Rectal Problems Overview
The rectum refers to the last four or five inches of the digestive tract. The rectal outlet or opening is called the anal canal or anus. Problems in this area are common, but many adults are too shy or embarrassed to ask their doctor about them. Fortunately, most of these problems are treatable when recognized early and properly diagnosed. Remember that symptoms of rectal pain or bleeding should always be thoroughly evaluated by your doctor.
- What are 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.
- What are the different types of hemorrhoids?
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 (stick out) through the anal canal. The most common sign of hemorrhoids is bright red blood on toilet paper or drops of blood in 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.
- How do hemorrhoids develop?
Hemorrhoids are very common. About half the American population has 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, genetic factors, and aging may also lead to hemorrhoids.
- How are hemorrhoids diagnosed?
As with all conditions involving the anal canal or rectum, the diagnosis is made by examining the anus visually and by performing a rectal examination (with a gloved finger). Following this, a lighted instrument is inserted into the canal so that the inside 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).
- How are hemorrhoids medically treated?
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, a moist wash cloth, or moist towelettes can be used.
Things to avoid: irritating soaps, spicy foods and coffee.
Sources of Dietary Fiber
Sources of Fiber Serving Gm/serving Vegetables & Beans Green beans ½ cup 2 Kidney beans ½ cup 5 Broccoli ½ cup 2.5 Brussel sprouts ½ cup 3.5 Carrots ½ cup 2.5 Corn ½ cup 3.0 Green peas ½ cup 3.5 Lettuce ½ cup 0.5 Potato (with skin) ½ cup 2.0 Fruits Apple medium 2.5 Banana 1 2.0 Blackberries 1 cup 2.0 Cantaloupe 1 wedge 1.0 Dry Figs 3.5 ounces 18 Grapefruit medium 3.5 Grapes 1 cup 1 Orange 1 medium 3 Pear 1 medium 4.5 Prunes 1 cup 13.5 Raspberries 1 cup 6.0 Strawberries 1 cup 3.5 Grain Products Bread, white 1 slice 0.5 Bread, whole wheat 1 slice 2.0 Kellogg’s All-Bran® 1 ounce 9-14 General Mills Fiber® 1 ounce 12 Kellogg’s Bran Flakes® 1 ounce 4 Cereal, Cornflakes® 1 ounce 0.5 Cereal, oat bran 1 ounce 4 Shredded wheat 1 ounce 2.5 Crackers, Graham® 4 squares 1 Crackers, Saltine® 10 regular 1 Rice, brown ½ cup 5 Rice, white ½ cup 1.5 Spaghetti 2 ounces 2.5 Fiber Supplements Psyllium (i.e., Metamucil®, Konsyl®) 1 tsp 3.4-6 Polycarbophil (i.e., Fibercon®, Perdiem®) 1 tsp 4.0
The goal is 30-35 grams of fiber per day. The average American diet contains only 10-20 grams.
Endoscopic & Surgical Treatment for Hemorrhoids
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.
- Radiofrequency ablation: a device that uses high-intensity sound waves to close off the hemorrhoids.
- Hemorrhoidectomy: surgical removal of hemorrhoid veins (commonly requires hospitalization).
- What is an 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.
- How is a fissure diagnosed?
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 a small scope (anoscope) can be used to determine the extent of the tear.
- How is an anal fissure treated?
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 (i.e., Preparation- H® or Anusol®)
- Some doctors will recommend nitroglycerine ointment or injection of botulinum toxin (Botox®)
Most fissures will heal within several weeks, but surgery may be necessary if symptoms persist. Surgery consists of cutting a portion of the anal sphincter muscle. This reduces tension of the anal sphincter and promotes healing. Risks of surgery include loss of bowel control, or accidental incontinence of stool.
Anal Abscess or Fistula
- What is an anal abscess/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.
- What are the symptoms of an anal abscess/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.
- How is a fistula treated?
Medical Treatment: When a fistula is caused by Crohn’s disease, your doctor may recommend treatment with medicines such as metronidazole azathioprine, or biological agents such as infliximab (Remicade®) or Adalimnunab (Humira®) or newer agents.
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.
- What is 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 labor, or delivery of a large baby, and this can contribute to fecal incontinence.
- How is incontinence evaluated?
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.
- How is incontinence treated?
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 or diphenoxylate HCl may decrease stool volume and frequency, improve stool consistency, or perhaps directly affect the sphincter muscles.
- What is biofeedback?
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.
- Is surgery helpful?
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.
- What are the causes of rectal pain?
Rectal pain may result from structural conditions such as hemorrhoids, fissures, fistula or abscess.
- What is levator syndrome?
The levator syndrome presents with an aching rectal pain related to spasm of the pelvic floor muscles. It is important for the doctor to evaluate the area to exclude inflammation or even an infectious problem. The levator syndrome is more commonly seen in women. The tenderness is often on the left side. Treatment consists of reassurance, application of heat, and local massage. Electro-galvanic stimulation may break the spasm pain cycle by delivering a high voltage-pulsed current using a rectal probe. Biofeedback has also been suggested for some patients.
- Are there other causes of rectal pain which should be ruled out?
Another unusual cause of rectal pain is coccygodynia (pain in the tail bone). This may be the result of traumatic arthritis or may even result from child birth. This pain may be triggered by bowel movements. Other rare causes of rectal pain include tumors of the spine, pelvis and rectum and endometriosis.
- What is pruritus ani?
This refers to itching around the anal area. It is often most troublesome at night or following a bowel movement.
- What causes pruritus ani?
Excessive cleaning or wiping of the anal area is common cause. 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.
- How is pruritus ani treated?
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. Applying a paste consisting of zinc oxide and menthol can protect the perianal skin area and reduce itching.
Arnold Wald, MD, MACG, University of Wisconsin School of Medicine and Public Health – Updated Spring 2017