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Anal fistula is a common disease of the anal region that can be treated using a cutting seton. The objective of this study was to investigate healing and recurrence outcomes of anal fistulas treated via cutting setons performed by a specialist colorectal surgery group at a single academic institution. This retrospective chart review study included 143 patients who underwent a cutting seton procedure at a single academic institution to treat their anal fistula between January 2013 and December 2018. The main outcomes measured in this study were healing rates, recurrences rates, incontinence rates, and infectious complication rates of anal fistulas being treated with a cutting seton. In total, 127 (88.8%) patients’ fistulas healed after treatment with a cutting seton. Fifteen (10.5%) patients had a fistula recurrence after treatment. Fourteen (9.8%) patients experienced an infectious complication after the cutting seton procedure while 8 (5.6%) patients developed some form of incontinence during the fistula healing period. Average healing time for fistulas after cutting seton treatment was 1.9 months (7–8 weeks). This study indicates that the cutting seton procedure is an effective and safe method for treating anal fistulas. Cutting setons lead to low rates of complications (like infections and incontinence) and good long-term outcomes when it comes to maintaining anal sphincter function after presence of a complicated and/or high anal fistula. This study suggests that the cutting seton remains an alternative to other procedures, which maybe more invasive and compromising.

Neuropathy may cause fecal incontinence and mixed fecal incontinence/constipation, but its prevalence is unclear, partly due to the lack of comprehensive testing of spino-anorectal innervation.This study aimed to develop and determine the clinical usefulness of a novel test, translumbosacral anorectal magnetic stimulation for fecal incontinence.This observational cohort study was conducted from 2012 to 2018.This study was performed at a tertiary referral center.Patients with fecal incontinence, patients with mixed fecal incontinence/constipation, and healthy controls were included.A translumbosacral anorectal magnetic stimulation test was performed by using an anorectal probe with 4 ring electrodes and magnetic coil, and by stimulating bilateral lumbar and sacral plexuses, uses and recording 8 motor-evoked potentials at anal and rectal sites.The prevalence of lumbar and/or sacral neuropathy was examined. Secondary outcomes were correlation of neuropathy with anorectal sensorimotor function(s) and morphological changes.We evaluated 220 patients: 144 with fecal incontinence, 76 with mixed fecal incontinence/constipation, and 31 healthy controls. All 8 lumbar and sacral motor-evoked potential latencies were significantly prolonged (p0.01) in fecal incontinence and mixed fecal incontinence/constipation groups compared with controls. Neuropathy was patchy and involved 4.0 (3.0) (median (interquartile range)) sites. Lumbar neuropathy was seen in 29% to 65% of the patients in the fecal incontinence group and 22% to 61% of the patients in the mixed fecal incontinence/constipation group, and sacral neuropathy was seen in 24% to 64% and 29% to 61% of these patients. Anal neuropathy was significantly more (p0.001) prevalent than rectal neuropathy in both groups. There was no correlation between motor-evoked potential latencies and anal sphincter pressures, rectal sensation, or anal sphincter defects.No comparative analysis with electromyography was performed.Lumbar or sacral plexus neuropathy was detected in 40% to 75% of patients with fecal incontinence with a 2-fold greater prevalence at the anal region than the rectum. Lumbosacral neuropathy appears to be an independent mechanism in the pathogenesis of fecal incontinence, unassociated with other sensorimotor dysfunctions. Translumbosacral anorectal magnetic stimulation has a high yield and is a safe and clinically useful neurophysiological test. See Video Abstract at http://links.lww.com/DCR/B728.ANTECEDENTES:La neuropatía puede causar incontinencia fecal y una combinación de incontinencia fe-cal/estreñimiento, pero su prevalencia no está clara, en parte debido a la falta de pruebas comple-tas de inervación espino-anorrectal.OBJETIVO:Desarrollar y determinar la utilidad clínica de una nueva prueba, estimulación magnética trans-lumbosacral anorrectal para la incontinencia fecal.DISEÑO:Estudio de cohorte observacional del 2012 al 2018.ENTORNO CLINICO:Centro de referencia terciario.PACIENTES:Pacientes con incontinencia fecal, combinación de incontinencia fecal/estreñimiento y controles sanos.INTERVENCIONES:Se realizó una prueba de estimulación magnética translumbosacral anorrectal utilizando una sonda anorrectal con 4 electrodos anulares y bobina magnética, y estimulando los plexos lumbares y sacros bilaterales y registrando ocho potenciales evocados motores las regiones anal y rectal.PRINCIPALES MEDIDAS DE RESULTADO:Se examinó la prevalencia de neuropatía lumbar y/o sacra. Los resultados secundarios fueron la correlación de la neuropatía con las funciones sensitivomotoras anorrectales y cambios morfológi-cos.RESULTADOS:Evaluamos 220 pacientes, 144 con incontinencia fecal, 76 con combinación de incontinencia fe-cal/estreñimiento y 31 sujetos sanos. Las ocho latencias de los potenciales evocadas motoras lum-bares y sacras se prolongaron significativamente (p0,01) en la incontinencia fecal y el grupo mixto en comparación con los controles. La neuropatía fue irregular y afectaba 4,0 (3,0) (mediana (rango intercuartílico) sitios. Se observó neuropatía lumbar en 29-65% en la incontinencia fecal y 22-61% en el grupo mixto, y neuropatía sacra en 24-64% y 29-61 % de pacientes respectivamen-te. La neuropatía anal fue significativamente más prevalente (p0,001) que la rectal en ambos grupos. No hubo correlación entre las latencias de los potenciales evocadas motoras y las presio-nes del esfínter anal, la sensación rectal o los defectos del esfínter anal.LIMITACIONES:Sin análisis comparativo con electromiografía.CONCLUSIÓNES:Se detectó neuropatía del plexo lumbar o sacro en el 40-75% de los pacientes con incontinencia fecal con una prevalencia dos veces mayor en la región anal que en el recto. La neuropatía lumbo-sacra parece ser un mecanismo independiente en la patogenia de la incontinencia fecal, no asocia-do con otras disfunciones sensitivomotoras. La estimulación magnética translumbosacral anorrec-tal tiene un alto rendimiento, es una prueba neurofisiológica segura y clínicamente útil. Consulte Video Resumen en http://links.lww.com/DCR/B728.

Background Anorectal malformations (ARM) represent a wide spectrum of defects. Caudal and genitourinary malformations can associate with anorectal malformations. Genetic factors may play role in the development of anorectal malformations. Perineal masses like sacrococcygeal teratoma, rectal prolapse, or duplication cysts were reported before, but their association with perineal hamartoma and anal atresia is extremely rare. Case presentation Here, we report an 11-month-old female infant. She had 551 kb duplication at 7p12.3 with perineal hamartoma and anal atresia consisting a cystic lesion with a diameter of 4 mm at the filum terminale (L2 vertebra) on lumbar magnetic resonance imaging (MRI) in neonatal period. She presented with hypotonia. She had anorectal anomaly and external perineal mass bulging from left major labium extending across anal region with imperforate anus. There was 1 × 1 cm polyp-like protrusion on it. She was operated in neonatal period. Genetic laboratory investigations showed karyotype 46, XX. The microduplication of the chromosome 7p12.3 was detected by microarray analysis. There were not any significant homozygous or heterozygous variants determined by whole-exome sequencing. Conclusions To the best of our knowledge, this is the first report of a patient with a microduplication of the chromosome 7p12.3, and second case with perineal hamartoma and imperforate anus. Clinicians should pay attention to microdeletions and microduplications while giving genetic counseling to patients with urogenital and anorectal abnormalities.

Purpose of the study: to conduct a morphological study of experimental material to assess the features of wound healing in the anal sphincter area when using the domestic drug “Heprocel” as a hemostatic agent. Material and methods. The study was carried out in the Department of experimental surgery and the department of pathological anatomy of the Republican Specialized Scientific and Practical Medical Center for Surgery named after Academician V. Vakhidov. The state of experimental models of wounds with the application of a hemostatic agent in the form of a gel was studied. The experiments were carried out on 72 white male rats weighing 210-250 g. Two series of 36 animals each were produced. All animals were divided into groups: norm - experiment in the absence of drug hypocoagulation; control - an experiment with intravenous heparin to achieve drug hypocoagulation; experience - an experiment with intravenous administration of heparin to achieve drug hypocoagulation using an application on a model of a skin wound and a dissected anal sphincter of the hemostatic agent "Heprocel". Results. Morphological differences in the process of wound healing were most pronounced after 3 days of the study. In the control group of animals with hemostasis using an electrocoagulator, necrotic and exudative processes of inflammation in the stratified squamous epithelium and mucous membrane of the glands in the anal region were evident. In the experimental group, on the 3-5th day of the experiment, the proliferative process of inflammation predominated morphologically. A special feature is that the hemostatic gel is absorbed into the wound, forming a thin uniform layer. On the 10th day of the experiment, the above difference became more obvious. In the control group, chaotic squamous epithelial cells and fibroblasts were formed. The fibrin-necrotic layer is preserved. Focal infiltration of macrophages-lymphocytes was observed. In the experimental group, the intestinal layers began to change. In the area of the surgical incision, the hemostatic layer is preserved; in this area, the growth of thin fibrous connective tissue is observed. Differentiation and transformation of cells led to the regeneration of the epithelial layer and parakeratosis of the flat cell. Signs of complete remodeling were evident over a long period of time, such as 14 days. Conclusion. The use of a hemostatic agent in the form of a gel provides not only an increase in the processes of local hemostasis, but a decrease in the activity of inflammatory reactions and infection, as well as the risk of developing post-traumatic cicatricial deformity of the anus.

The concept of combination of thermo reversibility and mucoadhesion has achieved a much valuable interest in various fields of pharmaceutics. Mucoadhesive drug delivery systems interact with the mucus layer covering the mucosal epithelial surface, and mucin molecules and increase the residence time of the dosage form at the site of absorption. Thermoreversible gels are the hydrogels that are liquids at room temperature but undergo gelation when in contact with body fluids or change in pH. A major problem faced by conventional formulation in various routes of administration viz. nasal, ocular, vaginal, rectal, etc is drainage of instilled formulation, poor patient compliance as in the case of vaginal and rectal delivery system. Also, blurred vision and irritation to mucosa is observed in the case of ocular and nasal delivery respectively. The drainage of the formulation results in inaccurate dose delivery thus decreasing the bioavailability of the drug which demands an increase in the frequency of the administration. To overcome these limitations, there is need of novel delivery system such as thermoreversible mucoadhesive insitu gel which provides an ease of administration and improved patient compliance as these smart delivery system is free flowing liquid at ambient temperature and gels at physiological temperature which is higher than the LCST (low critical solution temperature) of thermoreversible polymer. The combined effect of mucoadhesion and thermoreversible property will enhance prolongation of residence time of dosage form and the accuracy of the dose in body cavity respectively, leading to increased bioavailability of the drug. This review focuses on benefits of mucoadhesive thermoreversible system of drug delivery through rectum for the treatment of internal hemorrhoids.

Anal Fissure is one of the significant causes of pain in the anal region. The two primary signs of this disease are pain and bleeding, and pain is often unbearable. In males, anal fissure typically occurs in the midline posterior- 90 %, and 10 % midline anterior. Subsequently, female fissures on the midline anteriorly are significantly more frequent than posteriorly (60:40). In contemporary sciences, Parikartika can be correlated with Fissure in Ano. The objective of the prospective study is to find the effectiveness of Chakramarda Ghrita & GoGhrita in the management of Parikartika. The present study is designed as a randomized, single-blind parallel in which 30 patients will be enrolled. Ghrita will be applied for local application twice a day. Assessment will be done 0th, 7th day, 14thday, and 28th day. The changes are expected to be observed in subjective parameters such as pain bleeding per rectum with itching as well as with objective parameters such as Parikartika Healing and tenderness. The study is expecting the non-surgical management of fissure in ano concerning the impact of Chakramarda Ghrita & GoGhrita. The research is expecting to be baseline and benchmark of the prospective studies in Parikartika.

Bhagandara is one of the commonest diseases which occur in anorectal region. Acharya Sushruta had described this disease in Ashtamahagada that means disease difficult to cure. It starts as deep rooted Pidika around the Guda within two Angula or finger circumference and form into a track with an external opening in the skin of perianal region and an internal opening in the mucosa of anal canal or rectum lined by unhealthy granulation tissue and fibrous tissue which in modern science can be correlated to Fistula-in-ano. As the recurrence rate of fistula in ano is high after modern treatment. To overcome these difficulties, the concept of Ksharsutra mentioned in the classics is very beneficial from the treatment point of view. So, the Guggulu (Commiphora mukul) based Ksharsutra therapy along with oral Ayurvedic formulations is taken to prove its efficacy in treating Bhagandara. Here a case report of a 32 year old, male patient having history of Bhagandara (Fistula-in-ano) since last 2 years is discussed. He had complaints of left gluteal swelling, pain, pus discharge from perianal region and itching around anal region. For which he took allopathic treatment and got no relief, finally patient came to our hospital for better Ayurvedic management. He was treated with Guggulu based Ksharsutra therapy along with oral medication of Saptavinshati Gugglu vati 500 mg with water twice daily. Lastly, he got treated in 60 days and follow up of the patient was maintained up to 6 months where no complication was reported. It was proved that Ksharsutra application in combination with oral Ayurvedic medication worked effectively. This case report will help and enlighten the budding young scholars working in this area.

Despite their benefit for detecting primary tumors, data for normal 18F-fluoro-2-deoxy-d-glucose (FDG) uptake in the anal canal are insufficient. Here we used positron emission tomography–computed tomography (PET/CT) to determine the uptake of FDG in the normal adult anal canal (AC) and to evaluate its clinical significance compared with that of anal cancer. We conducted a retrospective study of–PET/CT images in the anal region, of 201 consecutive patients without symptoms or pathology taken from January 2015 to August 2019, after excluding two patients (one each with Crohn’s disease and hemorrhoid). These patients were included in the normal group, and data of eight patients with anal cancer were collected from January 2011 to August 2019 for comparison. FDG uptake was quantitatively evaluated (compared with the maximum standardized uptake value [SUVmax] to the SUVmax values of liver and distal rectum) and qualitatively (compared with background) in early and delayed phases. Normal grade 3 uptake was qualitatively defined as FDG uptake higher than the surrounding muscles. In the normal group, mean anal canal SUVmax of early phase was: 2.26 (range 1.00–6.30), and delayed phase: 2.52 (range 1.00–8.80). Their ratios to liver SUVmax were early: 0.74 (range 0.24–2.25), and delayed: 0.81 (range 0.23–2.32); ratios to rectal SUVmax were early: 0.87 (range 0.30–1.89), and delayed: 0.90 (range 0.30–1.27). Qualitatively, 25 patients (15.4%) had normal grade 3 uptake during the early and delayed phases. In contrast, qualitative data showed that all patients with anal cancer exhibited high FDG uptake in the anal canal. The mean early- and delayed-phase values of SUVmax of the anal canal and anal cancer group were 11.09 (range 5.40–17.73) and 14.23 (range 6.70–22.85), respectively. There was a significant difference between the mean-early and -delayed anal SUVmax values of the normal grade 3 and anal cancer groups. Furthermore, the ratios to liver SUVmax were significantly different between the two groups. PET/CT scans occasionally showed high FDG uptake in the anal canal of healthy adults. Comparing the SUVmax values of liver FDG uptake may help differentiate between normal tissue and anal cancer.

Haemorrhoid is one of the most common anorectal complaints1,2 reported in anorectal clinics with estimated prevalence of 4.4% in United States and 13–36% in the United Kingdom.3 It is one of the oldest ills known to mankind with accounts available in oldest literature like Atharwaveda (1500 BCE)4 from India and Egyptian Papyrus (1700BCE)5 from the west. Haemorrhoids are actually the vascular cushions that provide a physiological hermetic seal in the closure mechanism of anal canal and helps in maintenance of continence.6 Faulty dietary and toilet habits may cause the pathological enlargement of these cushions which create misery to the patient by producing bleeding, discomfort, prolapse and sometimes pain in the anorectal region. A modification in diet, lifestyle and defecation habits can alleviate the symptoms in many patients. For the rest, various surgical methods like haemorrhoidectomy, stapled haemorrhoidopexy etc. and the office procedures like rubber band ligation, sclerotherapy, photocoagulation, cryosurgery etc. are available with each having its own merits and limitations compared to other. Though haemorrhoidectomy is still considered as the ‘gold standard’ treatment for haemorrhoids,7 office treatments for symptomatic haemorrhoids are increasing8 over the last few decades. Rubber Band Ligation (RBL), as advocated by Barron,9 is one of the safe, simple, cost-effective and the most widely used office procedure by the surgeons which eliminate the pile mass by ischemic necrosis and promote submucosal fibrosis with subsequent fixation of anal epithelium to the underlying sphincter.10 In traditional Indian medicine i.e. Ayurveda, the term arsha is used to describe an abnormal fleshy growth originating in the anal region due to improper diet, lifestyle and defecation habits.11 By definition, the term arsha may broadly include sentinel tags, hypertrophied papillae, polyps and external as well as internal piles; however, to be very specific, haemorrhoidal disease may be corresponded with raktarsha (rakta means ‘blood’ and arsha means ‘fleshy mass’), a variety of arsha described in ancient texts. The management strategies for haemorrhoids include four modalities of treatments viz. medicinal treatment, chemical cauterization, thermal cauterization and surgical excision.12 While medical management is primarily advocated for uncomplicated haemorrhoids and focusses upon improvement of digestion, easy evacuation and correction of bowel habits; large and complicated piles are advised to be treated with thermal cauterization or excised surgically. Chemical cauterization is a form of parasurgical measure which is employed by local application of a caustic material, pratisaraneeya kshara (PK; pratisaraneeya means ‘to be applied locally’, kshara means ‘alkaline caustics’) in internal haemorrhoids. It is prepared from the ashes of medicinal plants by a special technique of preparation with addition of marine shells13 and, on application, brings about necrosis in the pile mass resulting into an ulcer which heals by fibrosis.14 Local application of PK, also known as kshara-karma, is one of the most widely practiced outpatient treatments for internal haemorrhoids by the Ayurveda surgeons in India. Thus, both RBL and local application of PK have a similar mode of action and are the office procedures of choice for internal haemorrhoids among the modern and Ayurveda surgeons respectively. So, the present study was designed to compare the efficacy of these two techniques in a prospective randomized trial.

Background: Anal fissure is the most common painful condition of anal region characterised by vertical ulcers affecting distal end of anal canal. The main aim of this study is comparing 2 % diltiazem and lateral internal sphincterotomy in the treatment of chronic anal fissure.Materials and Methods: The Study was conducted as a clinical trial in Sree Mookambika institute of medical sciences, Kulasekharam from May 2020 to November 2020.100 patients diagnosed with chronic fissure in ano on the basis of history of painful defecation with or without per rectal bleeding for more than 6 weeks and per rectal examination were enrolled in the study after obtaining an informed written consent from them. Results has been detailed in both descripted and statistical point of view and simplified in understandable format.Results: In 89.36% of patients in diltiazem group and 100% of patients in lateral internal sphincterotomy group fissure healed completely between 4-8 weeks. In the diltiazem group pain relief was good. 42 patients (89.4%) had pain relief at the end of 14 weeks. 5 patients (10.6%) had no pain relief. But pain relief in lateral internal sphincterotomy group was excellent with 100% patients having complete pain relief by 8 weeks’ time. Mild headache was experienced with diltiazem by 3(6.4%) patients.1 patient (2.1%) complained of flatus incontinence with lateral internal sphincterotomy.Conclusion: We conclude that lateral internal sphincterotomy is the gold standard treatment of chronic fissure in ano but chemical sphincterotomy using 2% diltiazem gel can be considered as a good second line treatment option in those unfit for surgery or for those not willing for surgery.

Background and Aims Chronic perineal pains is a painful condition. In this study, we aimed to assess the effect the ultrasound associated to the fluoroscopy for improve the effectiveness and the safety of the radiofrequency on the ganglion impar in the patient with perianal pain1, who did not respond to standard drug therapies2 Methods The case was a 79-year-old woman with history of continuous stabbing pain in the anal region. At her first visit, the VAS was 9/10. The patient was in the prone position on the operating table. After disinfection in the region of the sacral, a sterile echographic linear probe was placed transversely on the lower portion of the sacred until the identification of the sacral cornets. Then, the probe is rotated in a longitudinal position until the identification of the sacrococcygea joint.Under constant ultrasound guidance and fluoroscopy, a 22 G 100 mm radiofrequency needle was introduced in the precoccigeo space near the ganglion impar. The position of the needle tip was confirmed by injecting 1 mL of radiopaque dye in the retroperitoneal space.Then, a thermocouple connected to a radiofrequency generator was inserted to reproduce the patient‘s paresthesia via sensitive stimulation, 0.4–0.5 mV. The radiofrequency was performed at 90°C for 90 seconds. Results At the end of the procedure the patient reported VAS 0. Conclusions The result suggests that ultrasound guided combined with fluoroscopy enhances the safety and accuracy of radiofrequency on the ganglion impar. Furthermore, it significantly reduces radiation exposure for both patients and operator.

Perianal abscess often encountered in clinical practice, has a chance of recurrence and fistula formation if not treated properly. The system of modern medicine treats the condition with incision and drainage. This case report is of a 47-year-old male presenting with pain and swelling in the anal region. The patient was diagnosed by ultrasonography (USG) perineum as a recurrent perianal abscess in the right perianal region, who formed a fistulous tract, but who improved with homeopathic treatment, as documented with serial photographs and USG. It highlighted the scope of successful management without surgical procedures.

Background Coronavirus disease 2019 (COVID-19) has a broad spectrum from respiratory and nasopharyngeal symptoms, cerebrovascular diseases, impaired consciousness, and skeletal muscle injury. Emerging evidence has indicated the neural spread of this novel coronavirus. Restless legs syndrome (RLS) is a common neurological, sensorimotor disorder, but highly under diagnosis disorder. Restless anal syndrome as restless legs syndrome variant associated with COVID-19 has been previously not published. We report a case presenting with restless anal syndrome following COVID-19. Case presentation Although a 77-year-old male with COVID-19 improved to normal respiratory function 21 days after admission and treatment of favipiravir 200 mg per day for 14 days and dexamethasone 6.6 mg per day for 5 days, the insomnia and anxiety symptoms remained. Several weeks after discharge, he gradually began to experience restless, deep anal discomfort, approximately 10 cm from the perineal region. The following features were observed in the anal region; urge to move is essential, with worsening with rest, improvement with exercise, and worsening at evening. Colonoscopy revealed internal haemorrhoids without other rectal lesions. Neurological findings including deep tendon reflex, perineum loss of sensory and spinal cord injury, revealed no abnormalities. Diabetes militias, kidney dysfunction and iron deficiency status were not confirmed. Family history of RLS and periodic limb movements were not observed. Clonazepam at 1.5 mg per day resulted in the alleviation restless anal discomfort. Conclusions We reported a case presenting with restless anal syndrome following affection of COVID-19 as restless legs syndrome variant. This case fulfilled 4 essential features of RLS, urge to move, worsening with rest, improvement with exercise, and worsening at evening. To date, no case of restless anal syndrome associated with COVID-19 has been previously published. This case report may reflect the associative impacts of COVID-19 on the neuropsychiatric state. The long-term outcomes of neuropsychiatric conditions should continue to be monitored.

Purpose Abscess or fistula of the anal region is an uncommon presentation of malignancy. Under the assumption of a benign condition, diagnostics is often delayed, resulting in advanced tumour stages at first diagnosis. Due to the case rarity, treatment guidelines for cancers of anorectal region masquerading as abscess or fistula are missing. Methods We analysed all patients presenting with an abscess or fistula of the anal region in our department between January 2004 and August 2020. The malignancies were included to our study to acquire data on clinical presentation, treatment and outcome. Furthermore, a systematic review to present adenocarcinomas and squamous cell carcinomas associated to an abscess or fistula was performed. Results 0.5% of the patients treated for an abscess or fistula of the anal region met the selection criteria. Mean time from the onset of symptoms to diagnosis of malignancy was 100 days. Histology revealed adenocarcinoma and squamous cell carcinoma each in two patients. All patients had locally advanced tumours without distant metastases, in two cases with regional lymph-node metastases. Neoadjuvant chemoradiation was applied in two patients. All patients underwent abdomino-perineal resection of the rectum. The overall outcome reveals a recurrence-free survival of 4.5 and 3 years for two patients. Further two patients died within 5 months after the primary resection. Conclusion Advanced carcinomas of the anorectal region may masquerade as abscess or fistula, cause diagnostic problems and delay oncologic treatment. However, even in these very advanced situations, surgical therapy with curative intent should be attempted.

Background: Parikartika is charecterised by sharp cutting pain in anal region. In Parikartika Teevrashoola,bleeding is observed, equally extreme pain& slimy blood discharge are seen in Fissure-in-anoObjective: To test the efficacy of thelocal application of Kasisadi Ghruta in managingMethods: Classical signs and symptoms ofParikartika (fissure inAno) Age groups of 20 to 60 years havebeen recruited for the researchThe trial group obtained treatment with Kasisadi Ghruta local application for28 days, twice a day.Results: Average relief observed was observed 62.5% for most symptoms Shothahara, Vedanasthapana andRopana are in Kasisadi Ghruta. Properties because of which it helps in healing the ano fissureConclusion: Local Kasisadi Ghruta The programme has better results in the Fissure in ano.

In this case report, we aimed to describe the operative treatment of a three-day simmental breed male calf who was brought to our clinic with the complaint of stool coming from the preputium and not defecation from the anus. As a result of clinical and radiographic examinations, atresia ani and rectourethral fistula was diagnosed. Following premedication and local anesthesia, the skin and subcutaneous connective tissues were incised and the rectum was reached. The rectum, which was separated from the surrounding tissues by blunt dissection, was pulled out of the operation wound. After the closed end of the rectum was opened, the rectum part with a fistula hole opening into the urethra was extirpated. After the extirpation procedure, anus was created by suturing to the subcutaneous connective tissue and skin in the rectum anal region. Postoperative parenteral antibiotic administration and wound care with antiseptic warm water were performed for 7 days. Skin sutures were removed 10 days later. In the interviews with the owner for 6 months postoperatively, it was detected that the calf has any complication., Bu olgu sunumunda prepisyumundan dışkı geldiği ve anüsten defekasyon yapamadığı şikâyetiyle kliniğimize getirilen üç günlük simental ırkı erkek bir buzağının operatif tedavisinin tanımlanması amaçlandı. Yapılan klinik ve radyografik muayeneler sonucunda atresia ani ve rektoüretral fistül tanısı konuldu. Premedikasyon ve lokal anestezi uygulamasını takiben deri ve derialtı bağ dokuları ensize edilerek rektuma ulaşıldı. Çevre dokulardan küt diseksiyon ile ayrılan rektum operasyon yarasından dışarı çekildi. Rektumun kapalı olan uç kısmı açıldıktan sonra üretraya açılan fistül deliği bulunan rektum parçası ekstirpe edildi. Ekstirpasyon işlemi sonrası rektum anal bölgedeki derialtı bağ doku ve deriye dikilerek anüs oluşturuldu. Postoperatif olarak 7 gün boyunca parenteral antibiyotik uygulaması ve ılık antiseptikli sularla yara bakımı gerçekleştirildi. Deri dikişleri 10 gün sonra alındı. Operasyon sonrası 6 ay boyunca hasta sahibi ile yapılan görüşmelerde olguda herhangi bir komplikasyon bulunmadığı tespit edildi.

Anal sphincter spasm contributes to the delay in surgical wound healing after hemorrhoidectomy. A prospective, experimental, randomized, double-blind trial was conducted on two groups of patients that underwent closed hemorrhoidectomy. There were 26 patients in each group. Group A received topical diltiazem in the anal region three times a day. Group B received a placebo. Cicatrization time was documented for 6 weeks through digital photography. Mean healing time for the group treated with diltiazem was 3.19 weeks (22.33 ± 0.884 days) and 3.92 weeks (27.44 ± 1.130 days) for the control group (p = 0.012 95% CI). At week three, the wounds in 73.07% of the patients in the diltiazem group had healed, compared with 46.15% of the patients in the control group. Resumen: El espasmo del esfínter anal contribuye al retardo en la cicatrización de las heridas quirúrgicas después de una hemorroidectomía. Se realizó un estudio aleatorizado, prospectivo, experimental, doble ciego, de dos grupos de pacientes en los que se efectuó hemorroidectomía con técnica cerrada. Cada grupo incluyó 26 pacientes; el grupo A recibió diltiazem tópico en la región anal 3 veces al día, y el grupo B recibió un placebo. Se documentó el tiempo de cicatrización, mediante fotografía digital, durante 6 semanas. El promedio del tiempo de cicatrización para el grupo tratado con diltiazem fue de 3.19 semanas (22.33 ± 0.884 días); en tanto que en el grupo control fue de 3.92 semanas (27.44 ± 1.130 días) (p = 0.012 IC 95%). A la tercera semana, el 73.07% de los pacientes del grupo tratado con diltiazem habían cicatrizado, en comparación con el 46.15% de los pacientes del grupo control. Keywords: Diltiazem, Cicatrization, Post-hemorrhoidectomy cicatrization, Palabras clave: Diltiazem, Cicatrización, Cicatrización posthemorroidectomía

The history of association between HPV and cancer, risk factors, pathogenesis, diagnostics, treatment and prophylaxis of anal intraelithelial neoplasia (AIN) and squamous-cell anal cancer are discussed in this article. Although these conditions are rare, they may become some of the main health hazards in certain groups of patients, such as HIV-infected patients, patients with history of other HPV-related malignancies, patients practicing anal sexual intercourse and patients receiving systemic immunosuppressive therapy. A collaboration of different specialists is necessary in order to develop effective prophylactic measures for HPV-associated malignancies of anal region. There are no estabilished methods for AIN treatment. The use of ointments and local destruction are the most researched treatment methods. Vaccination is already developed as a prophylactic measure. However, a more thorogh research of HPV types in russian population is necessary prior to its wide implementation. Preliminary data favors the use of polivalent vaccines in russian population.

Adults of the Brown Ear Tick (Rhipicephalus appendiculatus) have a predilection for feeding inside and around the ears of cattle and other hosts. A previous study has shown that the tick locates the host ears by ‘push–pull’ deployment of a repellent blend emitted at the anal region and an attractant blend emitted at the ears. Interestingly, the two odours play reverse roles with Rhipicephalus evertsi, which prefer to feed around the anal region. The present study was undertaken to characterize the major constituents of the cattle anal odour and to evaluate their repellence to R. appendiculatus. The anal odour was trapped with reverse-phase C18-bonded silica, Porapak Q and Super Q placed in an oven bag attached at the anal region of the cattle for 6 h. The adsorbents were then removed and extracted with dichloromethane, and the extracted compounds analyzed by linked gas chromatography-mass spectrometry (GC–MS). The major constituents of the odour were o-xylene, 4-hydroxy-4-methyl-2-pentanone, 4-methyl-2-methoxyphenol, ethylbenzene, 2,6,6-trimethyl-[1S(1α,β,5α)]bicycloheptanes, 5-ethoxydihydro-2(3H)-furanone, 3-methylene-2-pentanone, 5-methyl-2-phenyl-1H-indole, and 3-pentanone. The repellency of the available compounds (o-xylene, 4-hydroxy-4-methyl-2-pentanone, 4-methyl-2-methoxyphenol, ethyl benzene, 3-methylene-2-pentanone, and 3-pentanone) and blends was evaluated using a dual choice tick climbing assay at different doses. The anal odour showed repellence with RD75 of 0.39. Of the compounds tested, 4-methyl-2-methoxyphenol was found to be most repellent (RD75 = 0.56) and 3-pentanone least repellent (RD75 = 622.7). The blend of the six constituents showed RD75 of 0.34, comparable to that of the crude anal odour blend. A series of subtractive bioassays with one constituent of the 6-component blend missing was also carried out. Subtraction of 3-methylpentanone gave the most repellent blend (RD75 = 0.097), whereas subtraction of 4-methylguaiacol gave the least repellent blend (RD75 = 160.7) consistent with the high individual activity of this phenol. The study lays down useful groundwork for on-host deployment of controlled-release of a selected repellent or blend to disrupt the tick’s ability to locate its preferred feeding site.

Background - Anal Fissure is one of the major causes for pain at anal region. The two primary signs ofthis disease are pain and bleeding, and pain is often unbearable. In males anal fissure typically occursin the midline posterior- 90 %, and 10 % midline anterior. Subsequently, female fissures on the midlineanteriorly are significantly more frequent than posteriorly (60:40). In contemporary sciences Parikartikacan be correlated with Fissure in Ano. Objective- The objective of the prospective study is to find theefficacy of Palashgudavarti & Diclofenac Sodium Suppository in the management of Acute Fissure inano(Parikartika).Material & Method: The present study is designed as a Randomized single blind parallelin which 60 patients will be enrolled. Varti will be applied for local application once a day. Assessment willbe done 0th, 7th day, 14thday, and 28th day. Results: The changes are expected to be observed in subjectiveparameters such as pain bleeding per rectum with itching as well as with objective parameters such asParikartika Healing. Conclusion: The study is expecting the nonsurgical management of fissure in ano withrespect to the impact of Palashgudavarti & Diclofenac Sodium Suppository. The research is expecting to bebaseline and benchmark of the prospective studies in Acute Fissure in ano (Parikartika).

Background : Calcinosis cutis is an uncommon dermatopathy characterized by the deposition of minerals in the skin, usually involving collagen and elastic fibers in the dermis. Usually, it results from dystrophic calcification and can be generalized or focal. The dermatopathy may be primary or secondary to certain disorders, especially chronic proliferative otitis, foreign body reactions, hyperadrenocorticism (HAC) and less frequently percutaneous penetration of calcium-rich products. The aim of this report is to describe a presentation of calcinosis cutis affecting the skin of the back, internal face of hind limbs and anal region of a 9-year-old bitch. Case : A 9-year-old, non-defined breed, bitch, ovariohysterectomized, weighing 9.45 kg, was attended at the Dermatological Service of companion animals at the Veterinary Hospital of the Federal University of Jatai (UFJ). The animal came in with the complaint of extensive dorsal alopecia, covered by firm lesions, with a 3-month evolution, additionally to polyuria and polydipsia. After physical examination, alopecic areas of great extension were confirmed on the dorsum, on the internal surface of the hind limbs and in the anal region. Also, an exudative and painful lesion located on the back was detected, plus loss of elasticity of the ventral abdomen skin and visible abdominal vessels. The screening tests showed a marked increase in the alanine aminotransferase enzyme (ALT), alkaline phosphatase (ALP) and total cholesterol. The specific urinary density was decreased. On the ultrasound examination, hepatomegaly and an increase in the caudal pole of the left adrenal were detected. Based on these findings, calcinosis cutis secondary to spontaneous hyperadrenocorticism (HAC) was suspected. For confirmation, skin biopsy and low dose dexamethasone suppression test (LDDS) were performed. LDDS test showed no reduction of serum cortisol after 8 h of dexamethasone dose administration and histopathological evaluation revealed multiple foci of calcinosis characterized by the deposition of basophilic material on the pre-existing collagen fibers, plus areas with pyogranulomatous inflammatory reaction and peripheral fibrosis with transepidermal elimination of minerals. Thus, trilostane and intense hydration of skin plaques were applied as treatment. Discussion : The dermatological alterations were compatible with those described in the consulted literature, with remarkable yellow-brown, firm, sandy-looking plaques, located on the back, internal face of hind limbs and anal region, possibly related to HAC later confirmed by LDDS test and biopsy. The management of the underlying disease and possible secondary bacterial infections are the basis of treatment. Therefore, the patient was treated with trilostane, antibiotic therapy and intensive hydration of the mineralized plaques resulting in a satisfactory involution of the clinical signs. Even though there are reports of calcinosis cutis on the dorsum, in the consulted literature there was no evidence of dorsum large extension lesion due to HAC as in this case report, but secondary to exogenous corticosteroid treatment, systemic blastomycosis and leptospirosis. In this case report, the affected thorax portion was the dorsum, differently from a study that pointed the ventral thorax as the affected portion. Similarly, anus and ventral part of the tail were hardly affected together with secondary inflammation and ulceration. Thus, the existent literature shows areas of calcinosis cutis in dogs in different parts of the body, but neither extensive as in the back of this reported female dog, nor widely affected as in the anal area, additionally to the internal face of hind limbs as already reported in the literature.

Parikartika is charecterised by sharp cutting pain in the anal region. In parikartika teevrashoola, bleeding is observed, equally extreme pain slimy blood discharge are seen in fissure-in-ano. To test the efficacy of thelocal application of kasisadi ghruta in managing. Classical signs and symptoms of parikartika (fissure in ano) age groups of 20 to 60 years have been recruited for the research. The trial group obtained treatment with kasisadi ghruta local application for 28 days, twice a day. Average relief observed was observed 62.5% for most symptoms shothahara, vedanasthapana, and ropana are in kasisadi ghruta. Properties because of which it helps in healing the ano fissure.

Over the past years, magnetic resonance imaging (MRI) has become a cornerstone in evaluating anal canal and adjacent tissues due to its safeness, the three-dimensional and comprehensive approach, and the high soft-tissue resolution. Several diseases arising in the anal canal can be assessed through MRI performance, including congenital conditions, benign pathologies, and malignancies. Good knowledge of the normal anatomy and MRI technical protocols is, therefore, mandatory for appropriate anal pathology evaluation. Radiologists and clinicians should be familiar with the different clinical scenarios and the anatomy of the structures involved. This pictorial review presents an overview of the diseases affecting the anal canal and the surrounding structures evaluated with dedicated MRI protocol.

To evaluate the mechanical properties of the tissues and muscles in the anal region with the shearwave elastography for anal fissure etiology.Descriptive study.Adana City Training and Research Hospital, Turkey, from March2019 to March 2020.In this study, 30 patients (fissure group), who were diagnosed with anal fissure in the outpatient clinic; and 20 patients (control group), who did not have any problem in anal examination were included. The anorectal tissues and muscles mechanical properties(elasticity,compliance and stiffness) were compared with the shear wave elastography values.Fissure area,internal anal sphincter,external anal sphincter and levator ani muscles elastographic measurements was performed with 5-18 MHzin lithotomy position, at rest and with Valsalva maneuver.In elastographic measurement of fissure area (fissure) and normal anorectal tissue (control, AFE); control group values were significantly higher than the fissure group values (p0.001, and padj0.001, respectively). Control group valuesof internal anal sphincter in rest and Valsalva maneuver (IAS-R, and IAS-V, respectively) were significantly higher than the fissure group values (p0.001, padj0.001, and p0.001, padj0.001, respectively). There was no significant difference between the elastographic measurement values in rest and valsalva maneuver of the external anal sphincter (EAS-R and EAS-V) (p0.05). Elastographic measurement values of levator ani muscle (LAM) resting state; were significantly higher in thefissure group than the control group (p0.001, and padj0.001, respectively). Elastographic cut-off values that differentiate the fissure group from control group were found to be ≤1kPa forAFE group, ≤44 kPa forIAS-R, ≤0.4kPa forIAS-V,and11kPa for LAM,respectively. Conclusıon: In anal fissure disease, tissues mechanical properties measured by shear wave elastography showed increased tissue stiffness, which may be added to etiology of this disease. Key Words: Anal fissure, Ultrasonography, Shear wave elastography, Anal sphincter, Tissue elasticity, Tissue stiffness.

Pilonidal sinus is a disease of a midline pit situated in mid gluteal cleft at post anal region associated with hairs. Continued sitting, obesity, hairy part, family history which increases the risk of diseases. The prevalence rate in males is more (Male & Female ration 3:1) and incidence is about 26 per 100,000 population. The treatment of pilonidal sinus includes excision and primary closure, excision with reconstructed flap technique etc. In Ayurveda pilonidal sinus is correlated with Nadivrana and it can be considered under shalyaj Nadivrana and Shushruta has explained Shastrakarma with intervention of ksharsutra as one of the treatment of Nadivrana (sinus) excision. In this case study, a case of pilonidal sinus, 21yr / Male patient diagnosed and treated successfully with integrated approach i.e. partial sinus excision adjuvant to Ksharsutra therapy. Partial sinus excision followed by Ksharsutra ligation in the remaining intact tract was performed under local anaesthesia, Patient was asked to attend surgical OPD for dressing on alternate days, and Seitz bath with lukewarm water was advocated before dressing. The Ksharsutra was changed weekly for 3 sitting. To reduce pain, inflammation and control infection, Analgesic,anti-inflammatory and oral antibiotic drug were also prescribed for 5 days. Observation revealed that sinus- track cut through and healed by 4 weeks. Patient was under observation for period of one year to check for recurrence. This innovative partial sinus excision along with Ksharsutra ligation under local anesthesia, proved an effective ,time conserving and non-recurrent, minimal invasive treatment alternative for pilonidal management.

Parikartika is a Guda-gata vyadhi related to Ano rectal diseases. This disease has been explained by all acharyas in bruhatrayee. Is the nirukti of parikartika i.e. cutting type of pain observed in Guda pradesha. Parikartika is a common painful condition among Anorectal diseases which resembles with fissure in ano. This Is a case report of 33yr male patient with complaints of Guda Pradesh Daha (Burning sensation at anal region), Sarakta mala pravrutti (stool mixed with blood), Malavasthambha (Constipation) since last 4 days. He was treated with Yashtimadhu Ghruta Matra Basti for 7days.He got significant positive relief within 7 days.

Parikartika is one of the ano-rectal diseases. Its references available in Bruhatrayees. The word Guda Vidar means Parikartanavat vedana around guda Pradesh. It is also having the symptoms like burning sensation, cutting type of pain, itching, something time swelling, bleeding from anus. In modern science it can be correlated to fissure in ano. Here a case Report of 28 years-Male Patient having of Parikartika (fissure in ano) from last 15 days. He was suffering from Guda Pradesh parikartanavatvedana(Excruciating pain), Guda Pradesh shoth (swelling at anal region), Guda Pradesh Daha (burning sensation at anal region), Malavashtmbha (constipation), Sarakta-malapravrutti (stools streaked with blood), since last 10 days. Generally, he got relief from modern medicines, but this time medicines not give relief. He was treated with Ayurvedic medicine, which gives effective result within 3 days with Ayurvedic treatment.

Hidradenitis suppurativa (HS) is a chronic, progressive inflammatory disease of the apocrine gland-bearing skin that typically affects the axillary, perianal, perineal, and inframammary regions. It causes open comedones (clogged hair follicle), tender subcutaneous papules, inflammatory nodules, abscesses, sinus tracts and scarring. The prevalence of HS is 0.1 to 4% worldwide; the mean age of onset is 20 to 24 years. Cigarette smoking and obesity are risk factors for HS. Dietary triggers include dairy products and highly refined simple carbohydrates. The anal region is the second most commonly involved area after the axilla; 30% to 50% of patients with HS have perianal lesions. A number of comorbid conditions are present in patients with HS including acne, inflammatory bowel diseases, spondyloarthropathy, genetic keratin disorders and squamous cell cancer. Management of the disease includes medical and surgical treatment. Local and small lesions can benefit from medical treatment but recurrence rates are high. Widespread disease is an indication for radical surgical excision with possible need for reconstruction.

If tumours arise in special locations such as around the eyes, mouth or in the genital area, patients and physicians are challenged by the need for complete removal of the tumour with safety margins and high demands on function and aesthetic aspects. Treatment should be performed by specialized physicians including ophthalmologists, head and neck surgeons, surgical, medical and radiation oncologists. The first-line treatment for most cutaneous malignancies is surgical excision; however, in several situations, such as well-differentiated cutaneous squamous cell carcinomas (cSCC) in the periocular or anal region, radiotherapy is a very reasonable and sometimes treatment of first choice, especially in patients with advanced age. In periocular SCC, radiotherapy with superficial x-ray combined with eye shielding, while in anal SCC, radiotherapy combined with chemotherapy is recommended. However, after failure of local treatment options including surgery and radiotherapy, systemic medications are indicated in order to achieve tumour control or cure. Systemic therapies include immunotherapy, targeted therapy or chemotherapy. Preventive strategies are based on UV protection in facial, and vaccination in HPV associated anogenital SCCs.

Cenopis croatanensis Brown and Sullivan, new species, is described and illustrated from North Carolina, Louisiana, and Texas, U.S.A. The new species is assigned convincingly to Cenopis on the basis of two features of the male: a highly modified hood of scales over the upper frons on the head and a fold in the anal region of the hindwing concealing a slender hairpencil. Males are easily distinguished from all congeners by features of the genitalia, in particular the short, broadly rounded sacculus with a free subapical process.

The review examines a role of HPV in the development of pre-cancer and cancer of the anogenital region. It presents the current data on the incidence of cervical (CIN) and anal intraepithelial neoplasia (AIN), the HPV infection of the anal region in women at risk (CIN, VIN, VaIN). Methods for the diagnosis of HPV-associated diseases of the anogenital region are considered. The article reviews the literature on the importance of AIN screening development in patients with CIN, VIN, VaIN. It also provides the results of own studies of HPV infection of the anal region in patients with cervical neoplasias, data on the HPV trophicity to the epithelium of the cervical canal and the anal region. Type 16 HPV is the dominant type of HPV in patients with CIN in the cervical canal and in the anus. HPV-associated cervical diseases, in particular CIN, create a risk of infection and development of HPV-associated diseases of the anal region, including AIN. A quadrivalent HPV vaccine is now available in Russia. Although initially created and used to protect against injuries to the cervix caused by HPV, it should also be considered for the prevention of other types of HPV-associated anogenital pre-cancer and cancer.

Aims Verrucous carcinoma (VC) is a variant of well differentiated squamous cell carcinoma and is in the anal region regarded as synonymous with giant condyloma (Buschke-Lowenstein tumor) (BLT). Etiology, diagnostic criteria and clinical behavior of both lesions are controversial. Recent studies suggest that VC at other sites is not associated with human papillomaviruses (HPV). We hypothesized that anal VC is also not related to HPV, while BLT is a HPV-induced lesion. Methods and results Ten cases of VC and 4 cases of BLT were included. Several techniques were used for HPV detection: in situ hybridization for HPV6, 11, 16 and 18, six different PCR protocols for detection of at least 89 HPV types from Alpha-, Beta-, Gamma- and Mu-PV genera, and in situ hybridization for high risk HPV E6/E7 mRNA. p16 immunohistochemistry and morphometric analysis were also performed. Alpha-, Gamma- and Mu-PVs were not found in any case of VC, while HPV6 was detected in all cases of BLT. p16 overexpression was not present in any of the lesions. Among microscopic features, only the absence of koilocytosis and enlarged spinous cells seem to be useful to distinguish VC from BLT. Conclusions Our results suggest that anal VC, similarly to VC at other sites, is not associated with HPV infection and must be distinguished from BLT which is associated with low risk HPV. Only with well-set diagnostic criteria will it be possible to ascertain clinical behavior and optimal treatment for both lesions. This article is protected by copyright. All rights reserved.

Cloacogenic carcinoma is a rare tumor originating from epithelium of the anal transition zone of embryonic residuals. It accounts for only 2%–3% of all neoplasm arising in the anorectal canal and has clinical and morphological characteristics that distinguish them from the ordinary varieties of adenocarcinoma and squamous cell carcinoma of the anorectum. We report here a case of a middle aged male who presented to us with history of altered bowel habits, pain during defecation, passage of fresh blood in stools and pruritus in anal region and on examination there was an ulcerative growth in the anal canal. The diagnosis of basaloid variety of cloacogenic carcinoma was made upon biopsy and histopathological examination. Patient was put on chemoradiation and responded well with complete disappearance of growth macroscopically and clinically but was then lost in follow-up.Owing to the paucity of published literature on this rare malignant tumor this case is being reported here.

The metastasis of rectal cancer to the anus is rare. Here, we report a case of advanced rectal cancer, which had a diffuse venous invasion with anal metastasis and multiple lymph node and liver metastases. The patient was a 72-year-old woman who complained of perianal pain and fresh blood in the stools for 6 months. She had neither history of fistula-in-ano nor anal surgery. Digital examination revealed a 2-cm tumor at the 7 o'clock position, and the barium enema and colonoscopy confirmed advanced rectal cancer. Abdominal computed tomography revealed thickness of the upper rectum wall, right inguinal lymph node of 10 mm and multiple liver metastases. Laparoscopically assisted anterior resection, anal tumor resection, and right inguinal lymph node resection were performed, and the histopathological examination of the resected primary and metastatic tumors confirmed similar findings of moderately differentiated adenocarcinoma, suggestive of metastasis of the rectal cancer to the anal region. In the next procedure, she had the liver lesions resected. This case suggested the importance of the careful examination of the anus during colonoscopy, or digital examination for the detection of anal metastasis.

Anal fistula, or fistula-in-ano, is a condition involving the anal region that is common yet debilitating. Surgery is the mainstay of treatment for an anal fistula and the chances of recurrence are quite high even after corrective surgical procedures. The risk factors for recurrence can be broadly classified into four categories: 1) risk factors related to the fundamental anatomy of the fistula and presence of comorbidities, 2) lack of proper preoperative assessment of the fistula, which includes failure to recognize the internal opening and overall structure of the fistula and not supplementing the proctologic examination with sufficient imaging, 3) intraoperative loopholes that include improper procedure selection, inexperience of the surgeon, and failure to get rid of the entire tract along with its ramifications, and 4) lack of proper postoperative care in the early and late periods following the surgery. The aim of this paper, therefore, is to highlight the factors that could increase the risk of recurrence in different types of anal fistulae. Once surgeons know these risk factors, they can anticipate any complication and detect recurrence early.

The normal function of the anal sphincter complex is crucial for quality of life, as it is the mechanism by which fecal continence is maintained. Additionally, the anal sphincter complex is an integral part of the coordinated effort of defecation. As imaging plays an important role in assessment of pathologic conditions involving the anal region, understanding the normal anatomy of the anal sphincter complex is important for correct image interpretation and accurate diagnosis. This review discusses the anatomy and function of the anal sphincter complex, important technical considerations for MRI, and various inflammatory, infectious, and neoplastic processes, as well as pathologic structural conditions that affect the anal region. Level of Evidence: 5 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2019;50:1018-1032.

Background: Fournier's gangrene (FG) is a synergistic necrotizing fasciitis that involves the genitalia, perineum, or anal region and can be life threatening and generally necessitates urgent surgical intervention. It often causes scrotal defects that require reconstruction after surgical debridement. The reconstruction of these serious scrotal defects poses certain challenges for surgeons. In this study, reconstruction of scrotal defects caused by FG with medial circumflex femoral artery perforator (MCFAP) flap evaluated. Patients and Methods: Seventeen patients with FG reconstructed using a MCFAP flap, admitted to our hospital between February 2003 and March 2017, are included in this study. Reconstruction with MCFAP flap results, mean debridement number, comorbid diseases, and length of hospital stay are analyzed together. Patients with FG reconstructed using techniques other than MCFAP were not included in this study. Results: Eighteen MCFAP flaps were performed in 17 patients. The mean duration of operation was 2 h 55 min. Diabetes mellitus was the most common comorbid disease. The mean days of hospital stay were 19.9. Total flap loss was not seen in 17 patients. Donor area of the flap is closed primarily, by V-Y advancement flaps or by split-thickness skin grafts. Acceptable cosmetic results and scrotal contours were obtained in all patients. No major complications were observed. Conclusions: Using a MCFAP flap, a method that has minimal donor site morbidity, requires single session surgery, provides good skin quality and color similar to the scrotum, is an easy-to-perform process, proving to be a reliable flap for scrotal reconstruction.

A 44-year-old male patient diagnosed with Anal Fissure and Stage II Hemorrhoids in 2013. He has been suffering ever since, avoiding surgery, using local analgesic and anti-hemorrhoidal crèmes. Physical examination in February 2017, showed a chronic character of his problem and hemorrhoids to have progressed to Stage III. The common shared decision between patient and surgeon was to proceed with a combination of a LIS for the Anal Fissure and an ELITE minimal invasive procedure for hemorrhoids. The operating time of the dual procedure was short and the patient witnessed a remarkable, painless post-op rehab period. The results of the ELITE technique using a diode laser for treating hemorrhoidal nodules are very promising. In the hands of an experienced surgeon the technique is applicable to be used in combination with other procedures in order to treat several problems in the anal region at the same time.

Ganglion impar block is a safe and useful treatment for chronic sympathetic pain in the anal region. The current ganglion impar block methods include the curved needle approach from the tip of the coccyx, the vertical approach from the sacrococcygeal or intercoccygeal region, and the lateral (parasacrococcygeal) approach. This article describes the lateral approach.

Neuroendocrine tumors in gastrointestinal (GI) tract are a rare source of GI malignancy with an estimated incidence of 2.5 - 5 per 100,000 people per year and the prevalence of 35 per 100,000. In the GI tract, they are located in decreasing order of frequency in appendix, ileum, rectum, stomach, and colon. Those found in the anal region represent just 1% of all malignancies of the anal canal. Their clinical presentation can be widely varying, sometimes being found incidentally with metastatic disease and an unknown primary source. We report a case of a 60-year-old male who presented with a 2-week history of intermittent bright red blood per rectum and anal pain. He was found to have a lesion in the perianal area which was subsequently diagnosed has a poorly differentiated large cell type neuroendocrine carcinoma (NEC) with hepatic metastasis.

Perianal giant condylomata acuminate (GCA) is a rare clinical condition associated with low-risk Human papillomavirus (HPV) type 6 and 11 infections. Human Immunodeficiency Virus (HIV) infection is one of the risk factors for GCA, that can increase the condylomata acuminate incidence and spread caused by HPV. A 28-year-old man came with a cauliflower-like mass complaint in his perianal and anal since 2 months ago. The patient did not complain of pain or itching on the mass but often bled when defecating. The patient is a male who has sex with men (MSM) and often changes partners. He has been diagnosed with HIV since 11 months ago and regularly taking anti-retroviral drugs, Efavirenz 600 mg daily. He was also diagnosed having lung tuberculosis at the same time, got 6 months treatment and was declared cured. The venereological examination of the perianal and anal region revealed erythematous and grayish stem-shaped vegetation and papules, verrucous surface, multiple, well defined, with 3 x 1.5 x 2 cm in size. A positive act of white examination was obtained. Blood tests revealed CD+4 230 cells /μL. Polymerase chain reaction (PCR) examination for HPV obtained HPV types 6 and 11 infections. Histopathologic examination revealed acanthosis, papillomatosis, and hyperkeratotic epidermis and koilocytotic cells. The patient was treated with electrodesiccation three times but obtained mass in anal getting bigger with a size of 6 x 3 x 3 cm. Therefore, he agreed to be referred to the surgical department with an extensive surgical excision plan. Screening of GCA using PCR is not a routine examination but PCR has high sensitivity and specificity for determining the type of HPV, is useful for determining GCA prognosis and therapy, and is recommended for malignant and possible GCA recurrence detection