Rectal Problems

Rectal Problems Overview

The rectum refers to the last four or five inches of the digestive tract. The rectal opening is called the anal canal or anus. Problems in this area are very 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.

Hemorrhoids

What are hemorrhoids?

Hemorrhoids are veins in the anal canal that can become swollen or stretched.
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 or 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. Please make your physician aware of any bleeding you are having. 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 during a bowel movement. Hemorrhoids frequently develop in women during pregnancy. Other factors that cause hemorrhoids include constipation, frequent diarrhea, genetic factors, and aging.
How are hemorrhoids diagnosed?

Most commonly these are diagnosed during a clinic visit with a physical exam as well as a digital rectal exam (with a gloved finger). Sometimes additional testing with lighted instruments (an anoscope or a sigmoidoscope) are used to visualize the inside of the rectum.
How are hemorrhoids medically treated?
Eliminate constipation: Bowel movements should be soft and should pass without need to strain. Increasing water intake, dietary fiber (see table below) and exercise are often effective.

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.

Fiber: The goal is 30-35 grams of fiber per day. The average American diet contains only 10-20 grams. Certain foods are high in fiber, but your physician may also recommend adding supplemental fiber to the diet.

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).

Anal Fissure

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 bowel movements. Bleeding may also occur. A fissure usually occurs after the passage of a large, hard bowel movement.
How is a fissure diagnosed?

The fissure can seen on physical exam or with a small scope (anoscope) which can determine the extent of the tear.
How is an anal fissure treated?
The best treatment is prevention with a high-fiber diet.
- Sitz baths several times a 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 last longer than expected. Surgery consists of cutting a portion of the anal muscle. This reduces tension of the anal sphincter and allows for 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. 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 is very painful and causes swelling just next 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, creating a connection between 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.

Fecal Incontinence

What is fecal incontinence?

Fecal incontinence is the accidental loss of stool. Causes of fecal incontinence in adults include back injuries, sphincter disruption as a result of trauma, anorectal surgery, or obstetrical trauma, and medical illness such as multiple sclerosis and diabetes mellitus. Many women have nerve or muscle injury to the anal sphincter from delivery of a large baby, prolonged delivery or delivery by forceps, 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 by the doctor inserting can help 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 of the anal sphincter muscles. X-rays with a special rectal paste can help identify physical abnormalities of muscle function. Ultrasound can also be used to study 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 cause bloating as well as and foods containing ingredients such as lactose, fructose and sorbitol. Fiber supplements can increase bulk and add form to the bowel movement which can sometimes help improve control. Kegel exercises to strengthen the pelvic floor muscles may improve anorectal control. Anti-diarrhea medications may decrease stool frequency and improve stool consistency.
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 usually needed if rectal prolapse is the cause of incontinence. Obstetrical injuries, trauma and disruption of the sphincter are usually managed by surgery. Testing of nerve and muscle function with manometry and MRI can help to identify those who may benefit from surgery.

Rectal Pain

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 due to spasm of the pelvic floor muscles. This can be caused by inflammation or even an infection. The levator syndrome is more commonly seen in women. 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 cause of rectal pain is coccygodynia (pain in the tail bone). This may be the result of arthritis or even from child birth. The pain may be triggered by bowel movements. Other rare causes of rectal pain include endometriosis and tumors of the spine, pelvis and rectum.

Pruritus Ani

What is pruritus ani?

This refers to itching around the anal area. It is often most troublesome at night or after a bowel movement.
What causes pruritus ani?

Excessive cleaning or wiping of the anal area is a common cause. Excessive sweating 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.

Anal Cancer

What is anal cancer?

Anal cancer affects the very end of the colon, called the anus. When found early, treatment works well. Early diagnosis leads to better outcomes.
What are the symptoms of anal cancer?
Symptoms can include:
- Rectal bleeding
- Pain, pressure, or discomfort in the anus
- Itching
- Discharge
- A lump or mass near the anus
These symptoms can also happen with other common problems, like hemorrhoids. Still, any new rectal symptom should be discussed with your doctor. Early testing helps find cancer sooner, when it is easiest to treat.
What are the risk factors for anal cancer?
The most common type of anal cancer is linked to human papillomavirus (HPV).

HPV is very common. About 8 out of 10 people are exposed at some point in life. The virus spreads through skin-to-skin contact and can affect the skin, anus, genitals, mouth, and throat. Most people clear the virus on their own, but some develop long-lasting infection. Certain strains of HPV can increase the risk of cancer, specifically HPV 16 and HPV 18.

Other risk factors include:
- Weakened immune system (such as HIV, organ transplant, or autoimmune disease)
- Smoking
- Older age
- Female sex
- History of HPV-related cancers (like cervical cancer)
- Having many sexual partners
- Anal intercourse
- Men who have sex with men
How is anal cancer treated?

In the past, surgery was the main treatment. Today, most anal cancers are treated with chemotherapy and radiation. The goal is to destroy the cancer while keeping the anus working as normally as possible.

Surgery is sometimes needed, but many patients can avoid it. When anal cancer is found early, treatment works very well.
How can anal cancer be prevented?
There are important ways to lower your risk:
1. Get the HPV vaccine
  - The HPV vaccine is safe and highly effective. It prevents infection and prevents cancer. It works best when given before exposure to HPV. It is recommended for ages 9–26 and may also help adults 27–45 in certain cases.
2. Practice safe sex
  - Use condoms
  - Limit sexual partners
3. Cervical cancer screening for women
  - Women should start cervical cancer screening at age 21. Cervical cancer and anal cancer are both linked to HPV.
4. Screening for high-risk groups
  
  Some people may benefit from anal cancer screening even if they have no symptoms, including:
  - People with HIV
  - Men who have sex with men
  - People with a history of HPV-related cancers
  - Organ transplant patients
5. Talk to your doctor about symptoms
  
  Some symptoms may feel embarrassing, but early testing saves lives. The sooner cancer is found, the easier it is to treat.
Common myths about anal cancer

Anal cancer is not colon cancer. They are different diseases with different causes, tests, and treatments.

You do not need to have anal sex to get anal cancer. HPV can spread through skin contact and from nearby areas, such as the vagina.

Treatment does not always mean surgery. Most people are treated with chemotherapy and radiation. Many do not need surgery or an ostomy bag.

You are not alone. Anal cancer can feel embarrassing or isolating. More people are being diagnosed each year, and more support, education, and treatment options are now available.
What is the outlook?

Most anal cancers are found early, which is very good news. Early treatment often avoids surgery and leads to excellent outcomes.

Some treatments can cause side effects, including bowel or sexual problems. These should be discussed with your care team so symptoms can be treated and managed.