Anorectal Procedures Dr Justin Bailey MD FAAFP AAPCE

Anorectal Procedures Dr Justin Bailey MD, FAAFP AAPCE Nov 2015

Procedural treatment of … Thrombosed Hemorrhoids Internal and External Hemorrhoids Anal fissures Anal/perianal condyloma Pilonidal cysts

Thrombosed External Hemorrhoid 45 y/o male with extreme pain, difficulty sitting down Symptoms started 24 hours ago

External treatment • Incision and Drainage • Excision • Timing 48 -72 hours,

External Hemorrhoid Tags 34 y/o MSM would like a cosmetically concerning anal skin tag to be removed

External Hemorrhoid Tags Symptomatic treatment Cleaning “ 1 soft, easy-to-pass bowel movement a day” Fiber, Miralax, Colace Topicals- Analgesics, Anti-inflammatory, Antispasmodics, Sitz Excision Don’t take off things that don’t need to come off.

Excision of External Tag Lidocaine with Epi 3 -5 cc 27 -30 gauge needle Ligation Excision

Internal Hemorrhoids 29 y/o male painless bleeding especially after his wife had a baby and he ate a lot of ramen and cheese quesadillas Blood on toilet paper and stool. Can sometimes feel something coming out that usually goes back in.

Internal Hemorrhoid TX Rubber banding Infrared Coagulator Sclerotherapy Laser, Cryo Complications

Anal Fissure 42 y/o male with rectal bleeding and pain with every bowel movement “like crapping a piece of glass” Frequent Constipation Pain lasts for 1 -2 hours after bowel movement

Anal Fissure Relaxation of internal sphincter Atraumatic passage of stool Pain Relief Sitz baths, Fiber, topical anesthetic creams

Anal Fissures Topical Nitroglycerin (58 -70%), Diltiazem (70%), Bethanecol Orals Nifedipine (60%), Diltiazem (38%) Injectable Botox injection (73%-95) Surgical Lateral Sphincterotomy (95% healing, 45% with transient incontinence, 6 -30% long term) Dilation Lords

The Anal Pap 21 y/o HIV + MSM who presents with anal condyloma.

Anal Pap Anal carcinoma 100/100, 000 High Risk MSM, HIV +, Immunosuppressed, Women with High Grade CIN, or Cancer, Anal warts Progression 1/377/ yr in HIV +, HPV+ LGSIL regression common, HGSIL rare regression

Anal Pap 3 forms Subclinical HPV+ HGSIL on High Resolution Anoscopy Anal Condyloma 20% of HIV+ MSM males + path (15% lgsil, 5% hgsil), 50% of MSM are +HPV HIV+ women, with anal receptive intercourse similar rates Progression HIV, Low CD 4, high risk HPV HGSIL low rate of regression HGSIL to anal carcinoma 5 years

anal pap Usually asymptomatic Screening suggestions >30 in HIV+ >40 in immunocomopent ? HG vaginal SIL, Anal Condyloma No USPSTF HIV Medical Association of the Infectious Diseases Society of America Weak recommendation based on moderate quality evidence for screening with anal cytology in MSM, women with a history of receptive anal intercourse or abnormal cervical Pap test results and those with genital warts

How to Left Lateral Side- damp non-cotton swab inserted to resistance. Standard vs liquid prep If positive then High Resolution Anoscopy

HRA Anascope Colposcope 4 x 4 acetowhite Biopsy

IF postive Tx Chemical- Immiqimod, Flourouracil (20 -30% effective) Ablation Infrared coagulation (40 -60%) Anoscopy lesion ablation (30 -50%)

Perianal Warts 45 y/o female with large volume perianal wart Hygiene difficult Can be painful

Anal Condyloma Topical. Irritants -Podophylin (20 -50%), TCA( 20 -50%), 5 FU+epinephrine (50%) Immunomodulators- Immiquimod 40 -70%, Interferon Alpha (25 -80%) Sinecatechins (55%) Surgery Cryo (63%-92%) Infrared Coagulation (61%-74%) Laser Therapy (100%, reoccurrence 45%) Excision (36%)

Pilonidal Cysts 24 y/o overweight male presents to the ER with painful abscess at the top of his gluteal fold. Has had once before.

Pilonidal Cysts Cause Basic Treatment I&D Currette Advanced?

Pilonidal cyst treatment Z- Plasty

V-Y advancement

Rhomboid Flap

Karaydakis Flap

The End