Anal & Perianal Disorders — Seminar Content List (4 Presenters)

🔵 Presenter 1 — Anatomy, Physiology & Hemorrhoids

1. Anatomy & Physiology

• Anatomy of the rectum (mesorectum, Waldeyer fascia, Denonvilliers fascia)
• Anatomy of the anal canal (anoderm, dentate line, anal crypts, anal glands, transition zone)
• Sphincter complex: internal anal sphincter, external anal sphincter, puborectalis muscle
• Continence mechanism and defecation physiology
• Blood supply and lymphatic drainage of the anal canal

2. Hemorrhoids

• Definition & classification (internal vs. external; degrees 1–4)
• Pathophysiology
• Clinical presentation (painless rectal bleeding, prolapse, thrombosis)
• Diagnosis
• Management:
  • Conservative (high-fiber diet, bulk-forming agents)
  • Office-based (rubber band ligation, sclerotherapy, infrared coagulation)
  • Surgical (hemorrhoidectomy — indications and techniques)
  • Thrombosed external hemorrhoid management

🟢 Presenter 2 — Anal Fissure, Abscess & Fistula-in-Ano

3. Anal Fissure

• Definition and pathophysiology (ischemic ulcer, internal sphincter spasm)
• Acute vs. chronic fissure
• Location (posterior midline most common)
• Atypical fissures (Crohn's, HIV, TB — warning signs)
• Treatment:
  • Medical: stool softeners, topical nitrates, calcium channel blockers, botulinum toxin
  • Surgical: lateral internal sphincterotomy (LIS) — technique and risks

4. Anorectal Abscess

• Pathogenesis (cryptoglandular origin)
• Classification: perianal, ischiorectal, intersphincteric, supralevator
• Clinical features and diagnosis
• Treatment: incision and drainage — principles and technique
• Recurrence and fistula formation

5. Fistula-in-Ano

• Pathophysiology (Parks classification: intersphincteric, transsphincteric, suprasphincteric, extrasphincteric)
• Goodsall's rule
• Diagnosis (EUA, MRI, endoanal ultrasound)
• Management principles: limit fecal access, preserve sphincter
• Surgical options: fistulotomy, seton placement, LIFT procedure, flap repair

🟡 Presenter 3 — Pilonidal Disease, Rectal Prolapse & Anal Incontinence

6. Pilonidal Disease

• Pathophysiology (hair as foreign body nidus; acquired, not congenital)
• Acute abscess vs. chronic sinus
• Clinical presentation and examination
• Treatment:
  • Acute: incision and drainage
  • Chronic: excision with primary closure vs. open healing; flap techniques (Bascom, Karydakis)
  • Laser-assisted procedures

7. Rectal Prolapse

• Definition (full-thickness intussusception through anal verge)
• Distinction from mucosal prolapse and internal intussusception
• Risk factors (multiparous women, elderly, chronic straining)
• Clinical features and examination
• Diagnosis: reduction maneuver, defecography
• Management:
  • Surgical — transabdominal: rectopexy (± sigmoid resection) — preferred in fit patients
  • Surgical — perineal: Altemeier procedure, Delorme procedure — for high-risk patients
  • Recurrence and complications

8. Fecal Incontinence

• Etiology (obstetric injury, sphincter damage, neuropathy)
• Assessment: clinical + anorectal manometry, endoanal ultrasound
• Management: dietary modification, biofeedback, sphincteroplasty, sacral nerve stimulation, colostomy

🔴 Presenter 4 — Anal Neoplasms, Condylomata & Special Topics

9. Anal Condylomata Acuminata (Anal Warts)

• Etiology: HPV (types 6, 11 — low-risk; 16, 18 — high-risk)
• Clinical presentation
• Diagnosis and anoscopy
• Treatment: topical (trichloroacetic acid, imiquimod) vs. surgical excision/fulguration
• Surveillance and recurrence

10. Anal Intraepithelial Neoplasia (AIN) / Squamous Intraepithelial Lesions (SIL)

• LSIL (AIN I) vs. HSIL (AIN II/III, Bowen's disease, CIS)
• Association with HIV and HPV (types 16, 18)
• High-resolution anoscopy with acetic acid/Lugol's iodine
• Treatment: ablation; surveillance with anal Pap smears every 3–6 months in high-risk patients

11. Anal Canal Carcinoma

• Epidemiology: ~2% of colorectal malignancies
• Classification:
  • Perianal (distal to dentate line, inguinal LN drainage)
  • Intra-anal (proximal to dentate line, inferior mesenteric/internal iliac LN drainage)
• Squamous cell carcinoma (epidermoid carcinoma) — most common
• Adenocarcinoma, melanoma, GIST
• Staging (TNM)
• Treatment:
  • Nigro protocol: concurrent chemoradiotherapy (5-FU + mitomycin C) as standard of care
  • APR (abdominoperineal resection) — salvage for residual/recurrent disease
• Prognosis and surveillance

12. Other Perianal Conditions (brief)

• Pruritus ani — etiology and management
• Hidradenitis suppurativa
• Perianal Crohn's disease — medical vs. surgical approach
• Sexually transmitted infections involving the anorectal region

Suggested Time Split