We’ve all experienced conditions that make us “feel bad all over.” When you have a headache, you just want to lie down in a quiet place and be left alone. When your feet hurt, you hurt everywhere! These problems make you feel irritable, put your nerves are on edge, and make you impatient with others.
Such is the case with situations that affect the more sensitive areas of our bodies—like the anorectal area. Pain in that area really gets to you. It hurts to walk, cough, laugh, and even talk. Having a bowel movement is another dimension, altogether. Grab something immovable because you’re about to see your knuckles turn white.
There are eight common benign conditions of the anorectal area. Benign is the important adjective because only in rare, unusual cases do they cause patient death. They are:
Hemorrhoids—Internal, External, Thrombosed (clotted blood)
Fissures—Acute, Chronic
Abscesses—Rectal, Peri-rectal
Pruritis ani (itching of the anus)
Prolapse
Warts—Condylomata
Incontinence
Functional Pain
Perhaps many of us have had one or more of these conditions and have experienced the general sense of discomfort associated there with. The symptoms patients experience most often are:
Pain
Bleeding
Itching
Swelling/Mass
Incontinence—loss of control
As one who had hemorrhoids for 40 years and has undergone rubber band ligation twice and a recent surgical excision for hemorrhoids, I can speak to the degree of discomfort one feels with these disorders. Pain, bleeding, and an overall lousy feeling are parts of the recovery one has to get past to see the benefits of the operation.
HEMORRHOIDS are varicose veins (like in your legs) in the rectum. They can be internal (inside the anus) or external (outside), and thrombosed (filled with clotted blood), but regardless they cause pain, swelling, itching, bleeding, and misery. Just like varicose veins, once you have them, they won’t go away, and you deal with them off and on by whatever means affords relief. Warm, or hot, sitz (tub) baths, stool softeners or bulk formers, high fiber diet, and topical creams (usually cortisone) are first-line conservative treatments. These measures can keep one away from surgery for a long, long time, but eventually surgery may be required. Rubber band ligation is the preferred procedure because of its benign nature and low degree of accompanying pain, but there’s a high rate of recurrence. Often, later, the need is for the more traumatic hemorrhoidectomy. And believe me it is a traumatic experience.
Dr. G’s Opinion: Hemorrhoids are by far the most common of the anorectal problems we encounter. Prevention is the best treatment, but cannot always be attainable. Don’t be afraid to treat symptoms with baths and cortisone cream, they are more effective than suppositories. Avoid constipation and straining by taking a bulk-forming stool softener and eating a high fiber diet. When it becomes necessary for surgery, be prepared to lose 2-3 weeks of your life activities during recovery.
FISSURES: Also called Anal Ulcers, can be acute (newly acquired) or chronic (persistently present) and cause rectal pain and some bleeding with bowel movements. They are merely a deep tear in the rectal lining. They will often heal with the usual conservative measures (sitz baths, stool softeners, topical creams, diet), but if they haven’t healed after 12 weeks, surgery is indicated. Chronic anal ulcers have a frequent association with Crohn’s inflammatory bowel disease.
Dr. G’s Opinion: Anal fissures are painful little buggers and can be stubborn to heal. Treating them with TLC goes a long way to ensure patient comfort. Crohn’s disease is not something one should have because it requires “big guns” (strong drugs) to treat and can occur anywhere from the the mouth to the rectum. Just hope your fissure is from trauma and not Crohn’s.
ABSCESSES: Rectal and Perianal—are bacterial infections of the anorectal area. When one has a swollen, red, painful mass (lump) in the anorectal area it’s most likely an abscess. These sometimes drain on their own after hot sitz baths, but more often than not won’t resolve without incision and drainage. The major complication is the formation of a tunnel of infection called a fistula. Established fistulas always require surgical treatment and a work up for inflammatory bowel disease such as Crohn’s colitis.
Dr. G’s Opinion: Abscesses are very painful, and the procedure to drain them is as well. But patient relief obtained thereafter drainage is significant.
PRURITIS ANI: Rectal itching is the second most common anorectal problem. It has many causes, but basically anything that irritates the skin around the anus can result in itching. Soap residue, scented powders or creams, and contact allergy to paper or other products are causes that can be corrected by avoidance of their use. Yeast infections, diabetes, various skin conditions, hemorrhoids, and fissures are other causes. Itching is the main symptom, but the irresistible scratching of the itch just makes it worse. Abrasion of the skin, bleeding, and pain then occur. Treatment focuses on personal hygiene by keeping the anorectal area clean and dry and the application of cortisone cream to symptomatic areas for brief periods.
Dr. G’s Opinion: This problem is more an annoyance than anything. It is aggravated by scratching, so alternative ways of relieving the itch are preferable. It tends to recur if the offending cause is not eliminated. Doing so will keep it from being such an irritation.
PROLAPSE: Rectal prolapse is fortunately uncommon, but tell that to women who have it far more often than men. It is the physical protrusion of the inside of the rectum through the anal opening caused by weakening or stretching of the suspending structures that hold the rectum in place. If the tear or stretch is significant, the rectum falls to the outside exposing the colon lining to the outer world. The only treatment for prolapse is the surgical repair and reestablishment of the proper location of the rectum.
Dr. G’s Opinion: Women are more often affected because of the permanent changes to the pelvic floor as a result of pregnancy and vaginal delivery. The tremendous stretching of the pelvic area that occurs from childbirth initiates the situation that only gets worse. Repair success rates are sometimes not as good as one might hope.
ANAL WARTS (CONDYLOMA): Much has been written about the Human Papilloma Virus (HPV) over the past 10-15 years. It is the known cause of diseases that occur from risky sexual behaviors and is a risk factor for rectal cancer. Anal warts are caused by HPV and are raised, wart-like growths in the skin around the anus. Treatment focuses on destruction of the causative organism and warty tissue changes by topical agents, cryosurgery, electrosurgery, or surgical excision. All of these treatments are painful and may require repeated attempts to gain success.
Dr. G’s Opinion: In my practice, I didn’t see much of this problem. It is seen more often in Sexually Transmitted Disease clinics, or by dermatologists and gynecologists. It is, however, effectively treated with topical drugs that destroy the warts by chemical cauterization. HPV vaccine, Gardisil, is given to 11 and 12 year olds for prevention of this and other diseases caused by Human Papilloma Virus.
FECAL INCONTINENCE: The uncontrolled passage of fecal material is caused by anal sphincter deficits, fecal impaction, prolapse and inflammatory bowel disease. Brain and spinal cord disorders will cause it, too. It is treated by using biofeedback to retrain the anal sphincter (pucker muscle) to work more effectively. There are surgical procedures available, but most cases are handled conservatively. A last resort measure is the formation of a colostomy which would require a desperate scenario.
Dr. G’s Opinion: This is a difficult, embarrassing problem for sufferers.You have no control and thus leakage can happen at any inopportune time, and usually does. Patients often become reclusive and have a difficult time coping. Treatments only work so well.
FUNCTIONAL RECTAL PAIN: That which has no discernible cause after all other possible causes are ruled out. Proctalgia fugax is one example. Sudden, sharp pains in the rectum coming episodically and lasting seconds to minutes for completely unknown reasons is what occurs in this disorder. Spasms of rectal muscles also cause pain, and finding a treatment to prevent them can be challenging.
Dr. G’s Opinion: It’s entirely possible that many of you, like me, have had proctalgia fugax. Once you’ve had it, you don’t forget it. Thank goodness it doesn’t happen often or last a long time because the pain is severe and debilitating. Undoubtedly, there is a reason for it to occur, but finding a cause is difficult if not impossible.
All of us have experienced some, or many, of these problems during our lives. As mentioned earlier, the anorectal area is a very pain sensitive part of the body so when these problems occur, our attention gets focused on them and our whole system is affected. Treating them early and aggressively brings about a quicker resolution of symptoms. Unfortunately, surgery of some type is often necessary for many of these problems. Proctologists (rectal surgeons) are busy practitioners and have many procedures that help these problems. But along the way to success and resolution is a bumpy, painful, miles-long road.
References: Cohen, ME, Hurff A, Gazewood JD Benign Anorectal Conditions: Evaluation and Management Am Fam Phys 2020 Jan 1;101(1):24-32.
