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Anal Fissure

• Doc, I feel like I am passing razor blades!
• I think I have a small tear back there.
• It feels like hot lava coming out!
• It is the worst pain ever!
• It is so bad, I have to hold on to something.

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Anal Fissure

• Small linear tear in the anal mucosa overlying
  the internal anal sphincter
• Accounts for 6.2-15 of office visits
• Majority (90) heal spontaneously (acute fissures)

J Fleshman, 1998
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Anal Fissure

• Location
• Woman 90 posterior 10 anterior
• Men 99 posterior 1 anterior
• Fissures in other locations and multiple fissures
  must raise suspicion for Crohns disease,
  tuberculosis, surgery, neoplasia

B. Hoexter, 2005
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Anal Fissure (etiology)

• Local Trauma
• High resting sphincter pressure
• Decrease in anodermal blood flow
• Location (posterior) may be secondary to
• Sitting position on toilet
• Anatomy of sphincter (elliptical)
• Decreased blood supply in posterior canal

B. Hoexter, 2005
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Anal Fissure (features)

• Deep wound
• Exposure of the IAS
• Sentinel tag
• Hypertrophied papilla
• Cavitation and abscess

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Anal Fissure (Treatment)

• Non-medical
• Dietary changes, hygiene
• Change in toilet habits
• Medical
• Topical creams
• Botox
• Surgical
• Sphincterotomy, Fissurectomy

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Anal Fissure (Medical)

• Topical Nitroglycerin
• Apply 3-4 times a day
• May relieve pain, most fissures do not heal
• Topical Diltiazem
• Reported success is 65-70

B. Hoexter, 2005
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Anal Fissure (Botox)
25 to 50 to 100 units injected. No consensus as
to method or location of injections. Reports of
healing up to 81. Rare cases of mild
incontinence. Works on theory that paralysis of
muscle can lead to healing of the fissure.
B. Hoexter, 2005
PERSONAL OPINON IT DOESNT WORK!
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Anal Fissure (surgical)

• Sphincterotomy
• Open or closed technique
• Always stay distal to dentate line
• Cut only as much muscle as you need
• Careful hemostasis
• When in doubt, get manometry first
• Advance flap closure

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Anal Fissure
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Anal Fissure

• 137 patients undergoing LLIS up to dentate line
• 98.5 healed
• 24 reported some degree of incontinence
• 6 incontinent of solid stool

Patel N, et al., 2004
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Anal Fissure

• 298 patients (47 female)
• 94.4 healed 5.6 recurrence
• 29 of women developed incontinence to flatus
  (after previous vaginal delivery)
• 31 of all patients had some temporary
  incontinence (1-3 months of symptoms)
• 30 still had incontinence to flatus after 5
  years
• Longterm incontinence to flatus not reported in
  medical record in 33 of patients

Zutshi M, et al., 2005
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Pilonidal Cyst/Sinus

• Two theories on etiology
• Result of a foreign body reaction to embedded
  hair
• Defect in the hair follicles in the natal cleft
• Incidence
• 1.2 of men 0.11 of women

Karulf and Perry, 1998
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Treatment Options

• ID
• Superficial excision and drainage
• Excision with or without marsupialization
• Sinus excision and lateral drainage (Bascom)
• Excision and primary closure
• Sclerosing injection
• Excision with skin graft
• Excision with lateral advancement flap
• Excision with Z-plasty
• Excision with buttock apposition
• Rotation flaps with gluteus muscle

MacKeigan, 2005
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Simple Excision with Marsupialization
Note remove residual sutures in 2 weeks. New
hair growth must be kept out of wound.
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Excision and primary closure
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Bascom Procedure

• Lateral incision
• Debridement of cavity
• Excision of midline pits with small incisions.
• Closure of midline wound
• Lateral wound left open to heal
• Recurrence lt10

Karulf Perry, 1998
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Anal Condyloma

• Caused by Human Papillomavirus (HPV)
• Types 6,11,16,18 associated with anal condyloma
  (70 subtypes known)
• Types 6, 11 benign disease
• Types 16,18 dysplasia and cancer
• A sexually transmitted disease
• Minor trauma at site, inoculation and 1-6 months
  incubation

Cintron, 2005
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Condyloma

• Usually located in perianal, anal canal,
  perineum, vulva, vagina, cervix, penis, urethra
• 50-90 of patient with perianal warts will also
  have intra-anal warts
• Genital warts in 80 of women and 16 of men

Cintron, 2005
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Treatment

• Medical
• Podophyllin 25 suspension with benzoin
• Repeated at weekly intervals
• Large amounts can have side effects on many
  systems
• Recurrence rates 30-65

Cintron, 2005
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Treatment

• Medical
• Imiquimod (Aldara)
• Applied 3 times weekly for 12 weeks
• Immune response modifier induces interferon,
  interleukin, TNF
• Expensive
• 19 recurrence at 12 weeks

Cintron, 2005
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Treatment

• Surgical
• Excision (recurrence 9-42)
• Electrocoagulation (recurrence 30)
• Cryotherapy (recurrence 24-37)

Cintron, 2005
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A fairly simple case
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A not so simple case
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Follow-up

• Close follow-up (every 6 months to yearly)
• Can repeat treatments
• Interferon-alpha (20-40 recurrence)
• HIV patients have recurrence rates up to 75

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AIN and High Resolution Anoscopy

• AIN (anal intraepithelial neoplasia)
• 3 Grades
• 1 needs treatment to prevent progression
• 2 3 need treatment to prevent cancer
• High resolution anoscopy
• Use of staining techniques to identify lesions
• Use of microscope

Chin-Hong Palefsky, 2005
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AIN Treatment

• Biopsy lesions
• Ablate tissue
• Electrocautery
• Infra-red coagulation
• Medical treatment
• Imiquimod may decrease AIN recurrence in HIV
  patients

Kreuter, 2007
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Final Thoughts

• Anal Fissures
• Always offer medical management first
• Beware the aggressive sphincterotomy
• Pilonidal Disease
• Pick one or two methods
• Plastic surgery consult for complex cases
• Condyloma
• Recurrence is high, so keep it simple
• High resolution anoscopy is helpful