Anal Conditions & Treatment
What is an anal fissure?
An anal fissure (fissure-in-ano) is a small tear in the anal canal. Fissures typically cause severe pain and bleeding with bowel movements. Many of these patients are wrongly assumed and diagnosed as haemorrhoids.
Symptoms of anal fissure:
• Severe pain during and after bowel movements.
• Bright red blood from the anus on toilet paper or on stool.
• Fear of passing stools.
Causes of anal fissure:
• Can be caused by trauma to the anal canal.
• Patients with tight anal sphincter muscles.
• Hard, dry stools typically can cause a tear.
After a bowel movement, severe anal pain can produce spasm of the anal sphincter muscle, causing decreased blood supply to the injured area resulting in impaired blood supply and delayed healing. The next bowel movement triggers more pain, anal spasm and more reduction in blood supply and the cycle is repeated. Treatments are aimed at interrupting this cycle by relaxing the anal sphincter muscle to promote healing of the fissure.
Types of fissures:
Acute anal fissures: These are of recent on-set.
Chronic fissures: present for a longer period:
• More difficult to treat.
• May have an external lump called a sentinel pile or skin tag
• Extra tissue called hypertrophied papilla may be found in the anal canal.
Treatment of anal fissures:
The majority do not require surgery. The most common treatment of acute fissure consists of making the stool more formed and bulky with:
• A diet high in fiber.
• Stool softeners.
• Increasing water intake.
• Topical anaethetics.
• Relaxation of anal sphincters medication: GTN, nifedipine, or diltiazem.
• Chronic fissures: more difficult to treat, and surgery usually indicated.
Surgery for chronic fissures:
Surgery involves division of a portion of the internal anal sphincter (lateral internal sphincterotomy). This can be performed as an out-patient procedure. The goal is to promote relaxation of the anal sphincter, thereby decreasing anal pain and spasm, allowing the fissure to heal. If a sentinel pile is present, it can be removed to promote healing of the fissure. Acute pain after surgery often disappears after a few days. Most patients will be able to return to work and resume daily activities in a few short days after the surgery.
Anal Skin Tags
atients often complain of painless, soft tissue felt on the outside of the anus. These can be the residual effect of a previous problem with an external hemorrhoid or may be a result of a chronic fissure in ano in this case called a sentinel pile. Skin tags will occasionally bother patients by interfering with their ability to clean the anus, anal irritation , itchiness and others just don’t like the way they look or feel. They do not cause any major problems but they can be removed surgically if the patient doesn’t want them.
Anogenital warts are caused by a virus that can be passed on by close sexual contact. If you have anogenital warts, you will usually be advised to have tests to check for other sexually transmitted infections (STIs).
What are anogenital warts and what causes them?
They are small lumps that develop on the genitals and/or anus. They are caused by a virus called the human papillomavirus (HPV).
How do you get anogenital warts?
The virus is passed on by sexual contact. You need close skin-to-skin contact to pass on the virus. This means that you do not necessarily need to have penetrative sex to pass on infection. Very rarely, anogenital warts may be passed on from hand warts. They may also rarely be passed on to a baby when a woman gives birth. Also, note that you may get anal warts even if you have not had anal sex.
How common are anogenital warts?
They are one of the most commonly diagnosed sexually transmitted infections. Many more people are infected with the virus but do not develop visible warts (they are carriers).
Where do anogenital warts develop?
In men, the warts usually develop on the outer skin of the penis. In women, the warts usually develop on the vulva, just outside the vagina. Warts may also develop on the skin around the back passage. Sometimes warts develop inside the vagina, on the neck of the womb (cervix), on the scrotum, or inside the anus.
What do anogenital warts look like?
Anogenital warts may have several different appearances. Sometimes individual warts join together to form one large warty area. Warts that develop on skin that is warm, moist and non-hairy (such as the vulva) tend to be soft. Warts that develop on skin that is dry and hairy (such as around the bottom) tend to be firm.
What are the symptoms of anogenital warts?
Often there are no symptoms, other than a lump on the skin being noticed. They sometimes cause irritation and soreness. Sometimes the warts can bleed or cause pain on intercourse. Warts around the anus can cause bleeding. They may cause embarrassment, or interfere with sexual activity.
What are the treatment options for anogenital warts?
Surgical removal: This can be done either under local anesthetic or general anaesthetic.
Electrocautery: This is a technique where the warts are destroyed by burning.
A laser: This is another technique sometimes used to destroy the warts by burning.
What about my sexual partner?
It is a good idea to advise your current sexual partner to be checked.
Is there a link between anogenital warts and cancer?
The types viruses that most commonly cause anogenital warts do not increase the risk of cancer. However, some other types of viruses do increase the risk of developing cancer.
It is particularly important that women with anogenital warts have cervical screening tests to exclude cervical cancer.
Anorectal bleeding refers to bleeding that occurs from the back passage and is extremely common condition. In the large majority of cases, it is coming from the anal canal.
What is anal bleeding?
Anal bleeding is nearly always due to benign conditions, usually haemorrhoids (“piles”) or fissures. The blood is usually bright red and fresh as though you had been cut. It usually occurs after a bowel movement but is sometimes seen as a stain on the underwear. When it occurs with bowel movement, it may be slight or heavier when it discolours the water in the toilet bowl. Sometimes, it will splash the bowl or even drip into the toilet after the motion has passed. Bleeding from a fissure may be quite painful while hemorrhoids are either painless or associated with only mild discomfort.
What is rectal bleeding?
When the blood is dark or clotted or mixed with the bowel motion, it is possible that the blood is coming from further up inside the bowel. While many of the causes of this type of bleeding are still innocent, it may be due to a more serious disease. The most serious of all is cancer of the bowel but it may also be coming from polyps arising from the bowel lining or inflammation of the bowel. All of these more serious conditions can be treated and cancers can be cured but the sooner they are identified the more likely it is that they can be effectively treated.
When should you report bleeding from your back passage?
You should report almost any episode of bleeding to your doctor if you have not had prior episodes. It is particularly important to report if it is associated with a change in your normal bowel pattern or a sense of incomplete emptying of your bowels.
What will your doctor do?
Having asked you a number of questions the Dr will examine your back passage. You will be asked to lie on your left side, to allow the doctor to have a careful look at the skin around the back passage. He will then insert a gloved finger into the back passage.
This is done gently and is much less painful than many people imagine. Further tests may include proctoscopy, rigid sigmoidoscopy, flexible sigmoidoscopy, colonoscopy or CT scans.
What do these tests involve and what are they for?
• Proctoscopy allows direct inspection of the anal canal to see if there are haemorrhoids present. It feels almost the same as the examination with the finger.
• Rigid sigmoidoscopy, flexible sigmoidoscopy and colonoscopy are all tests where the lining of the bowel is inspected directly via a telescope. They differ from each other in how much of the bowel can be seen, how long they take and where they are done.
The anus, which is also known as the “anal canal” is the tube connecting the lower end of the rectum with the outside of the body to allow the excretion of faeces. It is about 3 cm long and is surrounded by muscles – known as the anal sphincter- to keep it tightly closed most of the time.
Anal cancers arise from the types of cells lining the anal canal, known as “squamous cell carcinomas”. Cells that are becoming malignant but have not yet broken through the surface layer are referred to as “anal intraepithelial neoplasia (AIN)”, “high grade dysplasia”, “Bowens Disease” or “carcinoma in-situ”. Anal cancer is very rare and affects a slightly more women than men. The main risk factor for anal cancer is infection from the human papilloma virus (HPV). Other factors include smoking and impaired immunity from causes such as HIV or immune suppressing drugs following organ transplant. The risk of contracting the disease increases with age.
An anal fistula is defined as a small tunnel with an internal opening in the anal canal and an external opening in the skin near the anus. They form when an anal abscess doesn’t heal completely. Treatment is usually necessary to reduce the chances of infection in an anal fistula, as well to relieve symptoms. Different types of anal fistulas are classified by their location. They can either be simple fistulas or complex fistulas. The complex ones are difficult to treat.
• Anal discharge.
• Anal pain.
• Itching around the anus.
• Recurrent perianal abscesses.
• Pain passing stools.
It is usually simple to locate the external opening of an anal fistula but locating the internal opening can be more challenging. It is important to be able to find the entire fistula for effective treatment and to prevent recurrence. People who may have experience with recurring anal abscesses may have an anal fistula. The external opening of the fistula is usually red, inflamed, oozes pus, and is sometimes mixed with blood. The location of the external opening gives a clue to a fistula’s likely path and sometimes the fistula can actually be felt.
The best approach requires that each patient is assessed individually.
Treatment of an anal fistula is attempted with as little impact as possible on the sphincter muscles. It will often depend on the fistula’s location and complexity, and the strength of the patient’s sphincter muscles.
In a fistulotomy the surgeon first probes to find the fistula’s internal opening. Then the tract is cut open, scraped and then its sides are stitched to the sides of the incision in order to lay open the fistula. A more complex fistula is treated by usually laying open just the segment where the tracts join and the remainder of the tracts are removed. The surgery may be performed in more than one stage if a large amount of muscle must be cut. The surgery may need to be repeated if the entire tract can’t be found.
Advancement Rectal Flap:
A surgeon may core out the tract and then cut a flap into the rectal wall to access and remove the fistula’s internal opening then stitches the flap back down. This is often done to reduce the amount of sphincter muscle damage.
Haemorrhoids are commonly called ‘piles’. Normally, ‘vascular cushions’ (blood-filled sacs or veins) act as a seal in the back passage. When they enlarge, they are known as piles and they can protrude and bleed.
How do piles develop?
Increased pressure in the veins of the back passage may cause piles to develop. The following may cause raised pressure:
• Constipation, particularly prolonged attempts at straining to pass hard stools
• Pregnancy and childbirth
What are the types of piles?
Internal piles: These are inside and may cause no symptoms and are a frequent cause of bleeding from the back passage.
Prolapsing piles: These are sufficiently large that they ‘come down’ during
defaecation. They will either move back after or have to be pushed back.
External piles: These are always out. They are different from the very common finding of skin ‘tags’ around the back passage.
What are the symptoms?
• Bleeding from the back passage: This is the commonest symptom. The blood is usually bright red and separate from the stool.
• Lumpiness around the back passage: These may occasionally be external piles but are much more likely to be tags of skin.
• Prolapse: The piles sometimes protrude during defaecation.
• Pain: Piles often cause discomfort. If you have a severe pain during defaecation associated with bleeding, it may be due to a tear in the back passage (‘anal fissure’).
• Itching and soreness
Are tests needed?
Bleeding from the back passage is usually due to piles, but can also be an important warning symptom of bowel cancer. So tests are often done mainly to rule out cancer.
Is treatment required?
A diet with extra fibre may help those with a tendency towards constipation. This change in diet and stool consistency is often enough to stop the symptoms.
Is an operation ever needed?
If the piles are too big for the banding treatment they can be surgically removed. This is called a ‘haemorrhoidectomy’ and can often be carried out as a day case procedure.
Haemorrhoidal artery ligation operation (HALO) is an alterantive. This involves stitching the haemorrhoids blood vessels and part of the inside lining of the bowel to make the haemorrhoids shrink inside the bowel.
What is an anal abscess?
An anal abscess is a cavity filled with pus found near the back passage (‘anus’). It is a very common condition with. If you have pain, tenderness, fever, redness and/or a lump in the region of the anus you may be suffering from an abscess. When the abscess has been treated, it usually heals with no problems. If it doesn’t heal well it may form a fistula.
What is an anal fistula?
An anal fistula usually results from a previous abscess. It is a tunnel that connects the lining of the back passage with the skin next to the anus. Persistent leakage of pus from the opening next to the anus suggests that a fistula has developed. If this opening partially heals over, pus can build up in the tunnel. This leads to an abscess which discharges itself when the pressure builds up. So a fistula may lead to repeated abscesses occurring at the same site.
What causes an abscess?
An abscess is caused by infection getting in to one of the glands that produces mucus to lubricate the anus.
What causes a fistula?
When an abscess has discharged itself or has been drained, the skin will usually heal over but at times a small hole is left on the outside. This usually means that a tunnel (a “fistula”) has developed between the anal gland and the outside opening.
How is an abscess treated?
The majority of abscesses will require to be drained. This usually requires a general anaesthetic. It will usually take a few weeks for the abscess cavity to fill up with scar tissue.
How is a fistula treated?
A fistula nearly always requires surgery to cure it. The majority of fistulae are relatively easy to treat. The surgery usually involves cutting a small part of the anal sphincter muscle away. In this way, the tunnel is opened up to form a groove that heals from the bottom outwards. The surgery usually requires a general anaesthetic and can be done as a daycase procedure.
Sometimes the fistula is not the type that can be simply laid open as too much anal sphincter muscle is involved.In this case a string may be passed through the track (“seton”) and the surgeon will bring you back and discuss further options for your treatment.
What if the problem comes back?
Fistulae can be particularly awkward conditions to treat and can come back. In this case – and for the more complicated fistulae, it may be necessary to do a MRI (magnetic resonance scan) scan of the back passage to check that no other fistulae or “tracks” have been overlooked.
How long does it take to recover from this type of surgery?
Discomfort after fistula surgery is moderate for the first week and can be controlled with simple pain killers. The amount of time off work is usually minimal but will depend on the type of job you do.Bathing or showering two to three times a day helps keep the area clean and comfortable. Laxatives are recommended to minimise the discomfort associated with passing a motion.
Pruritis Ani / Itchy bottom
Pruritis ani is a common condition which causes itching or irritation around the anus (back passage).
What are the causes?
Pruritus ani has many possible causes, including haemorrhoids (piles) and certain skin conditions. The most common cause is a minor discharge from the anus. If small amounts of faeces or liquid mucus leaks from the anus, this can irritate the sensitive skin around the anus.
What measures can I take to help myself?
The following suggestions in personal hygiene may help:
• Pay special attention to personal hygiene. Try and keep the area as clean as possible, ideally by washing and gently drying the area at least once a day and after each bowel movement.
• A shower head may make washing the bottom easier. If you are at work, take a small plastic bottle of water into the toilet with you to wash with after each bowel movement.
• Don’t use soap as it can cause irritation.
• Use soft toilet paper or damp cotton wool.
• If you have a problem with faeces or mucus leaking from the anus, you could use a small amount of damp cotton wool on your fingertips to gently clean into the anus to make sure there is no residue left behind.
• If your leakage continues after cleaning into the anus, use a small plug of cotton wool in the anus to prevent the faeces or mucus from coming out.
• Dry the area by gently patting with a soft towel or tissue. Avoid rubbing.
• Try not to scratch the area.
• Do not use any creams, deodorants, talcum powder, antiseptics or anything else on your anus, apart from the treatment suggested by your Dr.
• Do not put anything in your bath water. In particular, avoid all antiseptics, bath salts, bath oils and bubble bath.
• Wear loose cotton underwear and change this every day. Avoid man-made fabrics coming into contact with the skin around your bottom.
Should I change my diet?
Although there is no specific diet to follow, it is important to try and establish a regular bowel habit.
• A diet that is high in fibre makes the faeces softer and more likely to cause leakage. You can try to make your faeces firmer and so less likely to leak by reducing the amount of fibre in your diet. This means avoiding large quantities of bran cereals, muesli, beans, peas, pulses and nuts. Limit the amount of fruit and vegetables, particularly those with skins, you eat.
• Avoid lagers and flat beers as these can make the problem worse.
• Avoid coffee, chocolate and fruit juices high in citric acid as these too make the pruritis worse.