Left lateral, right anterior, and right posterior hemorrhoidal plexuses

  External hemorrhoids cause pain when they thrombose

•  Distal to the dentate line, covered by sensate squamous epithelium; can cause pain, swelling, and itching

  Internal hemorrhoids cause bleeding or prolapse

•  Primary – slides below dentate with strain

•  Secondary – prolapse that reduces spontaneously

•  Tertiary – prolapse that has to be manually reduced

•  Quaternary – not able to reduce

  Tx: fiber and stool softeners (prevent straining); sitz baths

  Thrombosed external hemorrhoid → lance open (if > 72 hours) or elliptical excision (if < 72 hours) to relieve pain

  Surgical indications: recurrence, thrombosis multiple times, large external component

  External hemorrhoids can be resected with elliptical excision

  Can band primary and secondary internal hemorrhoids

•  Do not band external hemorrhoids (painful)

  Surgery for tertiary and quaternary internal hemorrhoids – 3 quadrant resection

•  Need to resect down to the internal anal sphincter (do not go through it)

•  Postop – sitz baths, stool softener, high-fiber diet

RECTAL PROLAPSE

  Starts 6–7 cm from anal verge

  Secondary to pudendal neuropathy and laxity of the anal sphincters

  ↑ with female gender, straining, chronic diarrhea, previous pregnancy, and redundant sigmoid colons

  Prolapse involves all layers of the rectum

  Medical Tx: high-fiber diet

  Surgical Tx:

•  Perineal rectosigmoid resection (Altemeier) transanally if patient is older and frail

•  Low anterior resection and pexy of residual colon if good condition patient

CONDYLOMATA ACUMINATA

  Cauliflower mass; papillomavirus (HPV)

  Tx: laser surgery

ANAL FISSURE

  Caused by a split in the anoderm

  90% in posterior midline

  Causes pain and bleeding after defecation; chronic ones will see a sentinel pile

  Medical Tx: sitz baths, bulk, lidocaine jelly, and stool softeners (90% heal)

  Surgical Tx: lateral subcutaneous internal sphincterotomy

  Fecal incontinence is the most serious complication of surgery

  Do not perform surgery if secondary to Crohn’s disease or ulcerative colitis

  Lateral or recurrent fissures – worry about inflammatory bowel disease

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