What is an Anal Fissure?
An anal fissure (punit sa puwit) is a small tear or cut in the skin that lines the anus. Fissures typically cause sharp pain during and after defecation and often bleed. Fissures are in fact quite common, but are often confused with other causes of pain and bleeding, such as hemorrhoids. Anything that can cut or irritate the inner lining of the anus can cause a fissure. A hard, dry bowel movement is typically responsible for a fissure. Other causes of a fissure include diarrhea or inflammatory conditions of the anal area.
What are the Symptoms of an Anal Fissure?
The typical symptoms of an anal fissure are pain during or after defecation and bleeding. Patients may try to avoid defecation because of the pain.
Treatment
Often treating one’s constipation or diarrhea can cure a fissure. An acute fissure is typically managed with non-operative treatments and over 90% will heal without surgery. A high fiber diet, fiber supplements, stool softeners, and plenty of fluids help relieve constipation, promote soft bowel movements, and aide in the healing process. Increased dietary fiber may also help to improve diarrhea. Warm sitz baths for 10-20 minutes several times each day are soothing and promote relaxation of the anal muscles, which can also help healing. Occasionally, special medications may be recommended. A chronic fissure may require additional treatment, likely surgery.
ANAL ITCHING
What is Anal Itching?
Anal itching or pruritus ani (proo-RIE-tus AY-nie) is itching around the anus (the outlet of the rectum), which may be temporary or persistent and accompanied by a strong, uncontrollable urge to scratch.
Possible causes of anal itching include:
• Local causes. Both dry skin due to aging and too much moisture around the anus from excessive sweating or from moist, sticky stools.
• Medical conditions such as fecal incontinence, skin disorders, yeast and other infections, hemorrhoids, anal abrasions, fissures, and fistulas, and anal tumors can all cause anal itching.
• Medications. Some antibiotics, as well as overuse of laxatives, can lead to diarrhea that can irritate the anus and cause excessive itching.
• Irritants from chemicals such as laundry soaps, colognes, douches and birth control products can irritate skin around the anus, and certain foods can cause diarrhea or may directly or indirectly irritate your anus as they exit your colon.
• Eating certain foods, smoking and drinking alcoholic beverages, especially beer and wine, may cause pruritus ani in some individuals. Some food items associated with anal itching are:
• Coffee, Tea
• Carbonated beverages
• Milk products
• Tomatoes and tomato products such as Ketchup
• Cheese
• Chocolate
• Nuts
• Personal habits such as scratching and excessive washing irritate the anus and aggravate itching.
• Other causes. Anal itching may be related to anxiety or stress.
• Sometimes, the cause is undetermined.
Symptoms
Anal itching is associated with other similar symptoms in and around the anus, including burning, soreness or pain.
Lifestyle and home remedies
Prevention of anal itching mainly involves washing properly and avoiding irritants. If you already have anal itching, try these self-care measures:
• Cleanse gently. Wash the area with water in the morning, at night and immediately after bowel movements.
• Dry thoroughly. Pat, don’t rub, the area dry with toilet paper or a towel, and keep the area dry with a piece of cotton gauze or non-medicated talcum or cornstarch powder.
• Use over-the-counter (OTC) treatments correctly.
• Don’t scratch. If you can’t tolerate the itching, apply a cold compress to the area or take a lukewarm bath to find some immediate relief.
• Switch tissue. Use moistened or extra soft unbleached, unscented toilet paper or unscented flushable bathroom wipes.
• Wear cotton underwear and loose clothing. Avoid wearing clothes that trap moisture such pantyhose and other tight-fitting garments.
• Avoid irritants such as bubble baths and genital deodorants, beverages or foods that you know irritate your anal area.
Should the itching persist, become too bothersome, or be accompanied by other symptoms, it would be best to see your colorectal specialist and discuss your problem with him.
What are anal warts?
Anal warts (also called “condyloma acuminata”) are skin eruptions that affect the area around and inside the anus and even the genital area. Usually, they do not cause pain or discomfort to afflicted individuals and patients may be unaware that the warts are present. Anal warts are thought to be caused by the human papilloma virus (HPV), which is transmitted from person to person by direct contact. HPV is considered a sexually transmitted disease. However, you do not have to have anal intercourse to develop anal condyloma. Anal warts can grow larger and spread if not removed.
What are the symptoms of anal warts?
Some patients will experience symptoms such as itching, bleeding, discharge and/or a feeling of a lump or mass in the anal area.
Treatment options
Topical medication – for small and superficial warts; sometimes for warts inside the canal.
Freezing the warts with liquid nitrogen.
Surgical removal – for bigger and recurrent warts; provides immediate result and can be done on out-patient basis but usually under anesthesia
Constipation
What is constipation?
Constipation is the presence of 2 or more of the following symptoms for at least 3 months:
• Straining more than 25% of the time.
• Hard stools more than 25% of the time.
• Incomplete evacuation more than 25% of the time.
• 2 or less bowel movements per week.
Constipation can be causedlow fiber diet; medical conditions such as hypothyroidism, diabetes, immobility, and neurologic disease; and some medications such as opiates, anti-hypertensives, iron and calcium supplements.
How is constipation detected?
Several examinations are needed by your specialist to determine the cause of your constipation:
• Digital examination—usually the first step, since it is relatively simple and may provide clues to the underlying causes of the problem.
• Colonoscopy—involves inserting a scope to visualize the inside of the large intestine and determine to rule out masses that are causing obstruction.
• Barium enema—a radiographic study where dye is inserted through the anal area, creating an image of the large intestine on x-ray.
• Colonic transit study—involves ingestion of a radiopaque marker and undergoing an x-ray to see where the markers are. It may show areas of the large intestine that exhibit slowed movement.
How is constipation managed?
Treatment depends on the possible cause as determined from the examinations done. Surgery maybe recommended if there is an anatomical problem (mass obstructing the intestine, internal prolapsed of bowels, elongated segment of large intestine etc.) causing the constipation. Otherwise, non-surgical intervention may be the key to improving the patient’s symptoms. These include:
• Treating the underlying medical problem.
• Patient counseling.
• Increasing physical activity.
• Increasing fluid intake.
• Using bulk-forming agents, laxatives, enemas or suppositories.
Diarrhea
What is diarrhea?
Diarrhea is passing out of loose, unformed or watery stool that occurs more frequently than normal. This may be accompanied by abdominal pain of the colicky type, feeling of being bloated, incontinence, anal pain, fever or chills.
What causes diarrhea?
• Diarrhea most often is viral in nature, and usually resolves after a few days.
• Bacterial diarrhea, such as food poisoning, may be accompanied by rectal bleeding.
• Some antibiotics may cause diarrhea.
• Inflammatory bowel disease such as Crohn’s disease, ulcerative colitis, or diverticulitis.
• Lactose intolerance.
Below are things to watch out for during an episode of diarrhea:
• High fever.
• Severe abdominal pain.
• Blood in the stool or black, tarry stools.
• Dehydration or feeling weak, tired or dizzy.
• Concentrated urine or urinating less than usual.
• Feeling thirsty.
Treatment
• Rehydration is important.
• Intake of water, fruit juices, salt-containing liquids such as warm broth and sports
drinks like Gatorade are recommended.
• In viral diarrhea, fluids and rest are usually enough.
• Persistent diarrhea (i.e., more than 3 days) or diarrhea accompanied by other
symptoms should NOT be treated with over-the-counter medications such as Imodium
without the advice of your doctor.
If a person cannot drink enough to keep up with the fluid lost during bowel movements, he should be brought to the hospital for rehydration. If any of these warning signs occur, please consult your specialist right away.
Hemorrhoids
What are Hemorrhoids?
Hemorrhoids are actually present in all individuals whether healthy of not. They are the vascular cushions which surround the general area of the rectum and anus. The term we call hemorrhoids is associated with the symptoms when this part of the body becomes enlarged, inflamed, thrombosed or prolapsed. Internal hemorrhoids are located inside the anus while external hemorrhoids are located outside.
What are the types of internal hemorrhoids?
First degree hemorrhoids - hemorrhoids that bleed but do not come out during passage of bowel movement.
Second degree hemorrhoids - hemorrhoids that occasionally bleed and come out during bowel movement but go back in.
Third degree hemorrhoids - jemorrhoids that occasionally bleed and come out during bowel movement but can be pushed back in manually.
Fourth degree hemorrhoids - hemorrhoids that are pushed outside and cannot be pushed back in manually anymore.
Symptoms
There is usually bleeding of bright red blood dripping into the toilet bowl during bowel movement. Often, a mass or fleshy tissue comes out during straining.
Medical management
For first and second degree internal hemorrhoids:
• A high fiber diet that includes fruits and leafy vegetables.
• Adequate fluid intake.
• Avoidance of straining in the bathroom.
Rubber band ligation: for bleeding first and second degree internal hemorrhoids. This involves application of an elastic band at the base of the internal hemorrhoid.
Surgery: for persistent symptoms of bleeding, fleshy mass coming out, and problems with hygiene; unresponsiveness to medical management; or third or fourth degree or mixed (internal and external component) hemorrhoids.
• Hemorrhoidectomy - for third and fourth degree internal hemorrhoids. This is the traditional method of removing hemorrhoids. It makes use of a knife, scissors and other devices such as ligasure or harmonic scalpel.
• Stapled hemorrhoidopexy makes use of a surgical stapler to remove hemorrhoids and is associated with minimal post-operative pain.
• Transanal hemorrhoidal dearterialization - for second and third degree internal
hemorrhoids. This method makes use of Doppler ultrasound to detect arteries which are
then ligated. This method is also is associated with minimal post-operative pain.
Incontinence
What is fecal incontinence?
Fecal incontinence means absent or insufficient voluntary control over defecation. It involves a range of symptoms, from mild trouble holding gas to severe difficulty
holding formed stools. Many people are shy and embarrassed to talk about incontinence, but treatment options are available for this condition.
What causes fecal incontinence?
• Injury to the anal muscles or sphincters due to childbirth (more common cause), anal or rectal operation or trauma.
• Anal nerve damage due to pregnancy, childbirth or constant straining.
• Neurological disease, such as stroke.
• Age-related loss of anal muscle strength.
• Loose stools.
Leakage accompanied by blood in the stool may indicate inflammation (colitis), rectal tumor or rectal prolapse. These conditions require prompt evaluation.
How is the cause determined?
Detailed medical history which includes:
• Medical illnesses and medications
• Bowel habits and other bowel symptoms
• In women, history of past childbirths
Physical examination of the anal region
Additional studies, as necessary
• Anal manometry
• Defecography
• Pelvic nerve testing
• Endoanal ultrasonography
Treatment
Treatment is based on the underlying cause:
• Medications – for cases caused by a medical illness, such as bowel infection or inflammation.
• Surgery – for incontinence caused by injury to the sphincter muscles.
• Dietary changes and pelvic floor muscle exercises – if the muscles are intact but are functioning poorly.
For uncorrectable causes of incontinence, different measures may be recommended to make the problem more manageable:
• Enemas or rectal irrigation – help empty the bowel and reduce the chance of leakage.
• Medications – can help control diarrhea.
• Fiber supplements – usually improve constipation.
• Colostomy – may help improve quality of life in patients with severe, life-debilitating incontinence.
Painful skin irritation associated with incontinence may be addressed in various ways. Details may be discussed with your specialist.
Endorectal Ultrasound, also called transrectal ultrasound, is a special ultrasound technique in which the transducer is directly inserted through the anus and into the patient's rectum. The sound wave echoes detected by the transducer are converted by a computer into an image.
Transanal Hemorrhoidal Dearterialization (THD)
Using a doppler ultrasound, the blood vessel supplying the hemorrhoid is identified and ligated with stitches. Deprived of its blood supply, the hemorrhoid then shrinks and shrivels. There is no wound outside and is therefore almost painless.
Stapled Hemorrhoidopexy
Written by CRSI TeamStapled Hemorrhoidopexy
Using a specially-designed, single-use stapler instrument, the hemorrhoids are excised and the anus repaired from the inside. The end result is that the surgical wound is inside, and no wound is visible outside the anus. Scientific studies have proven that this is less painful than traditional surgery. It is best recommended for hemorrhoids with prolapse.
