Proctology
The proctology is responsible for the diagnosis and treatment, whether surgical or non-surgical, of all diseases affecting the anus, rectum and colon.
HAEMORRHOID SURGERY
In the distal part of the anal canal it is normal to find "cushion-like" structures, mainly made up of vascular tissue, called the haemorrhoidal plexuses.
When the alteration of these structures results in symptoms (bleeding, pain, external leakage, etc.), we talk about haemorrhoidal disease or haemorrhoids.
Haemorrhoidal pathology is multifactorial, i.e. many causes can influence the development of haemorrhoids.
However, the most directly related to this pathology is constipation associated with frequent and constant straining.
Other possible causes of haemorrhoidal pathology are diarrhoea (due to the chemical irritation of liquid faeces on the haemorrhoids), the ingestion of certain foods (spicy foods, alcohol, etc.), pregnancy (due to the pressure that the foetus exerts on the circulation of the venous return at pelvic level) and even hereditary factors.
What are the symptoms of haemorrhoids?
The most common clinical manifestation in these patients is bleeding, typically scanty and associated with bowel movements, accompanying stools or during cleansing manoeuvres. However, it can sometimes be abundant and alarming.
Another common symptom is a fleshy mass, which corresponds to an internal haemorrhoid protruding outwards.
Pain is not a frequent symptom and when it appears it is associated with what is known as a haemorrhoidal crisis, which will always be associated with a prolapse of the haemorrhoids that is difficult to reduce and swelling. This should not be confused with thrombosis of a vein of the external haemorrhoidal plexus, which will cause pain and an isolated tumour on the anal margin.
Other less important symptoms of haemorrhoids are: anal itching, mucus emission, etc.
The most common symptom of haemorrhoids is bleeding, so much so that we should not think about them when they do not appear.
How are haemorrhoids diagnosed?
Diagnosis of haemorrhoids is based on the characteristic symptomatologyfollowed by a physical examination showing pathological dilatation of the haemorrhoidal plexuses.
The definition of symptoms in haemorrhoids is particularly important, given that if the haemorrhoidal plexuses are normal structures, it is only when their alteration produces clinical symptoms of any kind that we speak of haemorrhoidal disease.
However, given that other benign and malignant pathologies of the gastrointestinal tract can cause blood to be emitted from the anus, when this appears even with an obvious diagnosis of haemorrhoids, it may be advisable to undergo a colonoscopy to rule out other pathologies.
How are haemorrhoids treated?
The treatment of haemorrhoidal pathology depends on the intensity of the symptomatology.
Application of topical treatments in the form of creams, ointments, suppositories, etc. These compounds usually contain an association of local anaesthetics, anti-inflammatories (corticoids, etc.), venous decongestants, etc. Anti-hemorrhoidal creams should be used for a limited period of time (no more than 5-7 days, because they can cause more bleeding).
When the disease is more advanced but there is no major prolapse, intermediate treatments can be tried before surgery, mainly band ligation or radiofrequency.
These treatments are only used for internal haemorrhoids and their effectiveness depends on the severity of the disease.
When all of the above fail to control the symptoms of the disease, or if at the time of diagnosis there is already a lot of prolapse, the use of a surgical haemorrhoidectomyThe removal of the pathological plexuses by surgery. It is necessary to know that the postoperative period after haemorrhoidectomy is complicated, although it can be improved if alternative energy methods to conventional ones are used.
ANAL FISTULA AND FISSURE SURGERY
Anal fissures are small tears in the mucosa of the anal canal. The most common cause of an anal fissure is tramatism during defecatory straining due to constipation, and they are usually located in the anterior or posterior part of the anal canal. When a fissure is not in this location, other causes should be suspected, such as Crohn's disease or anal pathology related to ICH infection.
The most characteristic symptom of anal fissure is pain after defecation, which progressively increases in intensity and may persist for hours, then subsides and reappears with the next defecation. It is often associated with bleeding with defecation of red blood that stains the bowl and paper. Sometimes a visible crack in the skin of the anus can also be seen, but very often the anus is spasmodised and cannot be explored because of the intense pain it causes.
What is the treatment of anal fissure?
The therapeutic approach will be different in an acute form or if there are already signs of chronicity.
In the acute phase, medical treatment is most likely to be successful: sitz baths with warm water to relax the internal sphincter, painkillers and laxatives to achieve soft stools. The beneficial effect of nitroglycerin or diltiazem ointments is essential as they help the fissure to heal by increasing irrigation and relaxing the internal sphincter.
Is it possible to operate?
Yes. Anal fissure, in which the aforementioned "vicious circle" has been established and medical treatment has failed, the treatment of choice is surgery by means of a lateral internal sphincterotomy. The intervention consists of the controlled section of the internal anal sphincter, which eliminates the hypertonia of the sphincter, eliminating the pain and achieving the healing of the fissure in a few days.
Can incontinence be triggered after a sphincterotomy?
The reason why surgery is not the treatment of choice for anal fissure despite its high efficacy is the fear of incontinence. Indeed, anal fissure surgery can trigger incontinence in a small percentage of patients, although it is usually of low intensity. Even so, the quality of life benefits are very large in patients who undergo anal fissure surgery and the risks are well controlled.
Anal fistula (simple or complex)
Inside the anus are small glands that, if blocked, can create an abscess. An abscess is an infection that causes visible inflammation, swelling and accumulation of pus. This abscess sometimes protrudes into the perianal surface.
Depending on the elements that make them up, we can speak of a simple fistula or a complex fistula. A simple fistula is a fistula with a primary orifice and a secondary orifice, which in most cases is located in the perianal tissue. Both orifices are connected to each other via the direct fistulous tract.
A complex anal fistula is a fistula with one or more primary orifices and several secondary orifices, resulting in multiple tracts.
In addition, fistulas may affect more or less anal canal thickness, which conditions their treatment.
Fistulas may not cause pain, but in many cases pus or passage of faecal material can cause discomfort, as well as infection and itching.
Diagnosis can be made by anoscopy under anaesthesia or by outpatient examination. An anorectal MRI or anal echoendoscopy will be necessary to assess the fistulous tract.
Trans-sphincteric fistula
Depending on the relationship they have with the sphincters, anal fistulas also have different types, of which we highlight the transphincteric or transfincteric fistula as the most common type of fistula.
The transphincteric fistula gets its name from the fact that it passes through the two sphincters, i.e. across them, and the secondary orifice is in the skin of the perineum.
Horseshoe fistulas or abscesses (perianal)
Horseshoe anal abscesses are anorectal abscesses that occur due to an accumulation of pus in the post-anal space. Horseshoe fistulae are fistulae with an internal office in the post-anal mucosa and two curved paths running to the right and left.
In the presence of a perianal abscess, surgical drainage will be necessary to evacuate the pus in a controlled manner and prevent the spread of infection in the perianal tissues.
When treating a fistula, it is necessary to know the degree of involvement of the sphincteric apparatus, as surgical treatment may lead to incontinence. The most definitive treatment will be fistulutomy, which consists of cutting the fistula and allowing it to heal from the depth. If the sphincteric apparatus is only affected in its lowermost portion, it can be cured definitively without incontinence. However, if the sphincteric apparatus is affected more deeply, the patient will be incontinent. For this reason, it is sometimes necessary to place reference threads ("setons") to try to make the fistula easier. Anal mucosal grafts will often be necessary to close the internal orifice or to obturate the fistula with glues or plugs in an attempt to treat the fistula without sequelae. These techniques have a high failure rate.
PILONIDAL SINUS SURGERY
It is a cystic formation located in the intergluteal groove and containing pilose formations inside. They usually remain asymptomatic and are diagnosed when complicated by a secondary infection, forming an abscess in this location.
What is its cause?
The origin lies in the introduction of hairs inside the skin.
What are the symptoms?
Pilonidal sinuses usually remain asymptomatic, and the presence of small orifices through which hairy formations emerge in the space between the buttocks and the midline of the sacrum may be discovered accidentally. It is frequently from the second-third decade of life when, due to a process of superinfection of the latter, a typical clinical picture of an abscess is produced in this location, with tumouring, inflammation, pain, etc.
What is the treatment?
Treatment of pilonidal sinus is considered when it becomes complicated and causes symptoms. In the acute phase, in the case of abscessification, it is advisable to drain the purulent material and then proceed to complete removal of the cystic formation and secondary fistulous tracts, if present. Depending on the greater or lesser size of the sinus and, therefore, the greater or lesser amount of tissue removed, the defect created can be closed or closure by secondary intention can be allowed, leaving the wound open and requiring subsequent treatment.
It will always be necessary to remove the hair, as this is the best way to avoid recurrence.
Recently, pilonidal sinuses are being treated using minimally invasive approaches, the so-called EPSIT.