Rectal Problems

Hemorrhoids

Hemorrhoids are veins in the anal canal that can become swollen or stretched. Just like varicose veins in the lower legs, hemorrhoids often cause no problems.

There are two types of hemorrhoids: external and internal.

External hemorrhoids: are swollen veins that can be seen and often felt under the skin outside the anal canal. Usually they look like a small bulge and are the same color as the skin.

Internal hemorrhoids are swollen veins that arise from inside the rectum. When internal hemorrhoids become large, they may prolapse (protrude out) through the anal canal. The most common sign of hemorrhoids is bright red blood on the toilet paper or drops of blood into the toilet bowel. A thrombosed hemorrhoid contains a blood clot and may cause painful burning, pressure, or even an intense urge to scratch the area.

Hemorrhoids are very common. About half the American population have hemorrhoids by the age of 50 years. Hemorrhoids develop due to increased pressure often caused by straining to have a bowel movement. Hemorrhoids frequently develop in women during pregnancy when the developing fetus causes increased pressure on the rectal area. Chronic constipation, diarrhea, hereditary factors, and aging may also lead to hemorrhoids.

As with all conditions involving the anal canal or rectum, the diagnosis is made by examining the anus visually and by performing a digital rectal examination (with a gloved finger.) Following this, a lighted instrument is inserted into the canal so that the interior of the rectum may be visualized. This lighted tube may be an anoscope (a short tube which can examine the last few inches of the rectum) or a sigmoidoscope (a longer flexible tube that can also examine the lower part of the large intestine).

Eliminate constipation: Bowel movements should be soft and should pass without need to strain. Constipation is usually caused by insufficient bulk in the bowel movement. Increasing water intake, dietary fiber (see table below) and exercise are often effective remedies.

Creams and suppositories: Preparation-H ® or Anusol®.

Sitz baths: Sit in a tub of warm water several times a day, then gently blot the anal area dry.

Gentle cleaning after a bowel movement: for instance, cotton balls soaked in witch hazel or a moist wash cloth or moist towelettes.

Things to avoid: irritating soaps and spicy foods/coffee.

Sources of Dietary Fiber

When hemorrhoids bleed excessively or are very painful they can be treated with surgery.

Banding: a rubber band is placed around the hemorrhoid and causes strangulation followed by scarring.

Sclerotherapy: injection of a chemical solution into the hemorrhoid causing them to shrink.

Infrared coagulation: a special device used to destroy the internal hemorrhoid.

Hemorrhoidectomy: surgical removal of hemorrhoid veins.

The first three are office procedures, while hemorrhoidectomy generally requires hospitalization.

Anal Fissure

This is a fairly common condition in which the lining of the anal canal becomes torn. This generally produces pain or a burning sensation, especially with passage of a bowel movement. Bleeding may also occur. A fissure usually occurs after the passage of a large, hard bowel movement.

When an anal fissure is present, a digital examination is usually painful. The fissure can usually be visualized by external inspection of the anus or an anoscope can be used to determine the extent of the tear.

The best treatment is prevention; ingestion of a high fiber diet to promote bowel regularity is of utmost importance.

• Sitz baths several times day
• Stool softeners
• Creams and/or suppositories (Preparation- H® or Anusol®).
• Some doctors will recommend nitroglycerine ointment or injection of botulinum toxin, Botox®

Anal Abscess or Fistula

An abscess is a cavity filled with pus. This usually results from a blockage of the anal glands located just inside the anus. A fistula is a connection or tunnel between the anal gland and the buttocks, usually very close to the anal opening. An anal fistula is almost always the result of an anal abscess. There are other problems such as Crohn’s disease which may be the underlying cause of the fistula.

An abscess produces considerable pain and swelling just adjacent to the anal opening. Fever may also be present. A fistula produces drainage from the anal canal to the opening of the fistula on the buttocks.

Medical Treatment: When a fistula is caused by Crohn’s disease, your doctor may recommend treatment with medicines such as, metronidazole, Flagyl®, azathioprine, Imuran®, or infliximab, Remicade®

Surgical Treatment: Generally the sphincter muscle is cut to open the tunnel, thereby connecting the internal and external openings of the fistula. A groove is formed which then slowly heals and forms scar tissue. During the healing process, stool softeners and Sitz baths are frequently recommended.

Fecal Incontinence

Fecal incontinence is the accidental loss of stool. Causes of fecal incontinence in adults include back trauma, sphincter disruption as a result of accidents, anorectal surgery, or obstetrical trauma, and medical illness such as multiple sclerosis and diabetes mellitus. Many women have suffered nerve or muscle injury to the anal sphincter caused by forceps-assisted delivery, prolonged second stage of labor, or delivery of large baby, and this can contribute to fecal incontinence.

The doctor should look at the anorectal area to see if there are any changes, scarring, fissures, or prolapse (protrusion) of the rectum. A digital examination with the doctor inserting a finger into the rectum should be performed to determine if there is an impaction of stool, to assess muscle tone at rest and with squeeze effort, and to exclude a rectal mass.

Anal manometry is a specialized test that can measure the pressures generated by the anal sphincter muscles at rest and with maximal squeeze effort. X-rays may identify physical abnormalities of muscle function. This examination involves the placement of barium paste simulating stool into the rectum and asking the patient to defecate, strain, or squeeze while taking x-ray pictures. Ultrasound can be used to evaluate the muscles and other structures of the anal area.

Treatments for incontinence include dietary modification, medicines, biofeedback, and surgery. Avoid foods that promote production of gas, and foods containing ingredients such as lactose, fructose, and sorbitol. Fiber supplements can increase bulk and add form to the bowel movement and result in improved control. Kegel exercises to strengthen the pelvic floor muscles may improve anorectal control. Loperamide HCl, Imodium®, or diphenoxylate HCl, Lomotil® may decrease stool volume and frequency, improve stool consistency, or perhaps directly affect the sphincter muscles.

Biofeedback is a conditioning technique. Patients are taught how to work and strengthen the sphincter muscles. For successful results, the patient must be motivated, have some degree of rectal sensation and intact nerve and muscle function of the anal sphincter.

Surgery is often considered as primary therapy if rectal prolapse is the cause of incontinence. Obstetrical injuries, trauma and disruption of the sphincter are usually managed by primary repair of the defect. Pre-operative testing of nerve and muscle function may help to identify those who may benefit from surgery.

Rectal Pain

Rectal pain may result from structural conditions such as hemorrhoids, fissures, fistula, or abscess

The levator syndrome presents with an aching rectal pain related to spasm of the muscles of the pelvic floor. It is important for the doctor to evaluate the area to exclude inflammation or even an infectious problem such as Herpes virus. The levator syndrome is more commonly seen in women. The tenderness is often localized to the left side. Treatment consists of reassurance, application of heat, and massage. Electro-galvanic stimulation may break the spasm pain cycle by delivering a high voltage-pulsed current using a rectal probe.

Another unusual cause of rectal pain is coccygodynia (pain in the coccyx or tail bone). This may be the result of traumatic arthritis or may even result from child birth trauma. This pain may be triggered by bowel movements. Other rare causes of rectal pain include tumors of the spine, pelvis and rectum and endometriosis.

Pruritus Ani

This refers to itching around the anal area. It is often most troublesome at night or following a bowel movement.

Excessive cleaning or wiping of the anal area is frequently the culprit. Excessive sweating in the area around the anus is another cause. Certain beverages, including alcohol, citrus, and caffeine-containing drinks may aggravate the problem. Rarely, infectious and skin conditions can cause pruritus ani. Poor hygiene is usually NOT the cause. Unfortunately, when the problem develops, individuals often compound the problem by excessively washing and cleaning the anal area, only to aggravate the symptoms.

Avoid irritating soaps, especially those containing perfumes. Gently blot the area clean with a moist wash cloth, never excessively rub or scratch, and keep dry with powder. Eliminate irritating foods and beverages such as coffee, alcohol and spicy foods.

Rectal Prolapse

Rectal prolapse refers to the condition where the tissue of the rectum protrudes out of the anal canal. This protrusion may be temporary, but may become permanent over time when the end of the rectum cannot be pushed back into the canal. This condition often results in constant leaking of stool and/or mucus. While the symptoms may be similar to those produced by hemorrhoids, in this condition there is protrusion of the rectum itself and not just a swollen hemorrhoid.

This is often caused by a long-standing habit of straining to have a bowel movement. In some cases there is a genetic predisposition. Others have a weakness of the pelvic muscles and loss of control of the anal sphincter, the muscle which controls the release of stool. In some cases, a neurologic condition can lead to prolapse.

Unfortunately, once prolapse develops, surgical correction is often necessary. The type of operation performed depends on the severity of the prolapse, the age of the individual, and the presence of other health problems. As with most disorders of the anorectal region, prevention is best, and a high fiber diet and good bowel habits are most important.