Anatomy of the anal canal :

This is a section shows the anal canal region, and embryologicaly, the anal
canal has two origins:
1- outer part ectodermal origin.
2- inner part from the Hindgut.

"Coincidences are God's way of remaining anonymous."

(Albert Einstein)
 Outer (Lower) Part Inner(Upper) Part
Embryological origin Ectodermal origin From the Hindgut
Similar to the nearby Similar to the Rectum
skin with some & the rest of the GIT.
differences.
Epithelium Stratified Squamous Columnar Epithelium
Epithelium ,BUT it is (single layer)
modified , it lacks hair
follicles & lacks sweat
glands.
Innervation Somatic type of Autonomic type of
innervation, so it is so innervations, so –as the
sensitive to pain, touch remaining of the GIT- it
& temperature. is sensitive to distension
and ischemia.
Lymphatic Drainage Inguinal LNs Mesenteric & Para-
aortic LNs
Blood supply Systemic circulation Inferior Mesenteric
(Pudendal artery ) Artery
Venous Drainage To the systemic To the portal circulation
circulation area of porto-
systemic anastomosis
BUT with no clinical
importance like the one
in the lower esophagus.

* These 2 halves meet at the middle of the anal canal forming a line, we call
that line ( THE DENTATE LINE).
*in the area of the dentate line we have crypts , and in the crypts we have
openings of the anal canal glands (which are mainly located in the inter-
sphinteric region , and the number of them varies , up to 18 or so glands )

* To summarize :
anal glands ( inter-sphinteric region) ducts go through the internal
sphincter open in the Crypts ( at the dentate line ) >>>>>so important to
understand the pathology of some diseases of the anal canal .

Physiology of the anal canal :

*The most important function of the anal canal is to control defecation ( i.e
to have continence) , and this main function is made possible by the
presence of :

1)Internal sphincter : - smooth muscle

- involuntary control
-it is a continuation of the circular muscle layer of the
GIT but more developed and stronger.

2)external sphincter: -skeletal muscle

-voluntary control

3)levator ani muscle ( puborectalis part) : - skeletal muscle

- Voluntary control

4)Dilated cushions ( hemorrhoids) : finest closure.

*so in the resting state, what is contracting is the internal sphincter ( like
smooth muscles anywhere in the body ) while you use your external
sphincter voluntarily if the pressure of the rectum exceeds that which is
produced by the internal sphincter then you start thinking about the issue
then you start squeezing your external sphincter voluntarily.
BUT there is something we should notice here ; that the skeletal muscles
elsewhere in the body are in the resting state ( don’t have Tone ) , while the
external sphincter ( which is a skeletal muscle) have some tone at rest !
so if you test the anal canal you’ll find that not only the internal sphincter is
in contraction , but also the external sphincter and levator ani muscle ,
however, this is exaggerated by the voluntary action of squeezing .
Sooooo we can say that :
Resting tone of the anal canal = mainly by the internal sphincter + some
contribution by the external sphincter & levator ani muscle
1) Hemorrhoids (piles) :

*It should be clear that hemorrhoids are part of the normal structure of the
body , so everybody is having hemorrhoids. So when we say that this patient
is having hemorrhoids we mean that his hemorrhoids are causing problems
or they are diseased (( as we say this patient is having appendix; we know
that everybody is having appendix , BUT you mean that he is having
appendicitis for example ))
so when hemorrhoids start causing problems that means that there is
congestion of the blood vessels there which leads to stretching of the
overlying mucosa.

*These hemorrhoids are having rich arterial blood supply that directly
opens into venous spaces ,,, that’s why when they bleed , they bleed from
the venous system BUT you find that the blood is bright red – because of the
direct communications between arterial and venous system -

*They are cushions normally they help in the continence ( they provide
the anal canal with the finest and the last closure of the anal canal )

Pathophysiology :
dilation & engorgement of the blood vessels stretching of the overlying
mucosa formation of the lumps that may prolapse .

** Classification of hemorrhoids ( according to site ) :

1) external hemorrhoids : engorgement of the external venous plexus (

below the dentate line )
2)internal hemorrhoids: engorgement of the internal venous plexus ( above
the dentate line )
OR you may have both !

BUT how to differentiate between those two types ?

The internal hemorrhoids is covered by columnar epithelium type of mucosa
, so it looks pinkish . BUT the external hemorrhoids is covered by
squamous epithelium type of mucosa , so it looks opaque in color .

*When we describe hemorrhoids we assume that the patient is in the

lithotomy position ( delivery position ) and we look at the anal canal as a
clock , and we use the clock numbers in descriptions :

hemorrhoids are classically present at 3 classical sites ( 3, 7 , 11)

(( in the picture above ; 3 o’clock = left lateral cushion ; 7 o’clock = right
posterior cushion ; 11 o’clock = right anterior cushion )) …. WHY ?
because that’s the blood supply of the anal canal ( positions of the main
vessels) , two vessels at the right & one vessel on the left side.

P.S : these are the main vessels , but we have smaller branches ( those
smaller branches are between the main vessels , we call them daughter
hemorrhoids OR secondary hemorrhoids)

** Classification of hemorrhoids( according to the vessels involved) :

1) Primary hemorrhoids : if one or more of the main vessels of the anal canal
are involved (3, 7, 11)
2) secondary hemorrhoids: if one or more of the smaller branches ( daughter
hemorrhoids) are involved.
3) circumferential hemorrhoids: if you have hemorrhoids all around the anal
canal ( i.e. the main vessels and the smaller branches are involved) , and we
see that in severe cases.

** Classification of hemorrhoids by degrees :

1st stage : no prolapse to outside ( only bleeding ).

2nd stage : prolapsed , but reduces spontaneously after defecation.
3rd stage : prolapsed, but the patient has to reduce it manually.
4th stage: permanent prolapse ( irreducible hemorrhoid).

** Complications of the hemorrhoids ( other than congestion &

prolapsed) :

P.S : hemorrhoids are not having sharp pain if they are not complicated , the
type of pain they produce is the heaviness or dragging type of pain after
long standing or after defecation because of congestion (( just like the
varicose veins after long standing engorgement of the vessels the
patient will feel heaviness in the lower limb)) .
 ((Comment : This is what hemorrhoids feel like ))

BUT when you start having acute sharp pain it means that complications
have been occurred in the hemorrhoid OR there is an added pathology like
ANAL FISSURE.
and that’s how you can differentiate between a patient who come to the
outpatient clinic , and a patient who comes to the emergency … according to
the type of pain , a patient who has dragging type of pain because of non-
complicated hemorrhoid he’ll come to OPC ,,, BUT a patient who has acute
sharp pain because of a complicated hemorrhoid (( thrombosis ,
strangulation etc…)) he’ll come to the emergency .
soooo the complications of hemorrhoids can be listed as :

1) Thrombosis : which can occur in both ; external or internal hemorrhoids.

2) Ulceration
3) Strangulation : when the patient enter a vicious cycle : hemorrhoid
prolapsed to outside spasm of the sphincter congestion & ischemia
more spasm, more edema, more pain then the hemorrhoid will
become strangulated and if you wait the patient will start having sloughing
& necrosis of the anal canal hemorrhoid.

"Successes only last until someone screws them up. Failures are forever "
(House)
-You have to differentiate between a thrombosed hemorrhoid and any
thrombosis in the perianal area (perianal hematoma) where the thrombus is
away from the anal canal. thrombosis in the perianal area is felt as a firm
lump, and the patient usually comes after 6-7 days of pain, it will subside
gradually, the cause is usually straining or bleeding tendency.

(( External Hemorrhoids )) (( Internal Hemorrhoids))

(( Prolapsed Hemorrhoid)) (( Thrombosed Hemorrhoid))

** Symptoms of hemorrhoids (( Clinical Point of View)) :

1) Bleeding : pathophysiology : congestion in the hemorrhoidal vessels +

squeezing in defecation pressure on mucosa and the vessels trauma to
the congested vessels by hard feces rupturing of the vessels Bleeding
( and it is the most common problem in patients with hemorrhoids ).
2) prolapsing lump mainly in defecation.
3) sharp pain ( in complicated hemorrhoids).
4) irritation & itching : because of the secretions from the prolapsed mucosa.
** Treatment of hemorrhoids :

P.S : before you start treating hemorrhoids, you MUST make sure that you
have excluded more serious conditions like tumors , and to lesser extent
Inflammatory Bowel Disease.

Treatment ( according to the severity of the case , and according to the

response of the patient ) are three :

1) very conservative : like high fiber diet OR Bulk Laxatives….they will

make the stool softer and more bulky and that will :
- decrease the trauma.
- decrease the need to squeeze by patient so decreasing the possibility of
strangulation.
- make the stool bulky , and that will dilate the anal canal .

2)Interventional ( non-surgical methods) : if the conservative treatment fails

:
i)injection of hemorrhoid with sclerosing material.
ii)Infra-red.
iii)Cryosurgery ( cold nitrogen).
iv) Rubber band ligation : you ligate around the neck of hemorrhoid to
strangulate it.
3) Surgery : if the second method failed :

i) classical hemorrhoidectomy
ii) the newly introduced surgery using stabilizers ( you don’t have to know
more details about it )
-You can add sitz baths to the interventional treatment, because they will
help to relax the sphincter -after hemorrhoidectomy you either close the
wound or leave it open for secondary healing -stabilizers causes less pain
but in the long run it has the same outcome, plus the instrument is more
expensive.
 2)Anal fissure
Definition : a slit or a crack in the anal canal mucosa (specifically the lower
half of the anal canal which is lined by squamous epithelium )

- this fissure have a severe type of pain because this area is supplied
somatic nerves so it is sensitive to touch, pain and temperature just
like the skin.
- The cause: a vicious circle of (pain - spasm of internal sphincter -
constipation) with unknown starting point, but a good part of the
problem is caused by spasm of internal sphincter.
( the more you have pain the more you have spasm, spasm will cause
pain and the patient will try to avoid defecation to avoid pain, so
patient will complain of constipation which by itself aggravates the
pain and so on ….)

*Depending on the time interval, anal fissures divided into:

1- acute fissures 2- chronic fissures

Note: the best way to differentiate between them is the signs of chronicity
(triad) which are:

1- deep with a lot of fibrosis

2- reactionary polyps at the proximal end of the fissure
(hypertrophied anal papilla)
3- Sentinel piles or skin tags: a skin reaction trying to cover, protect
and heal the fissure), this can be seen at the distal end of the
fissure.
- Fissures are usually located in the middle more posteriorly than
anteriorly.
* from ro2ya: location of the primary fissures:

" treating illnesses is why we became doctors, Treating patients is what makes
most doctors miserable." (House)
 * from ro2ya: location of the primary fissures:
1-midline posteriorly (90%), more in males
2- midline anteriorly (10%), more in females
- Symptoms :
1- so painful
2- bleeding with defecation
3- constipation
4- some discharge causing pruritis

- treatment :
the aim is to break the circle of the triad (pain –spasm –constipation)
at any point :

A) conservative treatment :
1- to treat the constipation :
*high fiber diet
*bulk laxatives

2- to relieve the pain:

*local analgesics
*sitz baths

3- to relieve the spasm:

*nitroglycerin
*botulinum toxin
*ca channel blocker (to relax the spasm and to improve
the blood supply which will improve healing of the fissure)

B) surgery: the last choice if the conservative tt failed :

(Partial lateral sphincterotomy): to decrease the tightness of
the internal sphincter by cutting part of it
 From ro2ya :

#partial; to decrease risk of incontinence

#lateral; the sphincter is more bulky in the lateral sides

#sphincterotomy; cutting the sphincter.

**Types of anal fissures:

A) Primary fissures: without any obvious cause ( but mainly due to

combination of trauma and poor blood supply ).
B) Secondary fissures:
1- IBD mainly crohn's disease
2- HIV
3- Syphilis
4- TB
5- Herpes
6- Leukemia
7- Carcinoma of the anus
NOTE: the commonest are the crohn's disease and HIV infection.

**Characteristics of the secondary fissures:

1- away from the midline
2- multiple
3- its not only fissures; you'll find other pathologies such as ( fistulas,
sinuses, abscess and skin tags)
4- from ro2ya:
- large with bluish discoloration

- less pain because the problem is not associated with spasm of the
sphincter, the problem is in the main pathology, so you will find a big
lesion with minimal symptoms.
**Treatment of the secondary fissures:
We have to be very conservative here, its not advisable to cut the
sphincter because the problem is not in the sphincter, its not caused by
spasm in it, the problem is in the primary disease ( in contrary the sphincter
maybe damaged by the primary disease itself so those patients maybe
already incontinent ).
-There is another treatment of anal fissures which is dilatation, the
problem here is that you don’t know how much you are cutting from
the sphincter.

3)Anal suppuration:
- it means two stages of the same pathology :

1- Acute phase: the abscess

2- Chronic phase: the fistula

*How does the problem start?

-the most acceptable theory is (crypto-glandular theory):

1- The problem starts by having inflammation in the crypts (cryptitis).

2- The infection spreads through the ducts to the anal gland (glandulitis).

3- This will end up in the formation of (intersphincteric abscess) and

this is the starting point of anorectal sepsis

NOW:

5- If the abscess remains there, then the patient will present with
intersphincteric abscess.
6- If the pus goes down, the collection will be at the anal verge and the
patient will present with a bulge in the perianal skin (perianal
abscess).
7- If the pus goes up above the levator ani muscle (supra levator
abscess)
8- If the pus can pass through the external sphincter to the ischiorectal
space (ischiorectal abscess)
So the problem starts in the intersphincteric space but it can end anywhere.

9- not only that, you know that the anal canal composed of tubes each one
inside the other (internal sphincter, external sphincter…) so the pus can leak
through these tubes and go around the anal canal (horse shoe abscess).(for
ex. Two ischiorectal abscesses connected together or two supralevator abscesses and so on
…)
 So when you say this patient is having perianal abscess its not enough, so
after examination you have to say that this abscess is intersphincteric,
perianal, ischiorectal, supralevator or horse shoe abscess.

**Presentation of the patient with perianal abscess: ( like any abscess

anywhere septic picture ):

1- throbbing pain
2- fever and toxicity
3- patient is unable to set
**Physical findings: (depend on the type of the abscess):

1- in perianal abscess the perianal skin is red, tender and swollen

(more common If the abscess near to the skin)
2- in supralevator abscess deep pain with little or no outside physical
findings
3- in intersphincteric abscess if you do PR examination you'll find a
mass and tenderness
4- in ischiorectal abscess it depends on the site:
- in high level little or no external findings
- in low level red tender and swollen skin
So we may not find any physical finding in two cases: supralevator and high
ischiorectal abscesses.
**Treatment:

(Incision and drainage)

NOTE: Once you decide to drain the abscess, you have to warn your
patient that there is a chance around 50% after the drainage that he will
came back with perianal fistula, if you did not tell him that he will think
that it’s a complication of the surgery because the presentation will be
discharge from the incision site.

So, it is the natural course of the disease!

NOTE: after surgical drainage of the abscess OR after spontaneous

opening of it, it will end up with a tract around 50% of patient will
develop a fistula )

Fistula: abnormal communication between two epithelial surfaces(the

anal canal mucosa and the perianal skin)

It is composed of:

1- internal opening: the original opening of the abscess into the

anal canal
2- external opening: the surgical incision or the spontaneous opening
of the abscess into the skin.
3- Tract communicating between the two openings.

- If we put a probe (from an opening in the skin through the anal canal)
superficial to it we will have skin, subcutaneous tissue, and part of the
sphincter.

-types of fistula:

1)superficial: doesn’t go through the sphincter

2)intersphincteric: between the sphincters, 45% of

the cases

3)Transsphincteric: goes through the whole sphincter, 30% of the cases

4)supralevator fistula: if it goes to the supralevator fossa, 20% of the cases

5) extrasphincteric: if it goes to the rectum, it is the worst and

luckily its not common
 6)horse shoe fistula: if it goes around the anal canal

** From Ro2ya:

The fistula is divided into two parts according to the internal opening:

1- High fistula: the internal opening is above the dentate line.

2- Low fistula: the internal opening is below the dentate line.

-Presentation:

1)pain, it's not a sharp pain unless there is an abscess

2)discharge, causing irritation and dermatitis, yellow, pussy, bloody, not

related to defecation.

3) on physical examination: you will find the external opening which can
be a dimple or lump.
if the fistula is superficial you may feel the tract like a cord

-if the fistula is complex (not straight) you need to do investigations to

know the anatomy, like endoanal ultrasound (3 dimensional), MRI, CT,
fistulogram.
-Treatment:

fistulotomy: anything superficial to the probe is cut, you have to be sure not
to cut a big part of the sphincter so you won't end up with incontinence.

you have to be very careful if the fistula is high, or the patient is already
having weak sphincter like multiparous females.
fistula surgery is a very tricky field, so in these cases we put a circle of
thread through the fistula we call it seton
there is a lot of methods to deal with fistulas but non of them is satisfactory,
like fistula plug, fibrin glue or flap
the secondary causes of fistula are the same secondary causes of fissures but
you add malignancy to them, that's why in fistula surgery we always like to
take biopsy, even though the malignancy incidence is low

4) Vesicles:
- Herpes infection.
- Sexually transmitted disease.(STD)
- Very painful.
- In early stage we can treat it with antiviral drugs, but in late stage we
have to wait for the disease to limit by itself.

5) Warts:
-caused mainly by HPV
- there are more than 100 types of HPV, most of them are harmless, HPV16 is
associated with high risk of cervical cancer (50% of the cases) while HPV6
and HPV11 have low risk of cancer and they are more common.
-there is a latency period which can be long
-it affects the area around and inside the genital organs, depends on the
contact area
-transmission can occur even if the warts are not visible
-we have the problem of recurrence and 20% of the patient will have another
STD.
-presentation: itching, bleeding, headache, discharge, urethral obstruction
-treatment: we start with medical treatment if it fails, we remove them by
laser, cryosurgery, electrocautery, if it fails we go to the classical surgery.
keep in mind that it's important to take care of the partner also .
 6-pilonidal disease:
-it is chronic infection in the natal cleft area, characterized by the presence of hair,
can be present in the umbilicus (mainly after the sacral region), axilla, groin or
between the fingers.

-more in young obese males

- Presentation:
may be asymptomatic discovered incidentally, or the patient may have pain,
swelling and discharge.
on examination: you may see an abscess, sinus, fistula, pit.. different things.

-Treatment: we may do nothing if it's a little pits, we ask the patient to keep it
clean. if there is an abscess it has to be drained.
if you want to treat it completely you have to excise the whole area, but the
problem is how to close the deep defect that we create, you can close it or leave
it for secondary healing or you may use flaps.
- the main problem of the pilonidal disease is recurrence

7-rectal prolapse:
-it is a rectal disease not anal disease
-mostly in elderly women
-mostly there is no single cause (straining, delivery -even though
35% of the cases didn't give birth-, genetic, aging, neurological)
-there is 2 problems associated with rectal prolapse:
1)constipation
2)incontinence (the sphincter gets weaker due to recurrent
prolapse)
These problems may not be relieved even after treatment.
** Special Thanks to our family , Friends & Colleagues

The end
Done by: Enas Sarsak & Khaled Morshed