PERIANAL DISORDERS
While anorectal malformations have been discussed in Ch 14.9, some important acquired problems of anorectal region are as follows:
Anal fissures, i.e. small lacerations at mucocutaneous junction of the anus, are common in infancy and early childhood due to forceful passage of hard stools in constipated children.
Constipation and anal fissure are inter-related, as children with anal fissure avoid defecation to prevent pain, which further exacerbates constipation and hard stools.Clinically, these cases present with painful defecation and passage of hard stools laced with bright-red color on the surface.
Diagnosis involves local examination revealing the fissure and sometimes a peri-anal skin tag, due to chronic inflammation. Crohn's disease must be excluded in cases with recurrent anal fissures.
Management aims to break to constipation - fissureconstipation cycle, by use of stool softners/laxatives in response-adjusted doses and encouragement of regular evacuation habits. Fissures tend to recur in habitually constipated children.
Rectal prolapse denotes exteriorization of rectal mucosa through the anus. When this extrusion includes all layers of rectal wall, it is termed as Procidentia.
Etiologically, rectal prolapse is common in 1-5 years age group, with following predisposing factors: (a) severe malnutrition, (b) acute/persistent diarrhea, (c) constipation, (d) meningocele, (e) pertussis, (f) chronic inflammatory bowel disorders, e.g. ulcerative colitis, and (g) postoperative cases of anorectal malformations. Clinically, rectal prolapse may be painless or painful and reducible or non-reducible. Severe cases may develop congestion, edema and ulceration of exteriorized portion.
Management includes: (a) manual reduction of protruding mass, facilitated by warm compresses, (b) treatment of primary cause, (c) ensuring adequate nutrition, and (d) surgical correction in severe cases or procidentia.
Perianal abscesses are relatively common and selflimiting in infancy, probably caused by extension of infection from underlying crypts. However, these
abscesses in children beyond 2 years are usually associated with a significant predisposing illness, e.g. Crohn's disease, Hirschsprung disease or immunodeficiency disorders.
Most perianal abscesses are polymicrobial in etiology, commonest being E.coli, Staph. aureus and anaerobes.
Clinically, these children present with variable severity of fever, rectal pain, painful defecation and signs of perianal cellulitis. Many cases in infancy may be completely asymptomatic.
Treatment: Perianal abscesses in infants are usually selflimiting, though abscess drainage and/or fistulotomy is required in selected cases. Older children with predisposing factors require more aggressive treatment with antibiotics, excision/drainage and treatment of underlying cause.
14.16