|
Anorectal problems
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. These medical terms describe common ailments about which many people know little.
 What is an Anal Abscess?
An anal abscess is an infected cavity filled with pus found near the anus or rectum.
What is an Anal Fistula?
An anal fistula, almost always the result of a previous abscess, is a small tunnel connecting the anal gland from which the abscess arose to the skin of the buttocks outside the anus.
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. Certain conditions - colitis or other inflammation of the intestine, for example - can sometimes make these infections more likely.
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 of Fistula?
Symptoms of both ailments include constant pain, sometimes accompanied by swelling, that is not necessarily related to bowel movements. Other symptoms 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 draining the pus from the infected cavity, making an opening in the skin near the anus to 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 use of a different anesthetic method. Hospitalization may also be necessary for patients prone to more serious infections, such as diabetics or people with decreased immunity. Antibiotics are not usually an alternative to draining the pus, because antibiotics are carried by the blood stream and 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, and is preferably performed by a specialist in colon and rectal surgery. It may be performed at the same time as the abscess surgery, although fistulae often develop four to six weeks after an abscess is drained sometimes even months or years later. Fistula surgery usually involves cutting a small portion of the anal sphincter muscle to open the tunnel, joining the external and internal opening and converting the tunnel into a groove that will then heal from within outward. Most of the time, fistula surgery can be performed on an outpatient basis - or with 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 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. However, it is important to follow the directions of a colon and rectal surgeon to prevent.
Back to Top
 Anal Fissure
What is an Anal Fissure?
An anal fissure is a small tear in the lining of the anus which can cause pain, bleeding and/or itching.
What causes an Anal Fissure?
A hard, dry bowel movement can cause a tear in the anal lining, resulting in a fissure. Other causes of a fissure include diarrhea and inflammation of the anorectal area.
How can a Fissure be treated?
At least 50 percent of fissures heal either by themselves or with non-operative treatment, including application of special medicated cream, use of stool softeners, avoidance of constipation, and the use of sitz baths (soaking the anal area in plain warm water for 20 minutes, several times a day).
Is there a role for Botox in the treatment of anal fissures?
Yes, Botox has become a second line treatment for chronic anal fissures that do not respond to medicated creams. There has been exciting results with Botox injections and patients with severe fissures have healed completely with one or multiple injections. In the event that Botox injections are unsuccessful than a minor surgery may be necessary
What can be done if a Fissure doesn't heal?
A fissure that fails to respond to treatment should be re-examined to determine if a definitive reason exists for lack of healing. Such reasons can include scarring or muscle spasm of the internal anal sphincter muscle. Those which continue to cause pain and/or bleeding can be corrected by surgery.
What does surgery involve?
 Surgery may consist of a small operation to remove the fissure and the underlying scar tissue. Cutting a portion of one of the anal muscles helps the fissure to heal by preventing pain and spasm, which interferes with healing. Cutting this muscle rarely interferes with the ability to control bowel movements and can usually be performed without an overnight hospital stay.
How long does the healing process take after surgery?
Complete healing occurs in a few weeks, although pain often disappears after a few days.
Will the problem return?
More than 90% of patients who require surgery for this problem have no further trouble from fissures.
Can fissures lead to Colon Cancer?
No! Persistent symptoms need careful evaluation, however, since conditions other than fissure can cause similar symptoms.
Back to Top
Anal Warts
What are anal warts?
Anal warts (also called "condyloma acuminata") are a relatively common and bothersome condition that affects the area around the anus. They may also affect the skin of the genital area. They first appear as tiny blemishes, perhaps as small as the head of a pin, and may grow larger than the size of a pea. Usually, they do not cause pain or discomfort to afflicted individuals. As a result, patients may be unaware that the warts are present.
Where do these warts come from?
They are thought to be caused by the human papilloma virus which is relatively contagious. The virus can be transmitted from person to person, almost always by direct contact.
Do these warts always need to be removed?
Yes. If they are not removed, the warts generally grow larger and become more and more numerous. In addition, there is evidence that these warts can become cancerous if left untreated for a long time.
What treatments are available?
If warts are very small and are located only on the skin around the anus, they can be treated with medications, which are applied directly to the surface of the warts. This method, while relatively simple in concept, must be carried out with great care and precision by a physician to prevent injury to the normal skin surrounding the warts. This method usually requires several applications performed at various intervals over several weeks.
Another form of treatment involves more rapid destruction of the warts using electrical cautery, surgical removal or a combination of the two. Laser surgery may also be used but has no advantage over other treatments. These procedures provide immediate results but must be performed using either a local anesthetic - such as novocaine - or a general or spinal anesthetic, depending on the number and exact location of warts being treated.
Warts inside the anal canal usually are not suitable for treatment by medications, and in most cases need to be treated by cauterization or surgical removal.
Must I be hospitalized for treatment?
No. Almost always, the cautery and excision technique can be performed on an outpatient basis, and the patient can go home after the procedure.
How much time will I lose from work after a cautery treatment?
This depends on each individual situation and the extensiveness of warts removed. Most people are moderately uncomfortable for a few days after treatment, and pain medication may be prescribed. Depending on the extent of the disease, some people return to work the next day, while others may remain out of work for several days.
Will a single treatment cure the problem?
Not in most cases, unfortunately. Even with the cautery and surgical treatments that immediately destroy existing warts, many patients develop new warts after treatment. This occurs because viruses that cause the warts can live concealed in tissues that appear normal for up to six months or longer before another wart develops. New warts will often develop from the virus that was already present in the tissue, but these are not recurrences of warts already treated.
As new warts develop, they usually can be treated in the physician's office, using either a chemical solution or the electrical cautery procedure. These treatments are performed every few weeks initially, then less frequently as new warts become smaller and less numerous.
Sometimes new warts develop so rapidly that office treatment would be quite uncomfortable. In these situations, a second and occasionally third outpatient surgical visit may be recommended.
How long is treatment usually continued?
Follow-up visits are necessary for some months after the last wart is observed to be certain that no more warts occur from viruses living in the cells of skin.
What can be done to avoid getting these warts again?
In some cases, warts may recur repeatedly after successful removal, since the virus that causes the warts often persists in a dormant state in body tissues. Following are tips to avoid recurrence and reinfection:
Continue observation for several months after the last wart has been spotted to improve the chances that both the warts and the underlying virus that causes them have been eliminated.
Abstain from sexual contact with individuals who have anal (or genital) warts. Since many individuals may be unaware that they suffer from this condition, sexual abstinence or limiting sexual contact to marriage relationships will reduce your potential exposure to the contagious virus that causes these warts. As a precaution, sexual partners ought to be checked, even if they have no symptoms.
Back to Top
Pilonidal Disease
What is pilonidal disease and what causes it?
Pilonidal disease is a chronic infection of the skin in the region of the buttock crease (Figure 1). The condition results from a reaction to hairs embedded in the skin, commonly occurring in the cleft between the buttocks. The disease is more common in men than women and frequently occurs between puberty and age 40. It is also common in obese people and those with thick, stiff body hair.
Figure 1: Pilonidal disease is a chronic skin infection in the buttock crease area. Two small openings are shown (A).
What are the symptoms?
Symptoms vary from a small dimple to a large painful mass. Often the area will drain fluid that may be clear, cloudy or bloody. With infection, the area becomes red, tender, and the drainage (pus) will have a foul odor. The infection may also cause fever, malaise, or nausea.
There are several common patterns of this disease. Nearly all patients have an episode of an acute abscess (the area is swollen, tender, and may drain pus). After the abscess resolves, either by itself or with medical assistance, many patients develop a pilonidal sinus. The sinus is a cavity below the skin surface that connects to the surface with one or more small openings or tracts. Although a few of these sinus tracts may resolve without therapy, most patients need a small operation to eliminate them.
A small number of patients develop recurrent infections and inflammation of these sinus tracts. The chronic disease causes episodes of swelling, pain, and drainage. Surgery is almost always required to resolve this condition.
How is pilonidal disease treated?
The treatment depends on the disease pattern. An acute abscess is managed with an incision and drained to release the pus, and reduce the inflammation and pain. This procedure usually can be performed in the office with local anesthesia. A chronic sinus usually will need to be excised or surgically opened.
Complex or recurrent disease must be treated surgically. Procedures vary from unroofing the sinuses to excision (Figure 2) and possible closure with flaps. Larger operations require longer healing times. If the wound is left open, it will require dressing or packing to keep it clean. Although it may take several weeks to heal, the success rate with open wounds is higher. Closure with flaps is a bigger operation that has a higher chance of infection; however, it may be required in some patients. Your surgeon will discuss these options with you and help you select the appropriate operation.
Figure 2: Drawing B is a side view showing how most of the inflammation is deep under the skin just outside the coccyx (tailbone). The dashed line shows how it may be opened or unroofed. Dashed line in drawing C shows excision of all inflamed tissue.
What care is required after surgery?
If the wound can be closed, it will need to be kept clean and dry until the skin is completely healed. If the wound must be left open, dressings or packing will be needed to help remove secretions and to allow the wound to heal from the bottom up.
After healing, the skin in the buttocks crease must be kept clean and free of hair. This is accomplished by shaving or using a hair removal agent every two or three weeks until age 30. After age 30, the hair shaft thins, becomes softer and the buttock cleft becomes less deep.
Back to Top
Pruritus Ani
What is Pruritus Ani?
Itching around the anal area, called pruritus ani, is a common condition. An irresistible urge to scratch results. It may be most noticeable and bothersome at night or after bowel movements.
What causes this to happen?
Several factors may be at fault. A common cause is excessive cleaning of the anal area. Moisture around the anus, from excessive sweating or from moist, sticky stools, is another possible cause. In some people, a loose and/or irritating stool may be caused by a high intake of liquids.
In addition, drinking certain beverages, including some alcoholic beverages - especially beer - milk, citrus fruit juices and drinks containing caffeine, such as coffee, tea and cola, may be aggravating for some people. Similarly, some foods that may be a problem include chocolate, fruits, tomatoes, nuts and popcorn. Other rare causes of pruritus ani may include pinworms, psoriasis, eczema, dermatitis, hemorrhoids, anal fissures, anal infections and allergies.
Does Pruritus Ani result from lack of cleanliness?
Cleanliness is almost never a factor. However, the natural tendency once a person develops this itching is to wash the area vigorously and frequently with soap and a washcloth. This almost always makes the problem worse by damaging the skin and washing away protective natural oils.
What can be done to make this itching go away?
A careful examination by a colon and rectal surgeon or other physician may identify a definite cause for the itching. Your physician can recommend treatment to eliminate the specific problem. Treatment of pruritus ani may include these four points.
Avoid further trauma to the affected area:
Do not use soap of any kind on the anal area.
Do not scrub the anal area with anything - even toilet paper.
For hygiene, use wet toilet paper, baby wipes or a wet washcloth to blot the area clean. Never rub.
Try not to scratch the itchy area. Scratching produces more damage, which in turn makes the itching worse.
Avoid moisture in the anal area:
Apply either a few wisps of cotton, a 4 x 4 gauze or some cornstarch powder to keep the area dry.
Avoid all medicated, perfumed and deodorant powders.
Use only medications prescribed by your physician and use them only as directed. Apply prescription medications sparingly to the skin around the anal area and avoid rubbing.
Avoid excess fluids and the foods previously mentioned. In most instances, a maximum of six glasses of fluid daily is reasonable. There is not usually any health benefit to drinking more fluid than this in the course of a day.
How long does this treatment usually take?
Most people experience some relief from itching within a week. Complete cure usually comes within four to six weeks. A follow up appointment with your colon and rectal surgeon may be recommended to prevent recurrence of pruritus ani.
Back to Top
Rectal Prolapse
What is Rectal Prolapse?
Rectal prolapse is a condition in which the rectum (the lower end of the colon, located just above the anus) turns itself inside out. In the earliest phases of this condition, the rectum does not stick out of the body, but as the condition worsens, it may protrude. Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage and may result in leakage of stool or mucus. The condition occurs in both sexes, although it is more common in women than men.
Why does it occur?
Several factors may contribute to the development of rectal prolapse. It may come from a lifelong habit of straining to have bowel movements or as a delayed result of stresses involved in childbirth. In rare cases, there may be a genetic predisposition in some families. It seems to be a part of the aging process in many patients who experience weakening of the ligaments that support the rectum inside the pelvis as well as loss of tightness of the anal sphincter muscle. In some cases, neurological problems, such as spinal cord transection or spinal cord disease, can lead to prolapse. In most cases, however, no single cause can be identified.
Is Rectal Prolapse the same as hemorrhoids?
Some of the symptoms may be the same. There may be bleeding and/or tissue that protrudes from the rectum. Rectal prolapse, however, involves a segment of the bowel located higher up within the body, while hemorrhoids develop near the anal opening.
How is Rectal Prolapse diagnosed?
our physician can diagnose this condition by taking a careful history and performing a complete anorectal examination. To demonstrate the prolapse, patients may be asked to "strain" as if having a bowel movement or to sit on the commode and "strain" prior to examination.
At times, however, a rectal prolapse may be "hidden" or internal. In this situation, an x-ray examination called a videodefecogram may be helpful. This examination, which takes x-ray pictures while the patient is having a bowel movement, can also assist the physician in determining whether surgery may be beneficial and which operation may be appropriate.
Anorectal manometry may also be used. This test measures whether or not the muscles around the rectum are functioning normally.
How is Rectal Prolapse treated?
Although constipation and straining may be causes of rectal prolapse, simply correcting these problems may not improve the prolapse once it has developed. There are many different ways to surgically correct rectal prolapse.
Abdominal or rectal surgery may be suggested. Your doctor can help you decide which method will most likely achieve the best result by taking into account many factors, such as age, physical condition, extent of prolapse and the results of various tests.
Treatment of Rectal Prolapse depends on several factors:
Patient's age
Physical condition
Extent of prolapse
Test results
How successful is treatment?
Success depends on a number of factors, including the status of a patient's anal sphincter muscle before surgery, whether the prolapse is internal or external, the overall condition of the patient and surgical method used. If the anal muscle has been weakened, either because of the rectal prolapse or for some other reason, it may in many cases significantly regain strength after the rectal prolapse has been corrected.
Chronic constipation and straining after surgical correction must be avoided. A great majority of patients are completely relieved of symptoms, or are significantly helped, by the appropriate procedure.
Back to Top
|
