Ano-rectal examination
1) Inspection & palpation of the perineum
2) Per-rectal examination (PR)
3) Anoscopy
Localization &Recording
Anal verge
Dentate
line
Privacy & Witness
Instruments
Patient’s position & Exposure
90
90-100
10cm
Inspection & Palpation
of
the perineum
Inspection & Palpation
of
the perineum
Per Rectal Examination(PR)
Umbilicus
100
4cm
Per Rectal Examination(PR)
Umbilicus
100
4cm
Per Rectal Examination(PR)
Anoscopy
Anoscopy
Umbilicus
100
4cm
Anoscopy
Umbilicus
100
4cm
The most common benign anal-rectal diseases
1-Hemorrhoids(piles)
2-Anal fissure
3-Anorectal abscess and
4-Fistula-in-ano
Hemorrhoids
•
•
•
•
•
•
•
•
• EH: distal to dentate, covered
by anoderm, PAIN &LUMP
• IH: prox. to dentate, covered by
mucosa, PAINLESS BLEEDING
Combined hemorrhoids
• PE: make sure to evaluate
with straining, complete AR
exam.
11
3
7
Ext. Hemorrhoids
Thrombosed
Ext. Hemorrhoids
Treatment of External hemorrhoids
1) Conservative management:bulking agents,
NSAIDS,topical agents and
warm sitz baths
2) Less likely surgery: deroofing of the
thrombosed external hemorrhoids
Internal Hemorrhoids: Grade
Degrees of internal hemorrhoids
1- First degree : Bleeds, but does not prolapse.
2- Second degree :protrudes with straining; reduces
spontaneously.
3- Third degree : Spontaneous protrusion ; need
manual reduction.
4- Fourth degree : Irreducible to manual reduction
(constantly outside)
Internal Hemorrhoids (cont.)
Diagnosis:
• Painless anorectal
• bleeding is the
main complaint in the 1st.
degree
• Prolapsing mass is the
• main feature of the 2nd 3rd
• and the 4th.degrees
• P.R and proctoscopy are mandatory to exclude secondary
piles due to carcinoma.
Treatment of Internal hemorrhoids
1) –Consevative management:It is reserved for first
degree in the form of bulking agents, topical agents
and vasotonic agents
(diosamine).
2) - Sclerotherapy (1 – 2 ml sclerosing agent in
the submucosal space proximal to the
hemorrhoids)
3) – Infrared photocoagulation
4 )- Banding
Treatment of hemorrhoid (cont.)
5 )-Traditional hemorrhoidectomy:
- Open technique of Milligan.
-Closed technique of Ferguson
6 ) - Hemorrhoidectomy using Ligasure,
Harmonic scapel
7 )- Stapled Circular Hemorrhoidectomy.