Anorectal Surgery

Hemorrhoids

Hemorrhoids are painful, swollen veins in the lower portion of the rectum or anus.

Causes, incidence, and risk factors

Hemorrhoids are very common, especially during pregnancy and after childbirth. They result from increased pressure in the veins of the anus. The pressure causes the veins to swell, making them painful, particularly when you are sitting.

Hemorrhoids are common ailments. By age 50, about half of adults have had to deal with the itching, discomfort and bleeding that can signal the presence of hemorrhoids.

The most common cause is straining during bowel movements.

Hemorrhoids may be caused by:

  • Straining during bowel movements
  • Constipation
  • Sitting for long periods of time
  • Anal infections
  • Certain diseases, such as liver cirrhosis

Hemorrhoids may be inside or outside the body.

  • Internal hemorrhoids occur just inside the anus, at the beginning of the rectum
  • External hemorrhoids occur at the anal opening and may hang outside the anus.

Symptoms

Symptoms of hemorrhoids include:

  • Anal itching or burning
  • Anal ache or pain, especially while sitting
  • Bright red blood on toilet tissue, stool, or in the toilet bowl
  • Pain during bowel movements
  • One or more hard tender lumps near the anus

Hemorrhoid symptoms usually depend on the location. Internal hemorrhoids lie inside the rectum. You usually can’t see or feel these hemorrhoids, and they usually don’t cause discomfort. But straining or irritation when passing stool can damage a hemorrhoid’s delicate surface and cause it to bleed. Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus), resulting in severe pain, swelling and inflammation.

Complications from Hemorrhoids

A thrombosed hemorrhoid is a hemorrhoid that has become so large that blood as pooled in it causing a blood clot. It will turn blue-purple in color and is extremely painful. Thrombosed hemorrhoids are associated generally with external hemorrhoids. Most treatments involve surgically cutting the thrombosed hemorrhoid so that the clot can be drained and the pain will recede.

Anemia. Chronic blood loss from hemorrhoids may cause anemia, in which you don’t have enough healthy red blood cells to carry oxygen to your cells, resulting in fatigue and weakness.

Strangulated hemorrhoid. If blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be “strangulated,” which can cause extreme pain and lead to tissue death (gangrene).

Treatment

Treatments for hemorrhoids include:

  • Over-the-counter corticosteroid creams to help reduce pain and swelling
  • Avoidance of toilet paper and the use of moist wipes
  • Warm baths for 10 to 15 minutes
  • Hemorrhoid creams with lidocaine to help reduce pain
  • Stool softeners help reduce straining and constipation

If your hemorrhoids do not get better with home treatments, you may require further medical or surgical treatment.

Surgery that may be done to treat hemorrhoids includes rubber band ligation or surgical hemorrhoidectomy. Rubber band ligation is generally reserved for internal hemorrhoids. External hemorrhoids can be treated with surgical hemorrhoidectomy. These procedures are generally used for patients with severe pain or bleeding who have not responded to other therapy.

Prevention

Constipation and straining during bowel movements raise your risk for hemorrhoids. To prevent constipation and hemorrhoids, you should:

  • Drink plenty of fluids, at least eight glasses per day.
  • Eat a high-fiber diet of fruits, vegetables, and whole grains.
  • Consider fiber supplements.
  • Use stool softeners to prevent straining
  • Use moist wipes to avoid skin irritation and trauma

Anal Abscess/Fistula

A patient who feels ill and complains of chills, fever and pain in the rectum or anus could be suffering from an anal abscess or fistula.

What is an anal abscess?

An anal abscess is an infected cavity filled with pus found near the anus or rectum.

What causes an abscess?

An abscess results from an acute infection of a small gland just inside the anus, when bacteria or foreign matter enters the tissue through the gland.

What is an anal fistula?

Just inside the anus are a number of small glands. If one of these glands become blocked, an abscess—an infected cavity—may form. An anal abscess is usually treated by surgical drainage, although some drain spontaneously. About 50% of these abscesses may develop into a fistula, in which a small tunnel connects the infected gland inside the anus to an opening on the skin around the anus.

What causes a fistula?

After an abscess has been drained, a tunnel may persist connecting the anal gland from which the abscess arose to the skin. If this occurs, persistent drainage from the outside opening may indicate the persistence of this tunnel. If the outside opening of the tunnel heals, recurrent abscess may develop.

What are the symptoms of an abscess or fistula?

An abscess is usually associated with symptoms of pain and swelling around the anus. Individuals may also experience fatigue, fevers and chills. Symptoms related to the fistula include irritation of skin around the anus, drainage of pus (which often relieves the pain), fever, and feeling poorly in general.

Does an abscess always become a fistula?

No. A fistula develops in about 50 percent of all abscess cases, and there is really no way to predict if this will occur.

How is an abscess treated?

An abscess is treated by making an opening in the skin near the anus to drain the pus from the infected cavity and thereby relieve the pressure. Often, this can be done in the doctor’s office using a local anesthetic. A large or deep abscess may require hospitalization and the assistance of an anesthesiologist. Hospitalization may also be necessary for patients prone to more serious infections, such as diabetics or people with decreased immunity. Antibiotics are a poor alternative to draining the pus, because antibiotics do not penetrate the fluid within an abscess.

What about treatment for a fistula?

Surgery is necessary to cure an anal fistula. Although fistula surgery is usually relatively straightforward, the potential for complication exists. It may be performed at the same time as the abscess surgery, although fistulas often develop four to six weeks after an abscess is drained, sometimes even months or years later.

Fistula surgery usually involves opening up the fistula tunnel. Often this will require joining the external and internal openings of the tunnel by an incision (cut) and converting it to a groove will then allow it to heal from the inside out. Most of the time, fistula surgery can be performed on an outpatient basis. Treatment of a deep or extensive fistula may require a short hospital stay.

How long does it take before patients feel better?

Discomfort after fistula surgery can be mild to moderate for the first week and can be controlled with pain pills. The amount of time lost from work or school is usually minimal.
Treatment of an abscess or fistula is followed by a period of time at home, when soaking
the affected area in warm water (sitz bath) is recommended three or four times a day. Stool softeners or a bulk fiber laxative may also be recommended. It may be necessary to wear a gauze pad or mini-pad to prevent the drainage from soiling clothes. Bowel movements will not affect healing.

What are the chances of a recurrence of an abscess or fistula?

If properly healed, the problem will usually not return.

Anal Fissure

What is an anal fissure?

An anal fissure is a small tear or cut in the skin that lines the anus. Fissures typically cause severe pain, especially with a bowel movement, and often bleed. Fissures are quite common, but are often confused with other causes of pain and bleeding, such as hemorrhoids.

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.

What causes an anal fissure?

Trauma: 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. Anal fissures may be acute (recent onset) or chronic (present for a long time or recurring frequently). Chronic fissures often have a small external lump associated with the tear called a sentinel pile or skin tag.

How can a fissure be treated?

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 topical medication, high fiber diet, bulking agents (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 baths for 10-20 minutes several times each day are soothing and promote relaxation of the anal muscles, which can also help healing. A medication applied to the anus may help relax the sphincter muscle and allow the fissure to heal. A chronic fissure may require additional treatment.

Will the problem return?

Fissures can recur easily, and it is quite common for a healed fissure to recur after a hard bowel movement. Even after the pain and bleeding has disappeared one should continue to aim for good bowel habits and adhere to a high fiber diet or fiber supplement regimen. If the problem returns without an obvious cause, further assessment may be needed.

What can be done if a fissure doesn’t heal?

A fissure that fails to respond to treatment should be re-examined. Persistent hard or loose bowel movements, scarring, or spasm of the internal anal sphincter muscle all contribute to delayed healing. Other medical problems such as inflammatory bowel disease, infections, or anal growths (skin tumors) can cause fissure-like symptoms, and patients suffering from ¬persistent anal pain should be examined to exclude these conditions.

What does surgery involve?

Surgery is a highly effective treatment for a fissure and recurrence rates after surgery are low. Surgery usually consists of a small operation to cut a portion of the internal anal sphincter muscle (a lateral internal sphincterotomy). This helps the fissure heal and decreases pain and spasm.

A sphincterotomy rarely interferes with one’s ability to control bowel movements and is most commonly performed as a short outpatient procedure. Surgical treatments do have other risks, however.

How long does the healing process take after surgery?

Complete healing occurs in a few weeks, although pain often disappears after a few days.

Can fissures lead to colon cancer?

No! Persistent symptoms, however, need careful evaluation since conditions other than fissure can cause similar symptoms.