Perianal Surgery

Dr Felicity Adams regularly treats common benign perianal conditions such as haemorrhoids, anal fissure, anal skin tags and anal fistulae.

Haemorrhoids
Just inside the anus there are vascular cushions which help with continence. These pockets are designed to remain inside however with various factors such as constipation, straining or pregnancy, these cushions can enlarge and move outwards. As they move or prolapse out of the anus the blood inside them struggles to drain away and they become larger and it is more difficult for them to return inside where they belong.

Perianal Surgery

In the earliest grade (grade 1) internal haemorrhoids remain within the anus though can still cause bleeding. Grade 2 haemorrhoids prolapse but return spontaneously following toileting, Grade 3 prolapse and need to be helped back, grade 4 are permanently prolapsed and can not be replaced into the anus.

Haemorrhoids can cause bright red rectal bleeding, a lump and occaisionally discomfort. The simplest treatment is avoid constipation and straining. Fibre supplementation is often recommended as well as gentle exercise and drinking plenty of water. Creams and suppositories can be used short term for symptomatic relief though there is no evidence they are benefit long term and in some cases can be harmful.

Haemorrhoid banding is a simple procedure for internal haemorrhoids which can often be performed at the same time of colonoscopy. An elastic band is applied on or above the haemorrhoid. This interferes with the blood supply of the haemorrhoid causing it to wither and shrink away and also produces an internal scar which prevents prolapse. This procedure is performed as a day procedure and is generally well tolerated with only some short term discomfort following.

Haemorrhoidectomy is a surgical procedure performed in the operating room under a general anaesthetic. The haemorrhoids are surgically cut away. It can be used for internal & external haemorrhoids as well as perianal skin tags; and any combination of these. There are many nerve endings around the back passage and therefore the procedure can be quite painful.

Anal Fissure
An anal fissure is a painful condition where there is a non-healing wound in the anus which causes pain on passing a bowel motion. It can also be accompanied by bleeding. This is commonly begins with a patient passing a hard bowel motion which causes trauma to the skin in the anus resulting in a split or fissure. The wound itself is painful on passage of bowel motion and more pain comes from spasm of the anal sphincter. This spasm reduces the blood flow to area which impairs the healing of the fissure. There is then a viscous cycle of trauma, spasm, poor blood supply and healing; and treatment is aimed at interrupting this.

If a fissure is caught early it can heal with simple treatment. The most important is avoiding constipation. There are many medication options for this though fibre supplementation is of particular benefit. Prescription creams applied to the anus (such as GTN and diltiazem) relax the sphincter to encourage healing. Warm baths or showers can also help relieve pain associated with spasm. Narcotic pain killers should be avoided as they often cause constipation which can worsen the situation.

Unfortunately once a fissure has been present for six weeks, none of the above methods are likely to be successful. At this point Dr Adams may recommend Botox injection or surgery called a sphincterotomy. Botox injection into the anal sphincter causes temporary relaxation of this muscle for two to three months, which allows time for the fissure to heal. A sphincterotomy is performed as a day case in the operating room. A portion of the sphincter muscle is cut through a small incision adjacent to the anus. This procedure is permanent in contrast to Botox injection. Healing rate is good with both procedures though better with sphincterotomy. Not everyone is suitable for a sphincterotomy; factors such as previous anal surgery and vaginal child birth may be relevant, and will be assessed by Dr Adams prior to her making a recommendation for treatment.

Anal Fistula
An anal fistula is an abnormal tunnel between the anal canal and the skin close to the anus. Most commonly they result after an infection in an anal gland which lubricates the anal canal. A fistula intermittently or continually leaks pus and can cause recurrent perianal abscesses.

Surgery is required to cure a fistula. Surgical options vary depending on the path of tunnel and how much of your sphincter or continence muscle is involved. Commonly an examination under anaesthetic needs to be done to determine the anatomy of your fistula. Options include placement of a seton, a fistulotomy or laying open of a fistula, or more complex procedures aimed at closing the fistula.

A seton is a loop of soft rubber which sits in the tunnel or fistula, drains away infection preventing abscess formation.

A fistulotomy involves dividing all the tissue superficial to the fistula surgically. This leaves a wound which heals slowly, closing the fistula as it does. This is not an option where there is a large amount of sphincter muscle involved due to the risk of incontinence.

More complex fistulae are difficult to treat and the many different operations have variable success rates. Specialised testing such as ultrasound of the anal passage and muscle pressure testing can be required, and if so Dr Adams will refer you to a specialist colorectal surgeon.

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