Paraproctitis causes in women. Acute paraproctitis

paraproctitis- inflammation of the fiber and soft tissues located around the rectum. This disease is one of the most common (along with anal fissures) pathology of the rectum.

As a rule, the incidence of paraproctitis among men is 50% higher than among women.

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In most cases, the causative agent of the disease is a mixed microflora. Its composition is dominated by streptococci in combination with Escherichia coli. Occasionally (about 1% of cases), paraproctitis can be caused by a specific infection (for example, tuberculosis). Factors that favor the development of the disease and contribute to its course include:

• weakened immunity;
• vascular complications of diabetes;
• atherosclerosis;
• hemorrhoids, etc.

There are several options for getting paraproctitis pathogens into the peri-intestinal tissue:

• spread of infection through the lymphatic system;
• injuries of the rectal mucosa;
• inflammation of the anal glands;
• spread of infection from neighboring organs (prostate, urethra).

The disease begins with inflammation of the anal glands. Their ducts are located at the bottom of the crypts, "pockets" anatomically located between the rectum and the anus. In these "pockets" the infection easily enters directly from the rectum, but can also be transferred with the flow of lymph or blood from neighboring organs. As a result, the excretory ducts of the anal glands are clogged. A microabscess develops, which, if the course of the disease is favorable, does not go beyond the crypts. If the inflammatory process goes deep and reaches the perirectal fiber, then paraproctitis develops.

Of great importance during the course of the disease is the purulent course through which the infection spreads. Depending on the location of the abscess, a decision is made on the choice of the method of operation.

The abscess can be:

• subcutaneous;
• submucosal;
• intermuscular;
• ischiorectal (ischiorectal);
• pelvic-rectal (pelviorectal).

Clinical manifestations of the disease (symptoms)

Paraproctitis, as a rule, occurs abruptly. It has both general somatic and purely specific symptoms.

At the beginning of the disease, a man feels such symptoms, how:

• weakness;
• subfebrile temperature;
• chills;
• increased sweating;
• headache.

Later, intensifying pains in the perineum join. This period does not last long, and soon specific symptoms of paraproctitis appear. The degree and nature of their manifestation depends on abscess localization:

• Subcutaneous. The symptoms are bright and definite: there is a painful, hyperemic infiltrate in the anus.
• Ischiorectal. In the first few days from the onset of the disease, dull pains in the small pelvis are observed, increasing with the act of defecation. On the 5-6th day, a hypermic infiltrate appears.
• Pelviorectal. It proceeds the most difficult, since the location of the abscess is very deep. Within 10-12 days, a man is worried about general somatic symptoms (weakness, fever, chills), aching pains in the lower abdomen. The pain gradually increases, there are delays in stool and urine. With late diagnosis, a breakthrough of the abscess and the spread of its contents into the pararectal (perintestinal) tissue is possible.

With a belated appeal to a specialist, paraproctitis can lead to a severe putrefactive process. Therefore, at the first symptoms of the disease, you should immediately consult a doctor. Paraproctitis will not go away on its own!

If the abscess erupts on its own, then a fistula occurs in its place. This will indicate that the disease has become chronic.

Diagnosis of paraproctitis

The specialist, on the basis of complaints and the result of the examination of the patient, needs to detect an abscess in the perirectal space. Diagnostic methods vary depending on the location of the abscess:

• Subcutaneous. This type of paraproctitis is the easiest to diagnose, since the abscess is clearly visible. Palpation of the hyperemic area causes severe pain in the patient. A digital examination of the anus and rectum is carried out in order to find an inflamed crypt. Anoscopy, sigmoidoscopy and other instrumental studies are not performed.
• Ischiorectal. Visual changes are observed already at a late stage of the disease. Therefore, at the first complaints of the patient about pain in the perineum and painful defecation, the doctor is obliged to conduct a digital examination of the rectum. There is a thickening of the anal canal and smoothing of the mucous relief on the side of inflammation. After 5-6 days from the onset of the disease, the abscess swells into the intestinal lumen. If the purulent process has passed to the urethra or urethra, when they are palpated, the man has a painful urge to urinate.
• submucosal. Found on digital examination. The infiltrate is pronounced and bulges into the lumen of the rectum. With submucosal paraproctitis, self-opening of abscesses is often observed.
• Pelviorectal. Difficult to diagnose. Visual changes are visible only in the later stages of the disease. In the initial stage, a digital examination reveals soreness of one of the walls of the ampullar section of the rectum. If the doctor has a suspicion of pelvic-rectal paraproctitis, but the final diagnosis is not clear, the patient is prescribed sigmoidoscopy and ultrasound. Ultrasound will determine the size of the abscess, its exact location and the degree of damage to surrounding tissues.

Chronic paraproctitis

It flows in waves. Periods of exacerbation alternate with periods of remission. Outside of exacerbation, the patient is not bothered by any symptoms of paraproctitis. When such intervals can be quite long. With the next inflammation, the man begins to feel weak, the temperature rises. Treatment of chronic paraproctitis is also only surgical.

Treatment and prognosis

Treatment of paraproctitis is exclusively surgical. The operation belongs to a number of urgent interventions. It is performed exclusively under general anesthesia. The main task of the surgeon is to open the abscess, ensure its drainage (exit of pus), and, if possible, stop communication with the intestine.

With a timely operation, the prognosis for the course of the disease is favorable. With delayed treatment, the following are possible: complications:

• the transition of acute paraproctitis to a chronic form with the formation of fistulas;
• inflammation of the peritoneum of the small pelvis;
• spread of infection to the urethra and scrotum;
• postoperative changes in the rectum and anus.

After the operation, a diet is prescribed to speed up the healing process.

Prevention

Prevention of paraproctitis is to follow simple rules:

• compliance with the rules of personal hygiene;
• timely treatment of stool disorders;
• balanced diet;
• timely treatment of acute paraproctitis.

If measures for the treatment of paraproctitis were taken on time, this disease will not leave any negative consequences.

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The neglected form of paraproctitis develops as a result of incorrect or untimely treatment of the acute form of the disease. More than a third of patients turn to proctologists with paraproctitis. Often this is the chronic form. But paraproctitis is an ailment in which the sooner the patient seeks professional help, the more likely it is to quickly get rid of the problem with minimal discomfort!

Diagnosis of chronic paraproctitis does not cause difficulties: usually it will be sufficient to collect an anamnesis and clarify the details of the course of the disease, as well as a direct medical examination. On external examination, you can see the exit holes of the fistulas. Palpation of the rectum and perineum is also performed. When making a diagnosis, attention is paid to the characteristics of purulent discharge: this helps to determine if the disease has comorbidities.

The only guaranteed way to treat chronic paraproctitis is surgery. Before the operation, in order to collect data on the location, depth, size and other characteristics of fistulas, probing is most often performed. The need for ultrasound with a rectal probe, anoscopy or fistulography is not ruled out.

Acute and chronic paraproctitis: what are the differences

A distinctive feature of chronic paraproctitis is that it never occurs on its own, but always follows the acute form. When the infection has already entered the cellular sinuses, the primary manifestation of the disease occurs: acute paraproctitis. Usually, an abscess develops in the subcutaneous space near the anus, which causes the area near the anus to swell and turn red. All this is accompanied by pain. If the cellular spaces are located deep around the rectum (in the pelvic region), then there are no external manifestations of the disease, respectively, only a doctor can determine the inflamed area.

When pararectal sinuses with fiber, affected by infection, are filled with pus, an abscess is formed. If the abscess bursts due to improper or spontaneous opening, the pus literally looks for its way out, lays an abnormal channel - a fistula (usually with an outlet in the anus). An exacerbation of the disease occurs when the newly formed passage is clogged with pus and dead tissues.

So, in chronic paraproctitis, the stage of exacerbation and the stage of remission are distinguished. Acute and chronic paraproctitis in the acute stage have similar symptoms:

• severe fever, weakness and headache;
• severe intoxication of the body;
• pain in places where pus accumulates, aggravated by walking and coughing;
• swelling and redness of the affected area.

The stage of remission occurs as a result of a breakthrough of newly formed abscesses. Fever and intoxication recede, a constant discharge of pus with an admixture of blood begins, itching intensifies in places where pus comes out. The stage of remission in a patient can last quite a long time. But during exacerbations, serious complications can also occur. In this regard, the sooner medical intervention is performed, the easier it will be to get rid of paraproctitis forever.

What is dangerous chronic paraproctitis

Like any other chronic disease, in the long term, paraproctitis does not bring the patient anything but serious complications. Spontaneously, the focus of inflammation does not disappear. If the remission stage lasts for a long time, sooner or later the pus that accumulates around the rectum can melt the soft tissues of the internal organs. This threatens the following consequences:

• Melting of the wall of the rectum, provoking the formation of new fistulous passages.
• In women, melting of the vaginal wall may occur, which can lead to the development of gynecological diseases.
• In some cases, pus can melt the abdominal cavity. This is fraught with the occurrence of peritonitis.
• The pus can also melt the urethra.
• Some doctors have described such consequences of chronic paraproctitis as the formation of fistula outlets in the region of the abdominal wall, scrotum and inner thighs.

Chronic paraproctitis (especially complicated by other proctological diseases, such as cryptitis or chronic hemorrhoids) can be a precursor to rectal cancer. Attempts to treat chronic paraproctitis with folk methods with dubious effectiveness, as well as constantly postponing a visit to the doctor, can result in serious damage to your health in the future.

How to cure chronic paraproctitis forever

Many people suffering from problems with the rectum and anus do not go to doctors, considering visiting a proctologist as a shameful thing and preferring to deal with the problem at home using folk methods. Unfortunately, the treatment of chronic paraproctitis without surgery does not give a 100% result, respectively, the disease almost always returns again, only progressing more strongly.

Self-medication with untested methods with unproven effectiveness can not only lead to allergic reactions, but also provoke a deterioration in the patient's condition, causing an abscess to break through, as well as the emergence of new foci of infection.

In addition, folk remedies will not be able to replace surgical intervention. Some traditional methods (for example, baths with herbal decoctions with antiseptic and analgesic effects) can help temporarily relieve pain. The decision to use these funds can only be made by the attending physician, so be sure to discuss with him the possibility of auxiliary treatment of chronic paraproctitis using folk methods. Self-medication with exacerbation of the chronic form of paraproctitis is strictly prohibited!

Sometimes patients mistakenly believe that an alternative to surgical treatment of chronic paraproctitis is a conservative method of treating the disease. In fact, conservative treatment of chronic paraproctitis is used only in some cases. Due to the individual characteristics of the body and the health of the patient, the operation can be postponed to a later date. Then conservative means are used to reduce pain and avoid exacerbation of the disease.

The reasons for postponing the operation include exacerbation of chronic diseases of the rectum or anus (for example, hemorrhoids), as well as an exacerbation of the inflammatory process. Conservative treatment is carried out in order to deactivate inflammation, as well as eliminate the potential cause of postoperative complications. Sometimes the operation is canceled if the age of the patient does not allow to guarantee a successful result of the surgical intervention. In these very rare cases, conservative treatment of chronic paraproctitis becomes the only way to keep the disease in check, while this method does not give a 100% result.

A conservative method is, first of all, drug therapy aimed at eliminating an abscess in the affected areas. The main role in this type of treatment is played by the intake of broad-spectrum antibiotics with a course of at least 5-7 days. Additionally, baths with a solution of manganese are prescribed, rectal suppositories are used (for example, ichthyol or with propolis, as well as with an analgesic effect). Vishnevsky ointment or ointments containing antibiotics (for example, Levomekol) are used as compresses on damaged tissues.

The only way to permanently get rid of chronic paraproctitis is surgery. If there are no contraindications to the operation, while the patient is in the stage of exacerbation of chronic paraproctitis, then after the diagnosis is made, it is not delayed. Timeliness of treatment is one of the main guarantees of successful disposal of paraproctitis. If the patient has a stage of remission, then the operation is postponed until the next exacerbation with the concomitant appointment of conservative treatment.

During the operation, performed under general anesthesia or epidural anesthesia, the task of doctors is to excise the fistulous tract, as well as remove pus and remnants of dead tissue from the cavities, and then drain the focus of inflammation. Additional interventions may also be carried out depending on the complications and the nature of the disease, for example, suturing the sphincter or blocking the internal opening of the fistula with a flap of rectal tissue.

Postoperative treatment of chronic paraproctitis is another necessary part. Usually this is the use of broad-spectrum antibiotics or the use of compresses and dressings with local antibiotic ointments, as well as antiseptic ones. The patient is prescribed a therapeutic diet No. 3 in order to control digestion and prevent constipation. It is also strictly shown to monitor the hygiene of the perineum and anus.

Prevention of chronic paraproctitis: how to avoid the disease

The first and most important rule that will help you avoid the occurrence of chronic paraproctitis is the timely treatment of the acute form of the disease! If paraproctitis overtook you for the first time, then you need to see a doctor as soon as possible for medical assistance. A correctly performed operation to eliminate the abscess and the subsequent drainage of the damaged area guarantee that paraproctitis will leave you forever without becoming chronic.

Among other rules for the prevention of the disease are noted:

• annual medical examination by a proctologist;
• observance of personal hygiene of the genitals and anus;
• proper nutrition and prevention of bowel problems.

Despite the need for surgical intervention and the delicacy of the problem, paraproctitis will not pose a danger to your health if you consult a doctor on time, without waiting for complications to occur, while strictly following all medical prescriptions.

It is an inflammation of the tissues surrounding the rectum. To understand what paraproctitis is, you need to turn to our anatomy. The cellular spaces surrounding the rectum are quite numerous - and inflammation may occur in each of them, and in especially severe cases, even in several.

The mucous membrane, rich in crypts (depressions), at the bottom of which the anal glands are located, also has its own characteristics. Most often, inflammation begins with cryptitis, and later, thanks to the anal glands, the infection spreads to nearby tissues.

Classification of acute and chronic paraproctitis

1. Ordinary, anaerobic, traumatic, as well as specific(according to etiology).
2. Submucosal, retrorectal, subcutaneous, pelviorectal, osteorectal(depending on where the abscesses are located).

Chronic paraproctitis(or, as it is also called, rectal fistula) happens:

1. Complete, external, incomplete and internal(according to the anatomical principle).
2. Front, side, rear(according to the location of the internal opening of the fistula).
3. simple, complex(according to severity).

Of course, paraproctitis has its own characteristics, thanks to which it can be diagnosed. Often, each type of this disease has its own symptoms. We will review them below.

Paraproctitis symptoms

During the examination, the patient has hyperemia (redness), swelling of the affected tissue and deformation of the anal canal. During palpation (palpation), the patient experiences a sharp pain, sometimes a fluctuation is determined (a symptom indicating the presence of fluid in a closed cavity).

Submucosal paraproctitis. Occurs in a small percentage. Painful sensations, which, however, increase with defecation, are quite moderate at other times. Body temperature remains subfebral (that is, it can rise for a long time to 37-37.5 degrees). Palpation also determines the swelling of the abscess, soreness. If the abscess breaks into the lumen of the rectum on its own, recovery occurs.

Retrorectal paraproctitis It is considered the form of the disease, the least common among those who are ill. It is characterized by severe pain in the rectum, extending to the perineum, thighs, sacrum and even the rectum. Pain becomes stronger during defecation, sitting position, palpation of the coccyx or its pressure. The posterior wall of the intestine bulges sharply, which is noticeable during examination.

Ischiorectal paraproctitis, which occurs in 35-40% of patients, reports itself, first of all, with signs of inflammation of a purulent nature - the patient is disturbed by sleep disturbances, accompanied by weakness and chills.

Subsequently, the disease manifests itself in a more localized manner - in particular, in the perineum and in the rectum, pains of a blunt character begin, which become sharp and pulsating over time. Pain intensifies not only during physical exertion and during the act of defecation, but also during an ordinary cough.

In front of the rectum, with the appearance of an abscess, dysuria is noted. After 5-7 days, there is moderate redness and swelling in the perineum, where the abscess is localized. The semilunar fold is smoothed, and the gluteal lobes are asymmetric. On palpation, patients complain of soreness (though moderate) inside from the sciatic nerve.

Palviorectal paraproctitis(or, as it is also called, pelvic-rectal) is considered the most severe form of the disease. It is diagnosed in 2-7% of patients with acute paraproctitis. The main clinic is general weakness, malaise, a slight increase in body temperature (up to 37.5), headaches, loss of appetite and even aching joints.

Soreness is noted in the lower abdomen. When, after a week or three, an abscess of the palviorectal tissue infiltrate occurs, the body temperature begins to jump sharply by several degrees. Symptoms of purulent intoxication become more pronounced - pain intensifies, constipation is observed (but at the same time, patients complain of false painful urge to defecate, which are called tenesmus in medicine), impaired urine outflow. At this stage, there is no pain on palpation in the perineum, they appear later, with a longer course of the disease.

Diagnosis is difficult until the inflammatory process spreads to the ischiorectal and subcutaneous tissue. In this case, the symptoms are quite recognizable - hyperemia and swelling of the tissues of the perineum, pain on palpation. Also, during examination, the doctor can detect infiltration (accumulation of blood and lymph in the tissues) of the rectal wall, bulging of the abscess into the intestinal lumen (it is not possible to feel the upper edge of the bulge).

Classification by pathogens

Tuberculous paraproctitis occurs due to infection from the rectum or metastasis. The formation of a dense infiltrate is noted, which softens and opens over time, releasing a large amount of colorless pus.

Actinomycotic paraproctitis(caused by the fault of the fungus) in medical practice is very rare. It is characterized by the formation of a dense infiltrate, which then opens, releasing a small amount of thick pus. Whitish grains are visible in it - these are the fungi that caused paraproctitis.

Complications of paraproctitis

Complications of acute paraproctitis

1. Breakthrough of the abscess. If the abscess breaks through on its own, this is a plus, but the fact that when a pus breaks out of it can get into the nearest intercellular spaces, this is a minus, because getting pus into the rectum or vagina will cause infection.
2. An inflammatory phenomenon can pass to neighboring organs (uterus, prostate, rectum, vagina or even urethra), which will lead to their irreversible deformation, possibly leading to disability, because sometimes the only treatment is their removal. Also, the infection can enter the abdominal cavity, causing peritonitis.

Consequences of chronic paraproctitis

1. Growth of the fistulous tract into many branches, which makes treatment difficult.
2. Deformations of the rectum up to the impossibility of holding feces due to poor functioning of the sphincter.
3. If periodically aggravated paraproctitis takes place for more than five years, this can lead to the development of cancer.

Possible complications after surgery

1. Relapse (reappearance of a fistula).
2. Insufficiency of the anal sphincter (partial or complete incontinence).

Causes of paraproctitis

There have been cases when paraproctitis has occurred due to weight lifting, malnutrition (as well as excessive alcohol consumption), hypothermia, and even rhinitis. In other cases, it is impossible to find out the cause of paraproctitis. It has been established that in women it often occurs against the background of underwear constantly cutting into the skin of the anus.

A little about paraproctitis in children

However, in children (including infants) it is necessary to differentiate true paraproctitis from perineal abscesses, which, it should be noted, occur much more often. In general, some doctors are sure that childhood and paraproctitis are incompatible. Also, the purulent process that occurs with septicopyemia cannot be called a true paraproctitis.

Diagnosis and treatment of paraproctitis

*Often, paraproctitis is diagnosed quickly enough using a digital examination with the addition of a rectal speculum, if the patient's condition allows it.
* This disease is quite common, given that the percentage of patients with paraproctitis is 20-40% of all proctological diseases, ranking 4th among them in frequency.
* It is noteworthy that men suffer from this disease more often than women. The age of patients varies from 30 to 50 years.
* Paraproctitis affects not only people, but also animals - more often it affects dogs than cats.

In order to distinguish paraproctitis, additional examination methods are needed, which is especially necessary when the abscess is too high. Such instrumental diagnostics includes anoscopy, rectromanoscopy, fistulography. In some cases, ultrasonography is used.

Treatment of paraproctitis

Conservative treatment.

Conservative treatment of paraproctitis is, of course, possible, but in most cases it is ineffective due to relapses, therefore it is used only in the initial stages of the disease. In particular, conservative treatment consists in prescribing bed rest, antiseptics, sitz baths and warm enemas with a medicinal effect.

A diet is also prescribed. It consists in the need to comply with the regimen (eat at least 4 times a day at the same time), use hot liquid meals at least once a day, limit yourself in eating in the evenings and avoid harmful foods - fried, fatty, salty. It is important to drink plenty of water. It is recommended to avoid foods containing tannin, as well as dishes with a viscous consistency (rice porridge, semolina) and grated dishes.

Along with the diet, there have been cases of successful treatment of paraproctitis with the help of regular compresses (using Vishnevsky's ointment), baths with potassium permanganate, candles with antibiotics. Such suppositories as Relief, Anestezol, Ultraproct, Anuzol, suppositories with methyluracil and propolis have proven themselves well in the treatment of paraproctitis.

If conservative treatment is ineffective, surgery is indicated.

Surgery often prescribed immediately after diagnosis, because it is considered urgent. However, sometimes it can be postponed - in this case, the doctor advises the patient to take antibiotics, prescribes physiotherapeutic procedures. However, surgical treatment is mandatory because inflammation can occur if it recurs.

The main goal of the operation is to open and drain the inflammatory focus. The patient is given epidural and sacral anesthesia, in other, more rare cases, general anesthesia. When opening paralectal processes, local anesthesia is usually not given.

During the operation, the surgeon finds and opens the abscess, pumps out the pus. Then he finds an inflamed crypt, which is the source of infection, and excised it along with a purulent tract. If the focus of inflammation in the body remains, a relapse may occur in the future. Therefore, the source in the body is removed. After that, the chances of a full recovery are great.

The most difficult operation is the opening of the abscess, which is located in the pelvic area. If there is chronic paraproctitis, the fistula should be excised. But during the period of exacerbation, this cannot be done - you must first open and drain the existing abscesses, after which the fistula itself is removed.

If there are areas of infiltration, in the form of preoperative preparation, antibiotic therapy is prescribed along with anti-inflammatory. It is necessary to remove the fistulous course as soon as possible in order to avoid a relapse, which can occur quite quickly. In some cases, the operation becomes impossible. In this case, the patient's condition should be improved with the help of conservative therapy and only after that the operation should be performed.

Folk remedies for the treatment of paraproctitis

Treatment of fistula (chronic) with calendula. Brew fresh calendula flowers in boiling water and insist for two hours. Microclysters are made with this infusion, combining the method (if there are no contraindications) with stone oil. Patients usually have one course.

Milk with onions. Boil two liters of boiling water, then throw in 2 medium onions and 4 cloves of garlic. After a few minutes of boiling, cool it down a bit. Wrapped around with a blanket, sit on the pan. The procedure should be done as long as it is hot, when the milk has cooled down, the treatment can be completed today. To save money, you can boil the same milk every day.

Hot baths. It is necessary to take baths at night, when the patient feels that the pain will soon reappear. To do this, it is recommended to lie down in hot water and wait until the body gets used to this temperature. Then add more hot water. And so on until the patient can not endure. You should spend at least half an hour in the bathroom.

Prevention of paraproctitis

1. Drink plenty of fluids (from 1.5 liters per day).
2. Eat more cereals, fruits and vegetables that improve peristalsis.
3. Do not get carried away with laxatives (they cause constipation) and enemas.
4. Do not allow your own weight to increase.
5. Move a lot.

(paraproctitis; from the Greek para - around, around and proktos - anus) is an acute or chronic inflammation of the tissue adjacent to the anus and rectum. The term "periproctitis" cannot serve as a synonym for paraproctitis, since they determine the inflammation of the serous cover of the organ.

Acute paraproctitis flows with the formation of an abscess or phlegmon. Mostly people aged 20 to 50 get sick; paraproctitis is very rare in children. Mainly men are ill, because they are more likely than women to suffer from diseases that can be complicated by paraproctitis - anal fissures, and especially hemorrhoids. According to A. M. Aminev, previous hemorrhoids were observed in 25% of patients with acute paraproctitis. The structural features of the anus (see) and rectum (see) are of predisposing importance - the presence of morganian crypts with flaps, numerous anal glands. All the moments that can cause trauma to the rectal mucosa are important - voluminous, dense fecal masses (with constipation) or an abundance of solid inclusions in them, diarrhea, a multi-stage act of defecation, etc.

With inflammation of the cooper glands, bartholinitis, cellulitis of the gluteal region (sometimes after injection), paraurethral abscess, parametritis, osteomyelitis of the pelvis, the infection can spread to the pararectal tissue. Often the source of paraproctitis is a furuncle, diaper rash, eczema, abrasions in the anus, etc.

The causative agents of acute paraproctitis are more often polymicrobial flora - E. coli and cocci, less often only cocci. Tuberculosis bacilli and anaerobes are rarely found. Microbes enter tissues, usually through damaged areas of the mucous membrane in the area of ​​crypts or through inflamed areas of the skin.

Rice. 1. The main types of paraproctitis: 1 - subcutaneous; 2 - sciatic-rectal; 3 - pelvic-rectal; 4 - submucosal. (5 - periproctitis, Douglas space abscess).

There are the following types of acute paraproctitis (Fig. 1): subcutaneous (paraanal); sciatic-rectal (ischio-rectal); pelvic-rectal, or subperitoneal (pelviorectal, or subperitoneal); submucosal. Rare varieties of these forms are retrorectal and anterectal paraproctitis, horseshoe-shaped paraproctitis is somewhat more common, which encircles the intestine mainly behind and belongs to ischiorectal paraproctitis.

Beginning acute paraproctitis is usually characterized by an acute onset. Pain in the anus or rectum, stool retention without gas retention. In rare cases, diarrhea occurs (due to proctitis). Sphincter gaping, fever, blood changes - moderate leukocytosis and acceleration of ESR, loss of sleep, appetite, performance, general weakness.

Subcutaneous paraproctitis occurs in 56.6% of the total number of paraproctitis. It is characterized by pain in the anus, aggravated by defecation and making walking difficult. Patients can sit only on a healthy gluteal region. In the case of anterior localization of the abscess, dysuric disorders are possible. The chair is often delayed. Sometimes there are painful, fruitless urges to defecate and gaping of the sphincter with mucus. On palpation in the circumference of the anus, in the depth of the subcutaneous tissue, a sharply painful infiltrate is easily felt, then inflammatory swelling and redness appear. Radial skin folds are smoothed out. The anal region is deformed. Later, softening and fluctuation can be felt. When a finger is inserted into the rectum, which is possible with pressure on the healthy side, the absence of changes in the intestine itself is determined. In the future, the process can spread to the ischiorectal space, although more often on the 3-5-8th day it opens on its own through the mucous membrane or skin.

Ischiorectal paraproctitis often begins acutely, accompanied by chills, a significant increase in temperature, but it can also develop more slowly.

Rice. 2. The main ways of distribution and independent breakthrough of paraproctitis: 1 - subcutaneous; 2 - sciatic-rectal.

Pain in the depths of the pelvic region is aggravated by defecation. With localization in the anterior semicircle of the intestine, dysuric disorders are observed. When localized in the posterior semicircle, pain sometimes radiates along the sciatic nerve. In the first days, there are no visible changes to the eye. Only when examining the rectum with a finger, a sharply painful infiltrate is revealed, which later protrudes into the intestinal lumen, softens and fluctuates. Pus can break into the subcutaneous tissue (Fig. 2), cause symptoms of subcutaneous paraproctitis or into another ischiorectal fossa, then a posterior horseshoe-shaped paraproctitis occurs. Less commonly, pus perforates the levator ani muscle and enters the pelvic-rectal space. Anterior horseshoe paraproctitis is extremely rare. Spontaneous breakthrough of the abscess in ischiorectal paraproctitis usually occurs at the end of the second week, most often in the intestinal lumen, through one of the posterior crypts.

Pelvic rectal paraproctitis is the most dangerous form. Clinical phenomena resemble ischiorectal paraproctitis and usually develop gradually. In this case, fever and other general disorders often outstrip the development of local symptoms. Pain is felt in the depths of the lower abdomen or pelvis, radiating to the thigh, bladder, sacrum. Defecation is often not disturbed. The abscess opens spontaneously into the rectum, but can cause severe intoxication and threaten the development of sepsis.

The diagnosis is clarified only by examining the rectum with a finger. The lower edge of a dense, painful infiltrate protruding into the intestinal lumen is determined. The upper limit of the infiltrate is unattainable with a finger. The infiltrate may have some mobility, unlike ischiorectal paraproctitis.

Submucosal paraproctitis is rare. A limited abscess does not cause throbbing pain, has little effect on the general well-being of the patient. Pain is moderate. There are no dysuric disorders. Defecation is painful. The finger is determined by the accumulation of pus in the form of a painful protrusion of the wall of the rectum. Paraproctitis can develop slowly, with minor manifestations, sometimes in waves. Months, sometimes years, pass before the abscess opens or is opened with a cut. This course is typical for tuberculous, actinomycosis, coccidioidomycosis and syphilitic paraproctitis.

Treatment of acute paraproctitis only at the very beginning of the disease can be conservative (introduction into the tissues surrounding the infiltrate, novocaine with antibiotics, warmth, rest).

Surgery should not be delayed. The operation should be performed after the first sleepless night, even if the infiltrate is not clearly defined or if the abscess has already opened on its own. After a timely opened abscess, the wound heals completely in most patients. After self-opening of the abscess, only about 1/3 of patients recover steadily.

Anesthesia - raush anesthesia, which, if necessary, can be somewhat continued. The incision should always be made wide so that it provides good outflow and, if possible, prevents the formation of fistulas. Damage to the rectal sphincter should be carefully avoided. With subcutaneous paraproctitis, a skin incision is made over the infiltrate in the form of a semi-arc. Radial incisions are also acceptable with small limited superficial abscesses located near the anal ring. If the examination of the wound reveals thinning of the mucous membrane along the line of the posterior crypts, then it is advisable to excise the skin and mucous membrane above the purulent cavity in the form of a triangle (Gabriel's operation), with the apex directed towards the crypt, and the base outward (see Fig. 6 in Art. Posterior passage), without cutting the sphincter.

Ischial and pelvic-rectal paraproctitis are often combined. The same methods can sometimes be used to treat them. Deep, unopened abscesses are punctured from the intestinal lumen with the rectal speculum inserted, then they are widely opened along the needle with a longitudinal incision. A rubber drainage is introduced for three days, the end of which protrudes from the anus. Subsequently, the gaping of the wound is checked with a finger during dressings. The intestinal wound usually heals completely, less often an internal fistula is formed.

With the spread of deep paraproctitis to the subcutaneous tissue with all signs of a subcutaneous abscess, access from the intestinal lumen is not applicable. These extensive abscesses should be opened with a wide arcuate incision of the skin through the infiltrate, retreating from the anus by 3-4 cm. The tissues in depth are pushed apart only stupidly, better with a finger, especially when the abscess is located closer to the front, for fear of damaging the urethra (in men). A horseshoe-shaped posterior rectal abscess is opened with a wide arcuate incision with the intersection of the anal-coccygeal ligament. The cavity is filled with tampons with Vishnevsky's ointment.

With submucosal abscesses, a wide vertical incision is made over the site of the greatest swelling of the mucous membrane. The wound is drained for 1-2 days with gauze strips moistened with Vishnevsky ointment or any other ointment.

Dressings for the first 5-8 days are done daily as the dressing gets wet. During dressings, it is necessary to irrigate the wounds abundantly with hydrogen peroxide or a solution of furacilin 1: 5000. From the 5-8th day before dressing, usually after a stool, a sedentary warm bath with a solution of potassium permanganate is done.

After opening the abscess from the intestinal lumen and introducing a rubber drainage, the stool should be delayed until the latter is removed by prescribing 5-6 drops of opium tincture 3 times a day for 2-3 days.

Along with hemorrhoids and rectal fissure, this disease is one of the most common reasons for visiting a specialist. Paraproctitis is treated by a proctologist. An infection present in the human body, whether it be influenza or tonsillitis, penetrates into the fatty tissue of the rectum through microscopic damage to its mucous membrane and causes inflammation.

Men get sick more often than women. This ratio ranges from 1.5:1 to 4.7:1. Paraproctitis is a disease of adults: descriptions of rectal fistulas in children are rare.

Reasons for the development of the disease

The root cause that causes the appearance of the disease is an infection (E. coli, staphylococcus, streptococcus) that enters the cell space from the rectum. Any wounds, household injuries and microtraumas, mucosal surgery are the entrance gates for such infections.

Staphylococci and streptococci penetrate into the cell space not only through cracks in the rectal mucosa. There is an internal path: caries, or any other focus of a sluggish (chronic) infection. With the flow of blood and lymph, pathogens from the epicenter of inflammation are transferred to other organs and tissues.

Another way for the penetration of pathogens into the cell space is to block the duct of the anal gland.

The appearance of the disease is favored by malnutrition, a sedentary lifestyle and the presence of sluggish inflammatory processes. Additional aspects that increase the risk of the onset of the disease:

• weakened immunity;
• diabetes;
• anal intercourse;
• cracks in the anus.

In especially severe manifestations of the disease, inflammation can cover several zones located near the intestine at once.

Classification

Forms of pathology:

• according to the depth of the location of the pathology - superficial, deep;
• downstream - acute (formed for the first time) and chronic (formed fistulas);
• in relation to the fistula to the anal sphincter - intra-, extra- and transsphincteral;
• according to the complexity of the structure of the fistulous passages - simple and complex (the presence of several passages, streaks and purulent pockets);
• by the presence of a fistulous exit - incomplete (there is only an entrance through the anal crypt) and complete (the abscess has found an exit through the skin, into the abdominal space or into the lumen of the rectum);
• according to the localization of purulent foci - subcutaneous, submucosal, intrasphincteral (located between the fibers of the external and internal sphincter), ischiorectal (abscess located in the perineum, outside the anal sphincter), pelviorectal (high location, high threat of a total purulent process).

Paraproctitis symptoms

Since paraproctitis is a purulent inflammatory process, it will be characterized by classic symptoms:

• increase in body temperature to critical levels;
• pain syndrome in the area of ​​formation of paraproctitis - patients complain of the inability to sit and walk;
• tissues around the anus acquire a red-blue color;
• the patient himself, when feeling the place of development of the inflammatory process, determines the swelling of the tissues.

The acute form of paraproctitis is also characterized by common signs of intoxication of the body - nausea and dizziness, vomiting and slight tremor of the upper limbs, severe weakness. There is bound to be oozing.

Chronic paraproctitis has all the symptoms inherent in the acute form of the disease, but in a less pronounced form. The considered inflammatory process of a chronic nature has one feature - it always leads to the formation of a fistula. Through the opening of the fistula, a purulent-sanitary fluid regularly flows out - constant irritation of the perineum leads to severe itching. Such paraproctitis is not capable of self-healing. With each relapse, the scale of the pathological process only increases, more and more destroying the patient's body. Gradually, severe complications arise in the form of necrosis, malignant degeneration of paraproctitis.

Since the symptoms of acute paraproctitis are quite specific, when they are detected, it is important to contact a proctologist as soon as possible in order to avoid life-threatening consequences and to prevent the transition of the disease to the chronic stage.

Diagnostics

For diagnosis, as a rule, it is enough to collect complaints, an anamnesis of the disease and an external examination. In rare cases, especially with a deep location of the abscess, there may be difficulties in differentiating the diagnosis. Then instrumental research methods may be required, for example, computed tomography or ultrasound with a rectal sensor.

In the presence of fistulas, fistulography is performed - staining of the fistulous passage, to determine its depth, length and direction of the course.

Laboratory research methods determine the presence of inflammation.

Treatment of acute paraproctitis

In acute paraproctitis, surgery is indicated. It must be performed as early as possible (surgical intervention for acute paraproctitis is classified as urgent). Otherwise, the development of complications and the transition of acute paraproctitis to chronic is possible.

The operation for paraproctitis proceeds according to the following scheme:

• The surgeon specifies the location of the abscess by examining the rectum on the rectal mirrors.
• Then the abscess is opened and cleaned of pus. The surgeon must carefully examine the cavity, open all the pockets, destroy the existing partitions.
• The abscess cavity is washed with an antiseptic solution.
• Drainage is left in the wound (a graduate through which pus, ichor drains).
• A special tube may be inserted into the rectum to remove gases.
• In the future, dressings are performed daily, the patient is prescribed antibiotics.

Beforehand, the surgeon and the anesthesiologist inform the patient about the features of the operation and anesthesia, and talk about possible complications and risks. The patient must sign a written consent for surgery and anesthesia.

Local anesthesia during surgery for acute paraproctitis cannot be used, since it is most often not able to completely eliminate pain. The insertion of a needle can spread the pus. General anesthesia is used: mask or intravenous.

The three main tasks that the doctor must solve during the operation:

• open and clean the abscess;
• excise the affected crypt - as it is a source of purulent infection;
• dissect and clean the purulent passage that connects the crypt and the abscess.

The deeper the abscess is, the more difficult and difficult the operation. With a timely operation, the prognosis is favorable. If the patient did not turn to the doctor in time, then acute paraproctitis becomes chronic, complications develop.

Treatment of chronic paraproctitis

If the patient is diagnosed with chronic paraproctitis, then it will be necessary to excise the formed fistula. But during active purulent inflammation of the paraproctitis fistula, surgery is contraindicated, so doctors first open abscesses, clean them of their contents and drain them - after that, you can proceed with the operation.

If there are infiltrated areas in the fistulous canal, then doctors first carry out antibiotic therapy using physiotherapeutic methods. But the operation to remove the fistula must be carried out as quickly as possible after preliminary treatment - a relapse with purulent inflammation is inevitable.

Important: old age, severe somatic diseases and closure of fistulous passages are contraindications for surgical treatment of chronic paraproctitis. Doctors must first stabilize the patient's condition and only then refer him for surgical treatment.

Complications

Chronic paraproctitis is characterized by a high risk of complications:

1. Spontaneous opening of an abscess.
2. Purulent fusion and necrosis of the walls of the vagina, urethra.
3. The growth of scar tissue and a decrease in the elasticity of the walls of the anal canal.
4. Cancer degeneration in the presence of a fistula for more than 5 years.
5. The exit of feces into the perirectal tissue through the necrotic wall of the rectum, the lightning spread of the purulent process.
6. Breakthrough of an abscess into the abdominal space and the development of peritonitis, which is fatal.
7. Insufficiency of the anal sphincter due to severe damage to its fibers, leakage of feces.

When the first signs of paraproctitis appear, emergency surgical care is needed. The prognosis of the disease depends on the timing of its provision.

Prevention

Prevention of paraproctitis is simple:

• avoidance of hypothermia;
• strengthening immunity;
• compliance with the rules of intimate hygiene;
• timely treatment of diseases of the rectum (hemorrhoids, anal fissure, etc.);
• treatment of diseases accompanied by itching and irritation of the skin around the anus (worm infestation, diabetes mellitus, colitis);
• normalization of digestion in order to prevent the occurrence of constipation and diarrhea.