Proctology Conditions

What is accidental bowel leakage (ABL)?

Accidental bowel leakage of stool means the inability to control the passage of stool or gas. Some people have mild trouble holding gas; while others have severe trouble holding stool. Incontinence is a miserable problem that many people have trouble talking about. People are frequently embarrassed and afraid there is no help. However, treatment is available. Dr Chamisa is specially trained to care for this problem.

How common is this problem?

One study showed that over 2% of the population suffers from accidental bowel leakage. More than 30% of nursing home patients are incontinent. It affects women more than men, and it becomes more common as people age and their sphincter muscles lose tone.

What causes accidental bowel leakage?

Normal control of the passage of stool depends on many factors. A problem in any of the following areas can contribute to lack of control. One factor is the time it takes for stool to pass through the bowel. If stool moves through the bowel too quickly, a person may not have warning and may have an accident. This happens most commonly to people with irritable bowel syndrome or inflammation of the bowel (colitis). Anything that causes diarrhea can lead to incontinence. To prevent leakage one must be able to tell that stool or gas is present in the rectum. People with neurological problems may have abnormal sensation in the rectum. They will not be able to sense that gas or stool has entered into the rectum and therefore have no warning to go to the bathroom. The sphincter muscle, a circle of muscle around the anus (rectal opening), keeps the anus closed. It needs to hold the anus closed at rest and squeeze to tighten the anus when stool or gas enter the rectum. As people age, the muscle gradually loses strength. The sphincter muscle can also be injured during childbirth or during rectal surgery. Two nerves stimulate the sphincter muscle. If the nerves are injured, the sphincter muscle may become weak.

What tests are available?

First, the doctor will ask questions about your symptoms, bowel habits, and other medical problems. You will then be examined with particular attention paid to the sphincter muscle, rectum, and lower colon. You may need to have additional tests like anal manometry and nerve tests. An ultrasound probe inserted into the anus can provide a picture of the muscles, which would show any area of injury. You may need an x-ray to check for rectal prolapse.

How is accidental bowel leakage treated?

• If present, the underlying problems are corrected e.g. inflammation of the bowel, infection, or irritable bowel syndrome.
• Diarrhea and constipation are treated with dietary changes, usually emphasizing a high fibre diet.
• Accidental bowel leakage caused by injury to the sphincter muscles may require surgery.

Biofeedback or pelvic floor muscle training may also be recommended. This program teaches people to consciously identify and exercise their pelvic floor muscles. Finally, for patients with severe incontinence, a colostomy greatly improves their lifestyle. Patients with accidental bowel leakage are encouraged to speak with their doctors. Help is available.

Anal intra epithelial neoplasia AIN is a condition which affects the skin around the anus.  The severity of the condition is graded from I to III, with III being the most severe. AIN is important because some cases of AIN III can go on to develop into an anal cancer.

What causes anal intra-epithelial neoplasia?

Most AIN is triggered by the human papilloma virus (HPV). This is the same virus that causes anal warts. AIN is also related to changes in the vulva (Vulval Intra-epithelial Neoplasia, VIN) and cervix (Cervical Intra-epithelial Neoplasia, CIN) in women. The human papilloma virus is the common link between all these conditions. Other recognised risk factors include smoking and immunosuppression. Patients may be immunosuppressed because they are taking drugs to suppress their immune systems such as transplant patients. Other causes of immune suppression include HIV (Human Immunodeficiency Virus) infection. Patients with AIN who are immunosuppressed are at greater risk of developing anal cancer.

What are the symptoms of Anal Intraepithelial Neoplasia (AIN)?

Some patients may be unaware that they have AIN present. The principle symptoms are:

• Itching
• Raised nodules or tags by the anus

Sometimes AIN can affect all of the skin around the anus (multifocal disease), this is more common in immunosuppressed patients. In other cases it may be confined to a single area.

How is Anal Intraepithelial Neoplasia (AIN) Investigated?

When you are seen in clinic the consultant will take a full history and carry out a clinical examination. Usually this will involve a rigid sigmoidoscopy and sometimes a proctoscopy as well to carefully examine the anal canal. Skin biopsies are normally required to establish the diagnosis. The surgeon will normally take several biopsies from around the anus to assess the extent of the changes, this process is referred to as mapping. This is normally carried out under a general anaesthetic. We normally recommend that all women are also seen and assessed by a gynaecologist to check for vulval or cervical disease.

Anal Intraepithelial Neoplasia (AIN) Treatment

If isolated AIN is identified this is usually treated by excision. This can be carried out as a day case under a short anaesthetic. The affected area of skin is removed. The wound is usually left open to heal by itself. Areas of AIN I or II do not normally require any treatment other than careful observation. Where the AIN III changes are extensive (multifocal) the surgeon will recommend removing any suspicious ulcerated or raised areas. Some topical preparations such as Imiquimod may be beneficial. In very rare cases the surgeons may consider removing all of the skin around the anus in this case a skin graft would be required. Very occasionally if left untreated anal cancer can develop. Follow-up visits to the clinic are required to ensure that the anal skin can be closely monitored. Further biopsies may be required.

Anal Cancer:

This is a type of cancer that forms in tissues of the anus. The anus is the opening of the rectum (last part of the large intestine) to the outside of the body.

General Information about Anal Cancer

Anal cancer is a disease in which cancer cells form in the tissues of the anus. Two ring-like muscles, called sphincter muscles, open and close the anal opening to let stool pass out of the body.

Risk factors include the following:

• Being over 50 years old.
• Being infected with human papillomavirus (HPV).
• Having many sexual partners.
• Having receptive anal intercourse (anal sex).
• Frequent anal redness, swelling, and soreness.
• Having anal fistulas (abnormal openings).
• Smoking cigarettes.

Symptoms of anal cancer:

Symptoms of anal cancer include the following:

• Bleeding from the anus or rectum.
• Pain or pressure in the area around the anus.
• Itching or discharge from the anus.
• A lump near the anus.
• A change in bowel habits.

Tests and Procedures to detect anal cancer:

Physical exam and history:  An examination of the body to check general signs of health. A history of the patient’s health habits and past illnesses.

Digital rectal examination (DRE):  An exam of the anus and rectum. The doctor inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual.

Anoscopy:  An exam of the anus and lower rectum using a short, lighted tube called an anoscope.

Proctoscopy:  An exam of the rectum using a short, lighted tube called a proctoscope.

Endo-anal or endorectal ultrasound:  A procedure in which an ultrasound transducer is inserted into the anus or rectum and used to bounce high-energy sound waves off internal tissues or organs and make echoes.

Biopsy:  The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer.

Factors affecting treatment outcome:

The prognosis (chance of recovery) depends on the following:

• The size of the tumour.
• Where the tumour is in the anus.
• Whether the cancer has spread to the lymph nodes.

The treatment options depend on the following:

• The stage of the cancer.
• Where the tumour is in the anus.
• Whether the patient has human immunodeficiency virus (HIV).
• Whether cancer remains after initial treatment or has recurred

Perianal abscess and perianal fistula

A perianal abscess is an infection in a mucous-secreting gland in the anal canal around your anus.

What is a perianal fistula?

A perianal fistula, almost always the result of a previous abscess, is a small passage connecting the anal gland from which the abscess arose to the skin where the abscess was drained.

What causes an abscess and a fistula?

An abscess is formed when a small gland just inside the anus becomes infected from bacteria or stool trapped in the gland. Certain conditions — constipation, diarrhea, colitis, or other inflammation of the intestine, for example — may make these infections more likely. After an abscess has been drained, a passage may remain between the anal gland and the skin, resulting in a fistula. If the gland does not heal, there will be persistent drainage through this passage. If the outside opening of the fistula heals first, a recurrent abscess may develop.

What are the symptoms of an abscess or fistula?

Perianal abscesses are generally manifested by intense anal pain and swelling. Fever is possible. Drainage of the abscess, either on its own or with an incision, relieves the pain and pressure. Fistulas are associated with drainage of blood, pus, or mucus, but they are generally not painful.

Does an abscess always become a fistula?

No. A fistula develops in up to 50 percent of all abscess cases. There is no way to predict if this will occur. If drainage persists for two to three months, the diagnosis of perianal fistula is made.

How is an abscess treated?

An abscess is treated by draining the pus through an opening made in the skin near the anus. Often this can be done in the doctor’s office using a local anesthetic. A large or deep abscess may require drainage in the operating room. Hospitalization may be necessary for patients susceptible to more serious infections, such as diabetics or people with decreased immunity.

How is a fistula treated?

Surgery is generally necessary to treat a perianal fistula. This usually involves cutting a small portion of the anal sphincter muscle to open the passage, joining the external and internal opening, and converting the passage into a groove that will then heal from the inside out. Most fistula surgery can be performed on an outpatient basis. If the fistula involves too much sphincter muscle, a two-stage procedure or more complicated repair may be necessary.

What can I expect after fistula surgery?

Discomfort after fistula surgery can be mild to moderate for the first week and can be controlled with pain medication. The amount of time lost from work or school is usually minimal. Soak the affected area in warm water three or four times a day. Stool softeners may also be recommended. You may need to wear a gauze pad or minipad to prevent the drainage from soiling your clothes.

Will an abscess or fistula recur?

If proper healing occurs, the problem usually will not return. If your bowels are otherwise normal, you are probably not at higher risk for developing another abscess.

Anal pain:

Anal pain can occur before, during, or after a bowel movement. It can range from a mild ache that can get worse over time to pain that is bad enough to restrict daily activities. Anal pain has many causes, most of which are common and treatable.

Common causes of anal pain:

1.  Thrombosed External Hemorrhoid 

This is a blood clot that forms in an outer hemorrhoid in the anal skin. If the clots are large, they can cause pain when you walk, sit, or have a bowel movement. Most experts recommend that the blood clots be removed surgically. This short surgery can be done in the surgeon’s office or at the hospital under local anesthesia.

2.  Anal Fissure

An anal fissure (also called fissure-in-ano) is a small tear in the lining of the anal canal. Treatments include a high-fiber diet, fiber supplements stool softeners; warm tub baths (sitz baths) and several types of medication. Although most anal fissures do not require surgery, chronic ones are harder to treat and surgery may be the best option. The goal of surgery is to help the anal sphincter muscle relax, which reduces pain and spasms, allowing the fissure to heal.

3.  Anal Abscess and Fistula

An abscess is an infected cavity filled with pus near the anus or rectum. In most cases, an abscess is treated by draining it surgically. A fistula is a tunnel that forms under the skin, connecting the clogged, infected glands to the abscess and out to the skin near the anus. Surgery is often needed to cure an anal fistula.   

4.  Fungal Infection or Sexually Transmitted Diseases

Patients with fungal infections or infections caused by sexually transmitted diseases (STDs) may have mild to severe anal or rectal pain. STDs include gonorrhea, chlamydia, herpes, syphilis, HPV, etc. Treatment includes topical or oral antibiotics and antifungal medications.

5.  Skin Conditions

Skin disorders that affect other parts of the body may also affect skin around the anus. Treatment is tied to the results of the skin biopsy and/or physical exam.

6. Anal Cancer

While most cases of anal pain are not cancer, tumors can cause bleeding, a mass, and changes in bowel habits, as well as pain that gets worse over time. If you have pain or anal bleeding that does not go away or gets worse, see a colon and rectal surgeon as soon as possible. Treatment of anal cancer or other anal tumors may involve chemotherapy, radiation and/or surgery.

When should I consult a doctor:

• Pain comes back or doesn’t go away
• There is ongoing rectal bleeding
• You can feel a mass that does not get better

Abnormal anal Pap Smear, Dysplasia

Abnormal anal pap smears, anal dysplasia and anal cancer are all caused by human papilloma virus (HPV).

What is human papilloma virus (HPV)?

HPV is a common virus which can be transmitted sexually. HPV infection may present differently: some HPV types cause warts while other HPV types cause anal and cervical cancer. 

Risk factors for HPV:

• Women: history of cervical high grade dysplasia or cervical cancer
• Women and men: HIV infection
• Women and men: history of receptive anal sex.
• Women and men: other HPV related diseases such as warts.
• Women and men: immunosuppression from diseases or from medications.

HPV prevention:

HPV vaccines: they are highly effective in preventing both HPV warts and HPV related cancers when given before becoming sexually active. Practicing safe sex reduces the risk of getting HPV; condoms are partially protective. Stopping cigarette smoking decreases HPV disease and risk of recurrence. Treating HIV with antiretroviral therapy may reduce the risk of getting anal dysplasia.

What is anal dysplasia:

Anal dysplasia is a pre-cancerous condition which occurs when the cells of the lining of the anal canal undergo abnormal changes.  The anal canal is the last few inches of the intestine.  Anal dysplasia may progress from low-grade (low risk) changes to high-grade (high risk) changes before it turns into cancer.

What causes anal cancer?

90% of anal cancers are caused by the HPV. Anal cancer may develop slowly over a period of years.  Anal cancer may occur inside the anal canal where the anus meets the rectum. Or it may develop in the skin just outside of the anal canal opening.  

What are the symptoms of anal cancer?

Sometimes there are no specific symptoms of anal cancer until it is quite advanced. There may or may not be a visible or palpable growth. People may also have anal pain, bleeding and discomfort. These same symptoms can be caused by other benign conditions, like haemorrhoids or anal fissures. This is one of the reasons you should be seen and examined when you have those symptoms, so the correct diagnosis is made. At a minimum, you should have the following examinations:

Digital rectal exam: your provider places a gloved finger in the anal canal to feel for lumps

Routine anoscopy: a visual examination of the anal canal. A short instrument is placed in the anal opening to allow the provider to see the lining of the anal canal.

Diagnosis of anal dysplasia

The diagnosis of anal dysplasia may be made by performing an anal pap smear. Just like a cervical Pap smear, cells are collected from a swab inserted into the anus.  Those cells are then examined by a pathologist looking for pre-cancerous or dysplastic changes.  Male/female patients with any of the following risk factors should have an anal pap smear:

• History of receptive anal sex
• HIV infection.
• History of cervical high grade dysplasia or cervical cancer.
• Other HPV related disease: genital warts.
• Immunosuppression from disease or medications.

Follow-up of anal dysplasia is based on the results of anal Pap smear

Results of anal Pap smear may be normal or abnormal. Any description of abnormal anal Pap smear usually triggers a recommendation to perform high resolution anoscopy.

High resolution anoscopy (HRA) uses magnification to obtain a more detailed view of the anal canal. The provider inspects carefully the entire anorectal junction under high magnification. HRA offers the opportunity to both diagnose and treat anal dysplasia. Suspicious or atypical areas can be biopsied, and the lesions may be destroyed in the course the same procedure.

Treatment:

Visible warts are usually treated even if they are not pre-cancerous lesions. There are multiple treatment options. Some include:

• Lesion destruction with electrocautery (heat) or by infra-red coagulation (IRC- intense beam of light).
• Trichloroacetic acid (TCA): the lesion is treated by being touched with acidsoaked cotton.  

After treatment: surveillance

Anal dysplasia can be treated successfully with very close follow up and monitoring.  Individuals with low-grade lesions will generally have a repeat HRA in 1 year.  Individuals with high-grade lesions will have a repeat HRA every 3-6 months.  This will continue until there is no further evidence of high-grade dysplasia.

Anal warts:

Anal warts, also known as condyloma, are growths found on the skin around the anus (rectal opening) or in the lower rectum. Anal warts are caused by the human papilloma virus, which is usually transmitted through sexual contact but not necessarily through anal intercourse. There are many types of human papilloma virus; some cause warts on the hands and feet and others cause genital and anal warts. The same type of warts may occur on the penis, scrotum, vagina or labia.

What are symptoms of anal warts?

Many patients with anal warts have no symptoms. Some patients may notice small growths in the anal area. Others have minor complaints of itching, occasional bleeding, or moisture in the anal canal.

Additional symptoms may include:

• Itching
• Bleeding
• Mucus discharge
• Feeling like there is a lump in the anal area

How are anal warts diagnosed?

Diagnosis is made by the doctor, who inspects skin around the anus and checks the anal canal with an anoscope (a short instrument inserted into the anus).

How are anal warts treated?

There are several ways anal warts can be treated, depending on the location, number and size of the warts. If the warts are small, they can be treated with podophyllin or bichloracetic acid, which are solutions applied directly to the warts intended to cause sloughing of the wart. Another form of treatment is cauterization. If the area contains numerous warts, the doctor may choose to remove them surgically. This is done as a same-day procedure in a hospital.

Do I need a single treatment to cure anal warts?

A single treatment will not cure anal warts in most cases. Close follow-up is critical because the virus may continue to be present and cause new anal warts to form. Even after there are no visible warts, the virus may remain in the tissue. Small warts that reappear are easily treated in the office. Follow-up visits are necessary even after there are no visible warts. There is a possibility of serious problems if the warts are left untreated. Rarely, these warts can become cancerous, so it is important to keep the follow-up appointments the doctor suggests.

How can I prevent the spread of warts?

There are several ways to prevent this virus from spreading:

• Sexual partners should be checked.
• Refrain from sexual activity until treatment is completed.
• Use condoms. They offer some, but not complete, protection. Because anal warts are highly contagious, you will lessen your chance of recurrence if these suggestions are followed

Diarrhea:

What is diarrhea?

Diarrhea is a common problem that we all suffer from occasionally. Fortunately, it is usually a limited episode that resolves quickly. When it doesn’t, there can be cause for concern. The word diarrhea means different things to different people. Some patients who regularly experience bowel movements every three days think they have diarrhea if they begin going everyday. Complaints of diarrhea should be compared to what is normal for each individual patient. Typically, diarrhea is thought to be loose, unformed or watery stools that come more often than normal. It is often accompanied by abdominal cramps, and less warning when it is time to go.

What causes diarrhea?

As was already mentioned, most of us will get diarrhea occasionally. Most of the time it is related to a viral illness, and will go away in a few days. Bacterial infections like food poisoning can also cause diarrhea which can be accompanied by rectal bleeding. This is a more serious situation, and you should call your doctor. Other more serious causes of diarrhea include inflammatory diseases like ulcerative colitis and Crohn’s disease, or diverticulitis. More common causes include irritable bowel syndrome, which is usually accompanied by constipation alternating with the diarrhea. Another common cause is lactose intolerance, which makes a person unable to digest milk products.

What can I do?

During a minor episode of diarrhea, simply forcing fluids and rest is enough. Fluids should be limited to water, fruit juices, non-caffeinated beverages and salt containing liquids such as broth and sport drinks like Gatorade or All Sport. Avoid all caffeinated beverages. Those people with a history of irritable bowel syndrome should make sure they are getting enough fiber and water in their diet. They should also make sure they are using any medicines their doctor has given them according to the prescription. If the diarrhea persists, over the counter medicines like Immodium A-D should not be used without the advice of your doctor. If a serious condition exists, use of those medicines can actually make the problem worse.

Are there warning signs?

Things to watch for during an episode of diarrhea include:

• bleeding with the stool
• high fever
• severe abdominal pain
• dehydration

If a person cannot drink enough to keep up with the fluid lost through bowel movements, they need to be in the hospital. If any of these warning signs occur, please call your doctor right away.

Constipation:

Constipation can be an uncomfortable experience.. The following information can help answer your questions about constipation and help you understand your doctor’s choice of treatment.

What is constipation?

Constipation may mean different things to different individuals. Most commonly, it refers to the passage of too few bowel movements per week.  It may also describe having hard, dry stools that are difficult to pass, a decrease in the size of the stool, or needing to strain to have a bowel movement.  Some individuals describe a sense of not emptying their bowel completely or the need for enemas, suppositories or laxatives in order to have a bowel movement. The definition of normal frequency of having a bowel movement ranges from 3 times a day to 3 times a week.

What causes constipation?

Common causes of occasional constipation include:

• Poor eating habits (for example, too much junk food, too much irregular eating times)
• Diet lacking in fiber and/or fluids
• Lack of exercise
• Some medications (including pain medications, tranquilizers, psychiatric medications) • Stress
• Pregnancy
• Travel

More serious causes of constipation include narrowing of the colon or growths in the colon. Sometimes constipation is caused by problems with the function of the pelvic floor muscles. The muscles may not relax appropriately when trying to pass stool, making it difficult and sometimes painful to have a bowel movement.

What can I do about constipation?

Help yourself maintain regularity by adding some of these simple steps to your daily routine:

• Gradually add high fiber foods to your diet, including dried fruits (apricots, prunes, raisins, and dates) raw vegetables, bran cereals whole-grain breads. • Drink 8 to 10 glasses of decaffeinated fluid each day
• Follow a regular exercise program.
• Respond to the urge to have a bowel movement.
• If one is recommended by your doctor, take a high-fiber supplement.
• Use laxatives only as your doctor recommends.

Should I take a laxative?

Your doctor may prescribe a laxative for you. There are many types of laxatives, each one having benefits and drawbacks for certain patients.

Bulk-forming agents are not digested but absorb liquid in the intestine and then swell to form a soft, bulky mass that stimulates a bowel movement.  

Stool softeners do not cause a bowel movement but ease the difficult passage often associated with hard dry stool.

Stimulant laxatives encourage bowel movements through action of the intestinal wall.  They increase the muscle contractions in the intestine that lead to having a bowel movement.

Hyperosmotic laxatives work by drawing water into the bowel from surrounding tissues.  This softens the stool and sends the bowel the message to empty.

Enemas fill the colon with fluid, which softens the stool and stimulates a bowel movement.

It is always a good idea to look for natural ways to meet your body’s needs and avoid long-term use of medication. Excessive use of stimulant laxatives can actually cause constipation and dependence upon laxatives because the colon loses its normal tone and the ability to contract.

Constipation

What is Constipation?

Constipation is the infrequent passage of stool that may be hard, dry, and leads to straining. There may be a feeling of incomplete evacuation and pressure on the rectum. The abdomen may feel bloated and the colon distension can cause abdominal pain. More than 30 % of our population suffer from constipation at some point. It is more common in women and the elderly. You should have an easy to pass, moist formed stool at least every two to three days. This will decrease your risk of symptomatic enlarged haemorrhoids. Time on the commode should be less than two minutes. Straining should be avoided.

Causes?

In most cases there is no obvious cause. A low fiber diet without enough fluid will make constipation worse. Increasing fiber, water, and exercise will help. Eating large amounts of dairy products may cause constipation. Slow transit time or colonic inertia is due to the colonic muscles not moving the stool through the colon normally. Pregnancy can make constipation worse and is a good time to increase fiber and water. Irritable bowel syndrome may be associated with constipation and diarrhoea. Haemorrhoids can add to the obstruction of stool which may cause a flattening of the stool. Constipation may be caused by high calcium, low thyroid, diabetes mellitus, low potassium, or renal failure. Neurological conditions such as stroke can lead to constipation as well.  Anxiety and depression may exacerbate it as well. Constipation is frequently worse around menstrual periods. The pelvic floor muscles may fail to relax causing difficulty with passage of the stool. Colon or rectal cancer can lead to a smaller stool, no stool, or blood in the stool. The acute onset of constipation, weight loss, severe pain, or change in the caliber of the stool demands immediate medical attention. An acute bowel obstruction may cause abdominal pain, cramps, bloating, nausea, vomiting, distension, decreased stools and also requires immediate medical evaluation.

Complications:

Chronic constipation may lead to bloating, abdominal pain, nausea, cramps, rectal pain or pressure, or rectal bleeding. The passage of a large or dry stool can cause a tear or anal fissure.

Evaluation:

A rectal exam, sigmoidoscopy, or colonoscopy should be done. For chronic constipation that does not respond to dietary changes the workup may include a physical exam, history, blood work, rectal exam, colonoscopy, barium enema, rectal manometry and transit time or motility studies.

Treatment:

No one product is perfect and trial and error is required. Usually, it takes 1-2 weeks to see the full benefit of the additive. Foods rich in fiber include whole grains, beans, fruits and vegetables. Many cereal products or snack bars now have good fiber content.  A trial of fiber and water may be helpful. An occasional prune may be helpful. Drink up to 6 glasses of water and add 5 grams of fiber per day for the first 5 days. Fiber helps make a soft bulky stool that stretches the rectum and gives you a signal to go to the bathroom. Smaller stool can lie in the rectum undetected and obstruct blood flow leading to worsening of the haemorrhoids. Increasing fiber in your diet will help lower cholesterol, decrease the risk of heart disease and diverticulosis, and may decrease the risk of colon cancer. Stool softeners are wetting agents and may be taken with fiber. If the stool is dry you may apply Vaseline, with your finger, inside the rectum to try and aid the passage of the stool and help prevent a fissure. Chronic constipation will exacerbate haemorrhoids and can cause an anal fissure.  Enemas should not be used on a regular basis as they may injure the rectum or disturb the electrolyte balances. Suppositories work by stimulating the rectum. They may occasionally be used for constipation. Do not use laxatives on a regular basis without having your colon evaluated by a physician.

Faecal Incontinence:

What is faecal incontinence:

Faecal incontinence is the impaired ability to control the passage of gas or stool. This is a common problem, but often not discussed due to embarrassment. Failure to seek treatment can result in social isolation and a negative impact on quality of life.

Causes:

There are many causes of faecal incontinence such as injury, disease and age.

Childbirth-related injury: This is the most common cause, resulting from a tear in the anal muscles. which can lead to incontinence. Some injuries may be detected right after childbirth; however, many  go unnoticed until they cause problems later in life. 

Trauma to anal muscles: Anal operations or traumatic injury to the tissues near the anal region can  damage the anal muscles and lessen bowel control.

Age-related loss of anal muscle strength: Some people gradually lose anal muscle strength as  they age. 

Neurological diseases: Severe stroke, advanced dementia or spinal cord injury can cause lack of  control of the anal muscles, resulting in incontinence.

Symptoms:

Symptoms can range from mild to severe. Mild cases may only involve difficulty controlling gas. Severe cases can lead to an inability to control liquid and formed stools. If there is bleeding with lack of bowel control, consult your physician as soon as possible. This may indicate inflammation within the colon and rectum, such as ulcerative colitis, Crohn’s disease, a rectal tumour or rectal prolapse.

Diagnosis:

An initial discussion of symptoms with your physician will help determine the degree of incontinence and the effect on your life. Possible underlying factors are often found during a review of your medical history, such as:

• Multiple pregnancies, large weight babies, forceps deliveries or episiotomies.
• History of prior anal or rectal surgeries.
• Medical illnesses or conditions.
• Medication side effects.

A physical examination of the anal region should be performed. An exam may easily identify an obvious injury to the anal muscles.  An ultrasound probe may be used in the anal area, which provides photographs of potentially injured anal muscles. 

Treatment:

There are nonsurgical and surgical treatment options that vary based on the cause and severity of the problem.   

Non-surgical options:

Dietary changes: Mild problems may be treated simply by changing one’s diet.

Constipating medications: Specific medications can result in firmer stools, enabling more bowel control.

Medications: Inflammatory bowel diseases (such as ulcerative colitis or Crohn’s disease) can cause diarrhea and contribute to bowel control problems. Treating these underlying diseases may eliminate or improve incontinence symptoms.

Muscle strengthening exercises: Simple home exercises to strengthen the anal muscles can help in mild cases.

Biofeedback: A type of physical therapy to help patients strengthen anal muscles and sense when stool is ready to be evacuated.

Surgical options:

There are several surgical options for the treatment of faecal incontinence. 

Surgical muscle repair: Injuries to the anal muscles may be surgically repaired.

Stimulation of the nerves: Insertion of a nerve stimulator can help nerves that control muscles and skin of the anus work more efficiently.

Bulking agent injections: Injecting a substance into the anal canal can bulk it up and strengthen the “squeeze” mechanism of the anal muscles used during bowel movements.

Surgical colostomy: In severe cases, a colostomy may be the best option for improving quality of life. During this procedure, part of the colon (large intestine) is brought out through the abdominal wall to drain into a bag.

Anal fissure-in-ano:

What is an anal fissure?

An anal fissure is a split or tear in the lining of the anal canal (rectal opening).

When does a fissure occur?

A fissure most commonly occurs after an episode of constipation, but it can happen after an attack of diarrhoea. A fissure begins on the surface and usually heals rapidly on its own. Sometimes fissures may deepen to reach the underlying sphincter muscle (the muscle around the anal canal). It is not completely understood why some fissures heal and others do not. One major factor is persistent constipation or diarrhoea, which can prevent healing. In addition, each time stool passes, the muscle goes into spasm, tightening the anal canal. If the sphincter muscle does not relax and the anal canal remains too tight, the fissure opens again with each bowel movement. Treatment for the underlying disease usually relieves the fissure. Fissures very rarely become infected and they do not become cancerous.

What are the symptoms?

• RECTAL PAIN: People often describe it as burning or tearing pain with a bowel movement. The pain may last for minutes or persist for hours after a bowel movement. The pain that lasts after a bowel movement is caused by the spasm in the sphincter muscle. Some people avoid having a bowel movement because of the pain.
• RECTAL BLEEDING: It is usually small amounts of bright, red blood that can be seen on the toilet paper or in the toilet water.
• SWELLING: Swelling at the outer end of the fissure can result in a skin tag. It may be noticed when cleaning the rectal area.
• ITCHING:  Discharge may result as the fissure alternately heals and reopens, causing itching.

How is a fissure treated?

Most superficial fissures heal without treatment, but some become chronic and cause ongoing discomfort. The first step is to correct the constipation or diarrhoea and treat any underlying disease. A high-fiber diet or dietary bulk agent with plenty of fluids is recommended. A topical anaesthetic ointment may help relieve the pain. The spasm may also be relieved by sitting in a warm bath several times a day. These measures usually result in healing. If they do not, or the symptoms return, surgery may be required. Your doctor will discuss this with you.

What can I do to prevent another fissure?

• If constipation is a problem, eat foods high in fiber. Drink 8 to 10 glasses of fluid that do not contain caffeine or alcohol.
• If symptoms do recur, take warm baths. This will help to reduce the spasm and lessen the pain.
• If your doctor recommends an ointment, apply it directly to the painful area.

HAEMORRHOIDS:

Often described as “varicose veins of the anus and rectum,” haemorrhoids are enlarged, bulging blood vessels in and around the anus and lower rectum. The rectum is the bottom section of your colon. The tissues supporting the vessels stretch. As a result, the vessels expand, the walls thin and bleeding occurs. When the stretching and pressure continue, the weakened vessels protrude. The two types of haemorrhoids, external and internal, refer to their location.

External (outside) haemorrhoids: form near the anus and are covered by sensitive skin. They are usually painless unless a blood clot (thrombosis) forms.

Thrombosed external haemorrhoids are blood clots that form in an outer haemorrhoid in the anal skin. If the clots are large, they can cause significant pain. A painful anal mass may appear suddenly and get worse during the first 48 hours. The pain generally lessens over the next few days. You may notice bleeding if the skin on top opens.

Internal (inside) haemorrhoids form within the anus beneath the lining. Painless bleeding and protrusion during bowel movements are the most common symptoms. However, an internal haemorrhoid can cause severe pain if it is completely prolapsed. This means it has slid out of the anal opening and cannot be pushed back inside.

Haemorrhoids  general facts: 

• Haemorrhoids are one of the most common known ailments.
• Millions of Africans currently suffer from haemorrhoids.
• The average person suffers for a long time before seeking treatment for haemorrhoids.
• Advances in treatment methods means some types of haemorrhoids can be treated with far less painful methods than before.

Causes of haemorrhoids:

The exact cause of haemorrhoids is unknown. Contributing factors include:

• Aging
• Chronic constipation or diarrhoea
• Pregnancy
• Heredity
• Straining during bowel movements
• Faulty bowel function due to overuse of laxatives or enemas
• Spending long periods of time on the toilet (e.g., reading)

Symptoms:

Any of the following may be a sign of haemorrhoids:

• Bleeding during bowel movements
• Protrusion of skin during bowel movements
• Itching in the anal area
• Pain in the anal area
• Sensitive lump(s)

Non-surgical treatment:

The surgeon  will perform a thorough examination and recommend treatment. Mild symptoms can be relieved frequently without surgery. With nonsurgical treatment, pain and swelling usually decrease in two to seven days. The firm lump should recede within four to six weeks.

Treatment includes:

• Eating a high-fiber diet and taking over-the-counter fiber supplements to make stools soft, formed and bulky.
• Avoiding excessive straining to reduce the pressure on haemorrhoids and help prevent protrusion.
• Drinking more water to help prevent hard stools and aid in healing.
• Taking warm tub baths (sitz baths) for 10 to 20 minutes, a few times per day to help the healing process.

Surgical treatment:

If pain from a thrombosed haemorrhoid is severe, your surgeon may decide to remove the haemorrhoid and/or clot with a small incision. These procedures can be done at your surgeon’ office or at the hospital under local anaesthesia.

Rubber Band Ligation: This treatment works well on internal haemorrhoids that protrude during bowel movements. A small rubber band is placed over the haemorrhoid, cutting off its blood supply. The haemorrhoid and the band fall off in a few days. The wound usually heals in one to two weeks. Mild discomfort and bleeding may occur. Sometimes this treatment needs to be repeated for complete treatment of the haemorrhoids.

Rubber band ligation of internal haemorrhoids:

• Bulging, bleeding, internal haemorrhoid
• Rubber band applied at the base of the haemorrhoid
• About seven days later, the banded haemorrhoid has fallen off, leaving a small scar at its base

Injection and Coagulation: This method can be used on bleeding haemorrhoids that do not protrude. Both methods are fairly painless and cause the haemorrhoid to shrivel up.

Haemorrhoid stapling: A special device is used to apply staples and remove tissue from internal haemorrhoids. While the stapling method can shrink internal tissue, it cannot be used for external haemorrhoids. 

Haemorrhoidectomy: This is the most complete surgical method for removing extra tissue that causes bleeding and protrusion. It is done under anaesthesia using either sutures or staples. Depending on the case, hospitalization and a period of rest may be required. Contrary to popular belief, laser methods do not offer any benefit compared to standard operative techniques. Laser surgery is expensive and no less painful.

Haemorrhoidectomy is considered when:

• Clots repeatedly form in external haemorrhoids
• Ligation is not effective in treating internal haemorrhoids
• The protruding haemorrhoid cannot be reduced
• There is chronic bleeding

Do haemorrhoids cause rectal cancer?

Haemorrhoids do not increase the risk of colorectal cancer nor cause it. However, more serious conditions can cause similar symptoms. Even when a haemorrhoid has healed completely, your colon and rectal surgeon may request other tests. A colonoscopy may be done to rule out other causes of rectal bleeding. Every person age 50 and older should undergo a colonoscopy to screen for colorectal cancer.  

About Haemorrhoids

At our Haemorrhoid Centre we can help you get the relief you deserve today with our nonsurgical haemorrhoid office treatment. You no longer have to suffer the pain, bleeding, or itching of haemorrhoids or fissures. Going to the bathroom does not need to be feared. Our patients are thrilled to get rid of their pain, bleeding, and itching without surgery. They only wish they would have done it sooner. Do yourself a huge favor and make an appointment today.

What are Haemorrhoids?

In the human body, several blood vessels supply the tissue in the lower rectum and these are called haemorrhoid vessels. They form three cushions that help fill the rectum and aid in continence.  As the haemorrhoids continue to enlarge they may break their connections and protrude outside the anal canal which is called prolapse. The vessels become swollen and  may lead to anal pain, itching, leakage, and bleeding. Straining from constipation or diarrhea, heavy lifting, core exercising, prolonged sitting, pregnancy, or even air travel may exacerbate your haemorrhoids.

What are Internal vs. External Haemorrhoids?

There are two types: internal, on the inside of the rectum, and external, under the skin of the opening of the anus. Internal haemorrhoid swelling is the main cause of rectal bleeding and pressure. External haemorrhoid swelling adds to the pressure and makes hygiene more difficult. Enlarged internal haemorrhoids can lead to a discharge of infected mucous causing skin infections, rash, and itching. Blood clots in the external haemorrhoids leads to a painful thrombosis that may rupture and bleed.

Treatments:

Mild haemorrhoid symptoms may respond to increased water, fiber, lubrication, and lifestyle modifications. The use of hydrocortisone, and topical anaesthetics may provide some temporary relief. It is not safe to assume your bleeding, pain, or itching is due to haemorrhoids. Change in bowel habits, black or tarry stools, passage of significant blood or clots, abdominal or pelvic pain, or weight loss may indicate other conditions and need evaluation as soon as possible. Topical Nitro-glycerine and the analgesic Lidocaine will reduce anal pressure, swelling, pain, and bleeding. If needed, we will use a bander ligation system to painlessly shrink your internal haemorrhoids.

Surgical Treatment Can Be Avoided

Traditional surgery for haemorrhoids is called haemorrhoidectomy. In this procedure, any internal and external haemorrhoids are excised and the tissue is either sewn closed, or left open to heal naturally. Another procedure, a “stapled” haemorrhoidectomy, offers a shorter healing period and less pain. Doppler guided ligation is effective. A variety of lasers have been used but are expensive and may require anaesthesia.

Non-Surgical Haemorrhoid Treatment:

Surgery has been replaced by non-surgical office haemorrhoid treatments. Sclerotherapy, injection of liquids that clot the haemorrhoids, is painful and rarely used now. Infrared coagulation has proven to be less successful than originally hoped.

Haemorrhoid Ligation System -The New Gold Standard

The preferred non-surgical haemorrhoid treatment is rubber band ligation. It uses gentle suction to place the rubber band over one internal haemorrhoid per treatment. Three banding sessions are frequently required. Within days, the haemorrhoidal tissue dies and is passed during a bowel movement. The procedure takes only seconds and is nearly painless.  As an office procedure, the patient can return to work comfortably right after the appointment. At our Haemorrhoid Centre we have helped thousands of patients avoid surgery and get the relief they deserve.

Did you know?

While haemorrhoids are the most common cause of rectal pain and bleeding, it is important to remember not all rectal complaints are due to haemorrhoids. It is impossible to determine the cause of rectal discomfort without a physical examination. If you are experiencing any of the symptoms associated with haemorrhoids, please consult a physician who specializes in treatment of haemorrhoids and anal fissures.

Internal haemorrhoids:

What are internal haemorrhoids?

A haemorrhoid is a cushion of blood vessels in the lining of the anal canal. All people have haemorrhoids; we are all born with haemorrhoids. Not everyone, however, has haemorrhoid causing symptoms. When these haemorrhoids become enlarged, you may have painless rectal bleeding. Swelling of haemorrhoids may cause them to prolapse (slide out) during a bowel movement.

How are internal haemorrhoids treated?

Your physician will determine if your haemorrhoids require one of the following treatments:

• Barron ligatures (rubber bands) – A rubber band is put around the haemorrhoid, causing it to wither and fall off over a 5 to 10-day period.
• Thermal coagulation – A light source is used to cause a small burn on the surface of the haemorrhoid, causing it to stop bleeding and shrink down to normal size.
• Injection of haemorrhoids – A liquid is injected into the haemorrhoid, stopping the bleeding and preventing it from protruding.

These treatments are only used for internal haemorrhoids. They would be extremely painful if used for external haemorrhoids.

What can I expect after internal haemorrhoid treatment?

• Symptoms You may feel mild to moderate pain, a dull ache, or essentially nothing for the first 36 to 48 hours. A sense of urgency to have a bowel movement is normal after these treatments. If discomfort is mild, take over-the-counter medications. Taking warm baths for 15 to 20 minutes will help relieve your discomfort. Usually only one area, or occasionally two, is treated at a time. Remember that bleeding and prolapse will probably persist until all the haemorrhoids and prolapsing tissue have been treated.
• Diet After your treatment, it is important to keep your bowel movements soft and regular. Eat high fiber diet and drink plenty of water (8 to 10 glasses a day). Continue the fiber supplement recommended by your doctor. Caffeine contributes to constipation so limit your consumption of coffee, tea, colas, and chocolate.
• Activity You may continue your normal physical activities. You will be able to drive your car, walk up stairs, and do normal exercise immediately.

What should I be concerned about after my treatment?

If any of the following problems occur, please contact us:

• Pain that does not gradually lessen in three days
• Increasing pain several days after treatment
• Tender swelling in the anal area
• Fever or chills
• Difficulty urinating
• Constipation (no bowel movement for three days)
• Diarrhoea (more than three watery stools within 24 hours)
• Increased bleeding (more than one cupful)
• Three to four large bloody bowel movements within three hours
• Drainage of pus from the rectum

In an emergency try to contact us for advice before you go to the hospital. A telephone call may save you a lot of time, discomfort and expense.

Thrombosed external haemorrhoids:

A thrombosed external haemorrhoid is a haemorrhoid with multiple blood clots that can be seen and felt under the skin around your anus. It is usually moderately to severely painful. These haemorrhoids often occur with chronic constipation, diarrhoea, or pregnancy, but they can also appear on their own.

How is a thrombosed external haemorrhoid treated?

The skin over the blood clot is cut and removed and the wound is either left open or closed with absorbable suture. If absorbable suture is used, this stitch will fall out on its own. The doctor then puts a dressing over the wound to soak up any blood or discharge.

What can I expect after treatment?

• Symptoms and Care: You will have pain after the local anaesthetic wears off. It may be moderately strong. Occasionally, your doctor may need to prescribe something else in addition to relieve the pain. Topical anaesthetic ointments available over the counter, such as Xylocaine may also help with the pain. A small amount of bleeding is normal. Leave the dressing in place for approximately 12 hours; then take your first sitz bath. If the dressing is difficult or painful to remove, do it after soaking in the bath. If the wound is still bleeding, cover it with a pad or gauze. It takes two to four weeks for the wound to heal. Don’t worry if some discomfort, bleeding, discharge, pus, or itching occur during this time; it is part of the normal healing process. Anal hygiene is important. Wash or sit in the tub after bowel movements or at least twice a day.
• Diet: It is important to keep your bowel movements soft and regular. Eat foods high in fiber and drink plenty of water (8 to 10 glasses a day). If you are constipated, take a fiber supplement (e.g. fybogel).
• Activity: Avoid strenuous activity for the rest of the day. Tomorrow you can go back to your normal activities.

What should I be concerned about after my treatment?

If any of the following problems occur, please call our office:

• Excessive pain unrelieved by your pain medication.
• Increasing pain several days after treatment.
• Fever or chills.
• Difficulty urinating.
• Severe bleeding that won’t stop with direct pressure using Kleenex or gauze
• Constipation (no bowel movement for three days)
• Diarrhoea (more than three watery bowel movements within 24 hours)
• Nausea and vomiting

Anal itchiness/Pruritis Ani

What is pruritis ani?

Pruritus ani is a bothersome and sometimes intense itching or burning sensation of the skin around the anus. It is most noticeable at night or after a bowel movement. The most common complaint is an irresistible urge to scratch. Some people will note occasional bleeding when wiping after a bowel movement. It affects men and women equally and may occur at any age.

How is pruritis ani diagnosed?

It is diagnosed by an examination of the skin around the anal area. The appearance of the skin will vary, depending on the severity and the length of time the condition has been present. It may start with redness of the skin and can progress to thickening of the skin.

What causes pruritis ani?

There are many causes of pruritus ani but most fall into four categories:

Excessive Cleanliness: Excessive washing, rubbing, cleansing with soap, face cloths, and brushes which lead to chronic skin irritation.

Moisture: Prolonged exposure to moisture from vaginal discharge, perspiration, loose stools or mucus discharge from other rectal problems may lead to pruritus ani. Tight clothing, nylon underwear, and skin folds resulting from obesity may trap moisture in the area.

Diet: Certain foods can produce irritation to the skin when stool is passed. The most common ones are products containing caffeine (coffee, tea, colas, and chocolate), spicy foods, dairy products, beer, acidic foods like citrus fruits.

Skin Irritants: Dyed or scented toilet paper, soaps, and laundry detergent may cause the irritation. Stool left on the skin from leakage or incomplete hygiene may be another cause.

Other Causes: Other rare causes are pinworms and various skin conditions such as fungal infections or skin burns from radiation. There is no specific test to determine the cause of pruritus ani.

How is it treated?

Treatment of pruritus ani is directed at the care of the skin and determination of the underlying cause. After gently cleansing the skin and patting it, it is important to make sure the skin is dry. Some people use a hair dryer. Apply the ointment recommended by your doctor. Place a wisp of rolled cotton between the cheeks to absorb moisture.

What can I do to speed healing and help prevent pruritis ani?

DO NOT:

• Scratch or rub the anal area. Wipe gently.
• Use scented, coloured or patterned toilet paper.
• Use cleansing pads moistened with alcohol.
• Consume spicy foods, tomatoes, nuts, dairy products, or beer.
• Consume caffeine (cola drinks, coffee, tea, chocolate). DO:
• Use plain white toilet paper or moist wipes to cleanse after bowel movements.
• Wipe gently – never rub harshly.
• Use mild soap or don’t use soap at all.
• Gently dry skin thoroughly (you can use a hairdryer).
• Wear loose clothing and underclothing.
• Wear cotton rather than nylon underwear.
• Take prescribed medications.
• Watch your diet and eliminate foods that seem to make your condition worse. When your symptoms (itching) disappear, you may be able to resume these foods in moderation.
• Increase your fiber and water or juice intake if you tend to be constipated.
• Loose stool may require evaluation. Increase your fiber intake to absorb the extra moisture in the stool.

Pelvic organ prolapse:

What is Pelvic Organ Prolapse?

Pelvic organ prolapse (POP) occurs when the muscles and connective tissue in the pelvis weaken, resulting in prolapse or shifting of the pelvic organs from their normal position.  This weakening is most commonly a result of pregnancy, childbirth, advanced age, connective tissue disorder, obesity, pelvic surgery or repetitive straining and heavy lifting.  The organs in the pelvis that can be affected by POP include the rectum, uterus, cervix, vagina, urethra and bladder. 

What are the common symptoms of POP?

• Feeling heaviness, fullness, pulling, or aching in the pelvis, vagina or rectum. It gets worse by the end of the day or during a bowel movement.
• Seeing or feeling a “bulge” or “something coming out” of the vagina or rectum
• Having a hard time starting to urinate or emptying the bladder completely
• Leaking urine with coughing, laughing, or exercise
• Feeling an urgency to urinate
• Leaking stool or having a hard time controlling gas
• Straining to have a bowel movement or feeling constipated
• Feeling an urgency to have a bowel movement
• Returning to the bathroom several times to finish having a bowel movement or repetitive wiping.
• Using digital support or manipulation to assist in having a bowel movement

What tests are available to help identify POP?

A thorough physical exam can help to identify the presence of POP.  Additional tests may also help to better determine the extent of POP and which organs are specifically involved. 

• Defecography: One of the most useful tests to evaluate POP is defacography. This is a fluoroscopic x-ray study that allows for visualization of the pelvic organs during defecation.  Shifting and prolapse of different organs can be seen during this special x-ray. 
• Urodynamic Testing: Urologists and urogynecologists may also perform urodynamic testing.  This testing focuses on both the ability to hold urine and the ability to empty the bladder. 
• Additional tests: Your healthcare provider may order one or more of the following tests: anorectal manometry, endoanal sonar, uterine ultrasound and colonoscopy.

How is pelvic floor organ prolapse (POP) treated?

Both non-surgical and surgical options are offered for treatment of POP.  The severity of prolapse and which organs are most affected by POP will determine which treatment option is best. 

Non-surgical treatment options for POP include

• Pelvic Floor Exercises: A type of exercise to strengthen the pelvic floor by contracting and relaxing the muscles that surround the opening of the urethra, vagina, and rectum. The exercises are commonly referred to as Kegels.
• Biofeedback therapy: A type of therapy that helps to retrain the pelvic floor muscles how to effectively squeeze and push the muscles.
• Pessary: A removable device that is inserted into the vagina to support the pelvic organ(s) that have prolapsed.

Surgical treatment:

• Sacrocolpopexy: Mesh is used to restore support to the vagina.
• Ventral Rectopexy: Mesh or sutures are used to restore support to the rectum and improve symptoms of leakage or constipation caused by prolapse.
• Bladder sling: Mesh is used to support the bladder and improve control and evacuation of urine.

PERIANAL ABSCESS:

What is an abscess?

You have either a perianal abscess, an infection that began in a mucous-secreting gland in the anal canal around your anus, or a pilonidal abscess, an infection in a hair follicle trapped under the skin overlying the tailbone. In either case, you did nothing to cause the infection, and you could have done nothing to prevent its development.

How is an abscess treated?

Drainage is the recommended treatment. First, the doctor injects a local anaesthetic around the abscess to allow the drainage to be as painless as possible. An incision is made into the abscess to drain the pus. A portion of skin and fat is removed to allow drainage while your body heals the abscess. A gauze dressing is then applied. In addition to drainage, antibiotics are sometimes given to diabetics, patients with artificial heart valves or joints, or those who have decreased immunities.

What should I know after my abscess has been treated?

Symptoms and Care: You will have some pain after the local anaesthetic wears off. It takes a minimum of two to four weeks for the wound to heal. Don’t worry if some bleeding, discharge, pus, or itching occurs during this time; it is part of the normal healing process. You may apply gauze, cotton dressings, or minipads to the wound as needed. Anal hygiene is important. Take a bath or shower at least twice a day. (A handheld sprayer is helpful if you are taking a shower.) Most patients with perianal abscesses will not need further drainage, but some will develop a fistula a drainage tract from the anal canal to the skin, and surgery may be necessary. Pilonidal abscesses may recur, possibly requiring further surgery.

Diet: It is important to keep your bowel movements soft and regular. Eat foods high in fiber and drink plenty of water (6-8 glasses a day). If you are constipated, take a fiber supplement e.g. fybogel.

Activity: Avoid strenuous activity for the rest of the day. Tomorrow you may go back to your normal activities.

What should I be concerned about after my treatment?

If any of the following problems occur, please call our office and speak with a nurse who will help you with your problem:

• Excessive pain unrelieved by your pain medication
• Increasing pain several days after treatment
• Fever or chills
• Difficulty urinating
• Severe bleeding that won’t stop with direct pressure using Kleenex or gauze
• Constipation (no bowel movement for three days)
• Diarrhoea (more than three watery bowel movements within 24 hours)
• Nausea or vomiting

Anal Skin Tags

What are Anal Skin Tags?

The skin around the anus is relatively loose to allow opening for the passage of stool. It is prone to be stretched by enlargement of the underlying haemorrhoid blood vessels. The stretched skin may persist leading to a bump or skin tag.

Causes:

Anal skin tags are usually due to previous swollen haemorrhoids. This may occur after flare ups of haemorrhoids during pregnancy, external haemorrhoid thrombosis, straining from constipation or diarrhoea, heavy lifting, or strenuous exercise.

Symptoms

Small asymptomatic tags are very common. Larger tags are more frequently associated with swelling, itching, heaviness, hygiene problems, and a skin rash.

Treatment

A proper exam, including anoscopy or sigmoidoscopy is done to rule out underlying rectal conditions. Enlarged internal haemorrhoids should be banded to reduce swelling, bleeding, and recurrence of tags. Skin infections are treated with anti-fungal creams. After preparation with anti-bacterial soaps and mild laxatives enlarged tags can be safely removed in the office under a local injection with lidocaine.  One tag is removed per visit to limit pain and complications. The small wound is usually left open and the base is treated to minimize bleeding. Dissolvable sutures are occasionally used to ligate internal haemorrhoids inside the opening of the anus. Patients relax at home for one day post tag removal. Antibiotic and anti-fungal creams alongside topical analgesics and Nitro-glycerine or Diltiazem are used to promote healing and decrease pain. Tag removals are separated at least one month apart to allow complete healing. Infection can lead to delayed healing and may require further antibiotic treatment. Anal skin tags are covered with many intense and sensitive nerve endings. The area is covered with bacteria and fungus. Do not attempt removal at home with any type of ligation device as it will lead to intense pain and infection.

PILONIDAL ABSCESS:

What is a pilonidal cyst?

A pilonidal cyst is a cavity underneath the skin over the tailbone. Pilonidal literally means “nest of hair” because the cavity is often found to contain hair. Research indicates that it is an acquired disease resulting from impaction of debris and hair into the midline hair follicles which rupture, spreading infection beneath the skin.

This condition is not hereditary.

What are the symptoms?

Some people have no symptoms, therefore no treatment is necessary. Occasionally, pus accumulates in the cyst, causing pain and swelling in the tailbone area to form (abscess). When this occurs, a patient will experience a fever and sometimes acute pain and swelling in the tailbone area. Other people may develop low-grade infections with milder, recurring episodes of pain and swelling.

Who is affected?

This problem is more common in young adults and teenagers. This condition is rare in patients over 40 years of age. It is three times more common in men than women.

How is a pilonidal cyst treated?

Patients with an acute abscess can generally be treated in the doctor’s office. The doctor uses local anaesthesia to numb the area. An incision is made to allow for drainage of pus. This immediately relieves pressure and decreases pain. Daily cleansing of the area in the bathtub or shower is important to keep hair and other debris out of the wound. The patient should return for follow up until the wound is healed. Healing occurs rapidly, and wounds are usually completely closed in three weeks. For patients with repeated episodes, or continuing infection, surgery may be required. This is done as an outpatient procedure at a hospital. In most cases, the cyst is opened, cleaned, and allowed to heal from the inside out. Stitches are often used, but they will dissolve in one to two weeks.  After surgery it is important to keep gauze in the wound to keep the skin edges separated until the wound fills in from the bottom. The patient typically returns to the office for follow up visits until the wound is healed. In some instances, a more complex procedure is necessary. Wound hygiene is the single most important part of caring for pilonidal disease. Careful cleansing and dressing of the wound will prevent infection or premature closure of the skin, both of which can lead to recurrent problems.

Will a pilonidal cyst recur?

After surgery approximately 10 percent of patients will develop another cyst. To help prevent the development of another cyst, keep the area free from hair with a depilatory (hair removal) cream or by shaving the area. If hair is allowed to grow back, recurrence is much higher.

PILONIDAL DISEASE

Pilonidal disease is a chronic skin infection in the crease of the buttocks near the coccyx (tailbone). It is more common in men than women and most often occurs between puberty and age 40. Obesity and thick, stiff body hair make people more prone to pilonidal disease.

Causes:

Hairs often grow in the cleft between the buttocks. These hair follicles can become infected.  Further, hair can be drawn into these abscesses worsening the problem.  3:

Symptoms:

Symptoms can vary from very mild to severe.  The symptoms may include:

• Small dimple
• Large painful mass
• Clear, cloudy or bloody fluid drainage from affected area
• If infected, the area becomes red and tender and the drainage (pus) smells foul
• If infected, may have fever, nausea or feel ill

Disease patterns:

Nearly all patients have an acute abscess episode (the area is swollen, tender and pus may drain from it). After the abscess goes away, either by itself or with medical care, many patients develop a pilonidal sinus. The sinus is a cavity below the skin surface that connects to the surface through one or more small openings. Some sinus tracts may resolve on their own, however, most patients need minor surgery to remove them.

Diagnosis:

Diagnosis is typically confirmed by a physician examining the buttock area.

Treatment:

Treatment depends on the disease pattern. The primary treatment for an acute abscess is drainage. An incision is made that allows pus to drain, reducing inflammation and pain. This

procedure can usually be done in a physician’s office under local anaesthesia.

Surgical treatment:

Complex or recurring infections must be treated surgically, either through excision or unroofing the sinuses. Unroofing the sinuses, as shown in Figure 2, involves opening up the abscess and tracts and trimming the edges of skin. Larger, open operations often result in better outcomes, although healing takes longer. Closure with flaps has a greater risk of infection, but may be required in some patients. Your colon and rectal surgeon will discuss all the options and help you choose the most appropriate surgery.

What happens after surgery?

When the wound is closed, it must be kept clean and dry until the skin is fully healed. If the wound is left open, dressings or packing are used to help remove secretions and allow the area to heal from the bottom up. After healing, the skin in the buttocks crease must be kept clean and free of hair. It is necessary to shave or use a hair removal agent every 2 or 3 weeks until the age of 30. After that age, hair shafts thin out and soften and the depth of the buttock cleft lessens. Pilonidal disease can be a chronic, recurring condition so it is important to follow your physician’s post-surgical care instructions.

Rectal Bleeding

Causes of Rectal Bleeding:

Rectal Bleeding may be caused by haemorrhoids or something more serious. Find out what is causing your bleeding and get the right help. The most common cause of rectal bleeding is from internal haemorrhoids. The blood is typically bright red and associated with bowel movements. It may be noticed on the tissue paper, on the surface of the stool, or drip into the bowel. The bleeding is typically mild and intermittent but occasionally is massive and causes anaemia. Internal haemorrhoids are present in everyone. If they become dilated the blood vessels become friable and bleed. There may be associated rectal pain, swelling, itching, incomplete evacuation of stool, or leakage of stool. Black Tarry stools are usually due to digested blood from the stomach or oesophagus. There may be an ulcer, inflammation-gastritis, or varices-dilated blood vessels from cirrhosis of the liver. Black liquorice, lead, iron, or Pepto Bismol can also cause black stools. Red or maroon-coloured stools, which may be foul smelling, is referred to as haematochezia or lower GI bleeding. Causes include diverticulosis, angiodysplasia, inflammatory bowel disease, polyps, cancer, colitis or radiation damage.  Not all rectal complaints are due to haemorrhoids. Fissures, thrombosed external haemorrhoids, Colon or Rectal Cancer, Proctitis, STDs, Pruritus Ani from fungal or bacterial infections, Ulcerative Colitis, Diverticulosis, Arterio-venous malformations, Crohn’s disease, hemangiomas, and rectal varices are other causes.

Diagnosis of Rectal Bleeding:

Do not assume the rectal bleeding is from haemorrhoids. A physical exam, rectal exam, sigmoidoscopy, and in some cases colonoscopy is mandatory to identify the cause of the bleeding and help rule out other conditions such as colon or rectal cancer. Associated change in bowel habits, weight loss, and abdominal pain mandate additional testing. New onset rectal bleeding in someone over the age of 40 that is not typical of haemorrhoids or does not respond to banding requires further testing with colonoscopy. Selected patients under the age of 40 may also need colonoscopy as colon cancer does occasionally occur in younger individuals. Sexually transmitted diseases of the rectum such as HPV, syphilis, gonorrhoea, or herpes may also cause rectal bleeding.

Colonoscopy:

Colonoscopy is an important procedure for screening for colon polyps and cancer. Rectal bleeding, abdominal pain, change in bowel habits, and weight loss require consultation and frequently colonoscopy. Colonoscopy has helped reduce the incidence of colon cancer.  Your doctor will outline bowel preparation for the procedure. You will likely be put under sedation during the colonoscopy. A flexible tube is used to look at the lining of the colon.  Biopsies or removal of any polyps will be done.

Treatment of Rectal Bleeding from Haemorrhoids:

If the haemorrhoid bleeding does not stop with adding fiber to your diet and limiting your time on the commode to two minutes, it is time to have the blood vessels shrunk with rubber banding. Preparation H, steroid creams, cold compresses, and haemorrhoid suppositories may provide temporary relief. In addition to haemorrhoid banding custom compound medications containing Nitro-glycerine, Diltiazem, or Nifedipine plus analgesics may be prescribed reduce anal pressure and pain.  Over half of us will suffer from haemorrhoids at some point in our life. At our Haemorrhoid Centre, it is our goal to provide you with a non-painful treatment for your haemorrhoid (piles) and/or anal fissures. We understand the fear and embarrassment you may be feeling. Our staff will help you feel comfortable. If you are having trouble with rectal bleeding, our Haemorrhoid Centre.

RECTAL CANCER

The rectum is the last 6 inches of the large intestine (colon). Rectal cancer arises from the lining of the rectum. Colorectal cancer is highly curable if detected in the early stages.

Who is at risk of rectal cancer:

No one knows the exact causes of rectal cancer. Rectal cancer is more likely to occur as people get older, and more than 90% of people with this disease are diagnosed after age 50. Other risk factors include a family history of colorectal cancer (especially in close relatives), and a personal history of inflammatory bowel disease such as ulcerative colitis, colorectal polyps or cancers of other organs.

Is rectal cancer preventable?

Rectal cancer is preventable. Nearly all rectal cancer develops from rectal polyps, which are benign growths on the rectal wall. Detection and removal of these polyps by colonoscopy reduces the risk of getting rectal cancer. Screening typically starts at age 50 in patients with average risk, or at younger ages in patients at higher risk for rectal cancer. Though not definitely proven, there is some evidence that diet may play a significant role in preventing colorectal cancer. As far as we know, a diet high in fiber (whole grains, fruits, vegetables, nuts) and low in fat is the only dietary measure that might help prevent colorectal cancer.

Symptoms of rectal cancer:

Many rectal cancers cause no symptoms at all and are detected during routine screening examinations. The most common symptoms of rectal cancer are a change in bowel habits, such as constipation or diarrhea, narrow shaped stools, or blood in your stool. You may also have pelvic or lower abdominal pain, unexplained weight loss, or feel tired all the time.  Abdominal pain and weight loss are typically late symptoms, indicating possible extensive disease.

Diagnosis of rectal cancer:

• Physical exam and medical history
• Digital rectal exam (DRE)
• Proctoscopy: An examination of the rectum using a proctoscope, inserted into the rectum.
• Colonoscopy: A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer.

What determines the outcome of rectal cancer?

• The stage of the cancer (how far advanced the cancer is).
• Where the cancer is found in the rectum.
• Whether the bowel is blocked or has a hole in it.
• Whether all of the tumour can be removed by surgery.
• The patient’s general health and ability to tolerate different treatment regimens.
• Whether the cancer has just been diagnosed or has recurred (come back).

How is rectal cancer treated?

For complete cure, surgery to remove the rectal cancer is almost always required.

 Depending on the location and stage, this may be performed through the anus (opening of the rectum) or through the abdomen. Rectal cancer surgery removes the cancer and lymph nodes, along with a small portion of normal rectum on either side of the tumour. Creation of a colostomy (opening the intestine to a bag on the skin) is typically needed only in a very small number of patients. Additional treatment with chemotherapy or radiation therapy may be offered either before or after the surgery, depending on the stage of the cancer.

What factors determine the outcome?

The outcome of patients with rectal cancer is most clearly related to the stage at the time of diagnosis, with cancer that is confined to the lining of colon having the best chance of success. This is one reason why early detection through screening methods like colonoscopy is crucial.

Any need for follow up treatment?

After treatment for rectal cancer, a blood test to measure amounts of CEA (a substance in the blood that may be increased when cancer is present) may be done to see if the cancer has come back. Routine CT scans, clinical examinations, and colonoscopy are also performed at intervals determined by the stage.

Rectal prolapse:

Rectal prolapse occurs when the upper portion of the rectum telescopes itself inside out and comes out through the rectal opening. It is seen most often in elderly women, but it can occur in men and women of any age.

What causes rectal prolapse?

Rectal prolapse is associated with chronic straining to pass stool. It is known that the attachments of the rectum to the pelvic bones progressively weaken. When these attachments are weak, straining to pass stool causes the rectum to turn itself inside out. In many cases, the cause is unknown.

What symptoms occur with rectal prolapse?

The primary symptom is the feeling of tissue coming out of the rectum. Bleeding and mucus drainage frequently accompany rectal prolapse. When the problem first starts, the rectum may turn itself inside out but not come out the rectal opening. During this phase a common symptom is the frequent urge to have a bowel movement when there is no need to pass stool. As the prolapse progresses, the rectum comes out with bowel movements and returns inside by itself. Later the prolapse may occur with any activity and finally just standing up may cause it. It may become necessary to push the rectum back inside. Constipation commonly occurs with rectal prolapse. The chronic straining associated with constipation may be a predisposing factor, or constipation may occur because the prolapse partially blocks the rectal opening. Continued straining and the prolapse itself may damage the sphincter muscle that controls the passage of stool. If that occurs, accidental bowel leakage or results. It can be difficult at times to differentiate true accidental bowel leakage from mucus discharge directly from the prolapsed tissue.

How does rectal prolapse differ from haemorrhoids?

Haemorrhoids are a cluster of anal cushions (spongy tissue with a lot of blood vessels). If an inside haemorrhoid enlarges, it may come out the rectal opening with a bowel movement or during exercise. However, only the lining and the blood vessels come out, unlike rectal prolapse where all layers of the rectal wall come out.

How is rectal prolapse diagnosed?

Your doctor can usually diagnose rectal prolapse by taking a careful history and performing a complete anorectal examination. To demonstrate the prolapse, the patient may be asked to strain as if having a bowel movement.  If the prolapse is internal or the diagnosis uncertain, a video defecogram (x-ray pictures taken while the patient is passing contrast instilled in the rectum) can help the doctor determine whether surgery would be helpful and what procedure would be best. Anorectal manometry, a test that measures whether or not the muscles around the rectum are functioning normally, may also be used.

How is rectal prolapse treated?

Rectal prolapse can be corrected. Options are available for treatment, regardless of age and condition of the patient. Treatment depends on the age of the patient and the severity of the condition. In adults, a high fiber diet to prevent constipation and straining is recommended if the symptoms are mild. Surgical correction is required in adults if the prolapse does not resolve by itself. Rectal prolapse can successfully be repaired through either an abdominal or rectal procedure. Your doctor will discuss which procedure is most appropriate for you. Rectal prolapse in children frequently corrects itself. The doctor will instruct parents how to reduce the prolapse when it occurs and how to prevent constipation in their child.

What is a rectocele?

A rectocele is a bulge of the front wall of the rectum into the back wall of the vagina. The tissue between the rectum and the vagina is known as the rectovaginal septum and this structure can become thin and weak over time, resulting in a rectocele.  Other pelvic organs such as the bladder (cystocele) and the small intestine (enterocele), can bulge into the vagina, leading to similar symptoms as rectocele.

What causes a rectocele?

The exact cause of a rectocele is unknown, but symptomatic rectoceles usually occur in association with weakening of the pelvic floor. There are many causes of weakening of the pelvic floor, including advanced age, multiple vaginal deliveries and birthing trauma during vaginal delivery (e.g. forceps delivery, vacuum delivery, and episiotomy during vaginal delivery).  A history of chronic constipation and excessive straining with bowel movements are thought to play a role in developing a rectocele.  Multiple gynaecological or rectal surgeries can also lead to weakening of the pelvic floor and rectocele.

What are the symptoms associated with a rectocele?

The majority of patients with a rectocele have no symptoms.  When symptoms are present, they may be classified as either rectal or vaginal.  Rectal symptoms may include:  difficulty with evacuation during a bowel movement and the need to press against the back wall of the vagina and/or space between the rectum and the vagina in order to have a bowel movement.  Vaginal symptoms can include the sensation of a bulge or fullness in the vagina, tissue protruding out of the vagina, discomfort with sexual intercourse, and vaginal bleeding. Symptomatic rectoceles can lead to excessive straining with bowel movements, the urge to have multiple bowel movements throughout the day, and rectal discomfort.  Faecal incontinence or smearing may occur as small pieces of stool can be retained in a rectocele, only to later seep out of the anus.

How is a rectocele diagnosed?

Examination of the pelvic region typically includes both a vaginal and rectal examination.  Additionally, a digital rectal exam will be performed which usually demonstrates a weakness in the anterior wall of the rectum. A special x-ray, called defecography, can also visualize and confirm a rectocele. In general, if the rectocele is larger than 2 centimetres and/or has significant retention of contrast, it is considered abnormal.

What is the treatment for rectoceles?

A rectocele should only be treated if you are having significant symptoms that interfere with your quality of life.  There are both medical and surgical treatment options for rectoceles.  Surgical treatment is reserved for only the most severe cases of symptomatic rectocele.

Non-surgical treatment of rectoceles?

The vast majority of a patient’s symptoms associated with a rectocele can be managed effectively without surgery.  It is very important to have a good bowel regimen in order to avoid constipation and straining with bowel movements.  A high fiber diet can help with this goal.  Additionally, an individual should also increase her water intake, with 6-8 ten-ounce glasses daily.  The combination of fiber and water will allow for softer, bulkier stools that do not require significant straining with bowel movements.  Stool softeners are also recommended.  During bowel movements, it is important to avoid straining. In addition, it is always important to avoid prolonged sitting periods on the toilet.  Biofeedback refers to exercises one performs with a provider to strengthen and retrain the pelvic floor and can also lessen the symptoms of a rectocele.

Surgical treatment options:

The surgical management of rectoceles should only be performed if you continue to have symptoms. There are multiple ways to approach the surgery including: transanally (through the anus), through the perineum, and through the vagina.  All of these aim to remove the extra tissue that makes up the rectocele and reinforce the rectovaginal septum (the tissue between the rectum and the vagina).  This can be done by plication (stitching the tissue together).  Occasionally, mesh (a prosthetic material or patch) can be used to reinforce the repair. A rectocele can also be repaired through the abdomen, either laparoscopically or open.  The approach will depend on the size of the rectocele and the symptoms associated with the rectocele.

Outcomes of surgical repair:

The overall success of the surgery depends on the symptoms, length of time symptoms have been present, and approach of surgery.  As with any surgical procedure, there are associated risks including bleeding, infection, new onset dyspareunia (pain during intercourse), faecal incontinence, rectovaginal fistula (a communication between the rectum and vagina), as well as a risk that the rectocele may recur or worsen. Some studies report significant improvement in about 75-90% of patients.

Rectovaginal Fistula

What is a rectovaginal fistula?

A rectovaginal fistula is a medical condition where there is a fistula or abnormal connection between the rectum and the vagina. Although generally uncommon, rectovaginal fistulas may be extremely debilitating. If the fistula is wide it will allow both gas and stool to escape from the rectum into the vagina, leading to faecal incontinence. Patients can experience recurrent urinary and vaginal infections due to this leakage. The severity of symptoms will depend on the size of fistula.

What causes a rectovaginal fistula?

Rectovaginal fistulas are often the result of trauma during childbirth, such as tearing, episiotomy or forceps/vacuum extraction. Rectovaginal fistulas are also seen where there is inadequate health care, such as in some developing countries. The rectovaginal fistula can become evident within 1 week of delivery. Rectovaginal fistula can also be a symptom of various diseases, including Crohn’s disease or less commonly rectal cancer.  Or, they can be an unintended result of surgery, such as vaginal hysterectomy, haemorrhoidectomy, abscess drainage or sexual reassignment surgery. They are seen rarely after radiotherapy treatment for cervical cancer.

How is a rectovaginal fistula diagnosed?   

Patients should undergo a thorough history and physical exam. History taking will focus on obstetrical history, previous abdominal and anorectal surgeries, history of radiation treatment, and signs and symptoms of Crohn’s disease.  Physical exam includes a thorough inspection of both the anus and the vagina, including anoscopy of the distal rectum and anal canal. Endoanal ultrasound and/or MRI may be performed to help in identifying the fistula.

How is a rectovaginal fistula treated?

After diagnosing a new rectovaginal fistula, it is best to wait for 3-6 months to allow the inflammation to subside. Surgical treatment of a rectovaginal fistula can greatly improve a patient’s quality of life. However, these can be challenging to repair successfully, and many patients require multiple attempts at repair. Several different operations have been described to fix rectovaginal fistulas.  The most common surgical options are a sliding endorectal advancement flap or an overlapping sphincter repair. While most rectovaginal fistulas will require surgical repair, patients with Crohn’s disease may be treated with medications, which can sometimes help in closing the fistula.