An anal fissure is a small tear in the lining of the rectal opening. A fissure can occur anytime, but many patients indicate that they have had an episode of constipation. A few patients indicate that they developed the fissure after having loose stools.
Fissures are usually superficial and sometimes they can even be difficult to detect for the doctor. Chronic fissures can be deeper and they can sometimes reach down to the sphincter muscle.
Many patients with a fissure have a tight anal canal and several of the treatments (please see below) are aimed at correcting this circumstance.
The main symptom of anal fissure is pain. This pain is usually worst with a bowel movement and the pain sometimes persists after the bowel movement. The pain thereafter gradually improves until the next bowel movement. Some patients with fissure have rectal bleeding from the tear at bowel movements. The bleeding is usually bright red. The fissure is sometimes associated with a skin tag at its most outer part. This tag can be felt as a slight swelling. A few patients also have problems with itching, which can be caused by discharge from the fissure when the fissure alternately heals and reopens.
Diagnosis of anal fissure
Fissures can be diagnosed with a clinical examination. Sometimes the fissure is small and located a bit on the inside. In patients with significant tenderness, it can therefore sometimes be difficult to diagnose the fissure. These patients can then need an examination under anesthesia in the operating room.
Chronic fissures may need to be biopsied to rule out other reasons for the symptoms. Sometimes endoanal ultrasound can be helpful, before embarking on surgical treatment of the fissure.
Treatment of anal fissure
Many fissures will heal spontaneously without any medical or surgical treatment. This spontaneous healing is more frequent if it is possible to avoid constipation through good diet with proper amount of fiber. Sometimes your doctor will recommend a commercially available fiber product or a mild laxative. Sometimes a warm bath can reduce the spasm and the pain from the fissure.
Treatments are otherwise aimed at relieving the spam in the sphincter muscle. There are several creams that can help with this and they are therefore considered to be the first line medical option. Some patients are treated with Botox injection in the rectal area, since this treatment can relax the sphincter musculature.
If the above mentioned treatment options are not successful, surgical treatment can be considered. Surgery is usually aimed at cutting/dividing a part of the sphincter musculature, which will then decrease the tone in the sphincter muscle. The advantage is that this treatment is permanent, but at the same time dividing sphincter muscled will carry some risk for postoperative continence problems (rectal leakage).
Anal warts and anal dysplasia
Anal warts, anal dysplasia and anal cancer are all caused by the human papilloma virus (HPV). HPV is a common virus that can be transmitted sexually. There are over 40 types of HPV that can infect the genital and/or anal area. Some HPV types can cause warts. Other HPV types can cause anal and cervical dysplasia and cancer.
Genital HPV infection is very common in the US and most infected individuals are unaware of being infected. In women, warts can appear on and around the genitals and inside the vagina, on the cervix, and/or around the anus. Men typically develop warts on the penis, the testicles and/or around the anus.
Anal dysplasia is a pre-cancerous condition, where the cells of the anal canal (lower rectum) undergo abnormal changes. Anal dysplasia can progress from low-grade (low risk) to high-grade (high risk) changes before it turns into cancer. Anal dysplasia can turn into anal cancer, which is therefore also caused by HPV. This tumor usually develop slowly over a period of years. Anal cancer usually starts in the anal canal (lower rectum) or in the skin just outside of the anal canal opening.
Symptoms of anal warts
Many patients have no symptoms from HPV or their warts. Patients with anal warts may notice one or many “bumps” around the anal opening or in the anal canal itself. Some patients see blood when they wipe or experience anal itching.
Diagnosis of anal warts and dysplasia
Warts can be seen at visual clinical examination and at anoscopy (a small instrument is used to hold the rectal opening open to facilitate inspection of the lower rectum).
At anal pap smear, cells are collected with a swab that is inserted into the anus. These cells are examined under a microscope for pre-cancerous (dysplastic) abnormalities. Anal pap smears are recommended for patients with anal warts or with risk factors for HPV infection (i.e. patients engaging in anal sex, HIV or immunosuppression of other reason, women with cervical dysplasia/cervical cancer).
Pap smear results can be either be normal or abnormal. Patients with normal pap smear are usually recommended to undergo renewed pap smear after one (HIV positive patients) or two (HIV negative patients) years. Patients with an abnormal pap smear can be referred for high resolution anoscopy (HRA).
High resolution anoscopy (HRA) is an advanced diagnostic tool with which your specially trained provider can get enhanced assessment of the anal area. This enables better diagnosis of precancerous or cancerous lesions that may be present. The HRA technique is available only in specialized centers, with specially trained providers, like BIDC. Biopsies at HRA can come back as normal, low grade, or high grade dysplasia. Low grade dysplasia biopsies/warts are low risk, while high grade dysplasia biopsies/warts have a higher risk of developing cancer.
Treatment is individualized. Visible warts are in general treated. Further treatment is usually tailored according to findings at the assessment (above).
Low grade lesions are low risk and they don’t need further treatment, in general. They should however be watched, since they can progress to more advance and high grade lesions (see below). High grade lesions should be treated, in general.
Treatment will be tailored to the types of lesion and our provider will discuss alternatives and listen to your preferences. Applying trichloroacetic Acid (TCA) can eradicate the lesion(s). This treatment frequently needs several consecutive treatments over a few weeks or months time span. Electrocautery can destroy the lesions and this treatment will destroy all or most lesions in one treatment session. – Topical 5% Imiquimod cream can decrease the risk for recurrence. Side effects of the cream include skin irritation and burns, but most patients are able to complete the therapy.
Follow-up is very important, since anal warts and dysplasia are caused by a virues that cannot be eliminated. Therefore, warts and dysplasia can recur and close follow up and monitoring is very important!
The follow-up program is tailored to the findings. Patients will low grade lesions are in general recommended to undergo a renewed HRA in about one year’s time (or sooner if new lesions are suspected). Patients with high grade lesions need follow-up more frequently and they are in general recommended a renewed HRA in three to six months (or sooner if new lesions are suspected).
We all have small cushions with blood vessels in our lower rectum close to the rectal opening. Sometimes these cushions get bigger and start giving symptoms. A contributing factor for this may be constipation.
Sometimes patients develop small blood clots in the hemorrhoids and they are “thrombosed”. These hemorrhoids are swollen and they are usually painful.
Normal hemorrhoids are usually not painful. Enlarged hemorrhoids can cause a bright red bleeding and sometimes larger hemorrhoids can cause them to slide out (prolapse) at bowel movements. Sometimes this prolapse is reduced spontaneously, sometimes the patient need to use their hand to push them in. As indicated above, hemorrhoids can be caused by constipation. At the same time, hemorrhoids themselves usually don’t cause constipation.
Thrombosed hemorrhoids usually occur suddenly and they usually present as a painful, firm lump at the rectal opening.
Diagnosis of hemorrhoids
Hemorrhoids are usually diagnosed by your doctor with a clinical examination. Your doctor may use a small instrument, an anoscope, to visualize the hemorrhoids better. Frequently your doctor will also recommend an evaluation of your colon with a flexible sigmoidoscopy or colonoscopy, if you have not undergone one of these examinations recently.
Office treatment of hemorrhoids
Normal, non thrombosed, hemorrhoids usually respond to improved eating habits and treatment of constipation. In addition, patients seen in our clinic are usually treated with banding procedures or injection therapy.
At banding of hemorrhoids, a rubber band is placed around the hemorrhoid, causing it to wither and fall off after about one week. You may feel a mild to moderate pain/pressure for a few days. If needed, you can take an over-the-counter pain medication, for instance Tylenol® or Advil®. When the rubber band falls off, you may notice a small bleeding. In general, you need to repeat the treatment a few times and we usually treat patients about once a month.
Hemorrhoids can also be injected with an agent that shrinks them. This may stop the bleeding and prevent the hemorrhoids to protrude. Also with this treatment you may notice some discomfort and/or minor bleeding.
Thrombosed hemorrhoids can be treated with a small incision, to evacuate the blood clots. This will frequently result in some pain and sometimes also some bleeding. If needed, you can take an over-the-counter pain medication. If the thrombosed hemorrhoid is already improving, sometimes it is better not to incise them and let nature to heal and improve the condition spontaneously.
Surgical treatment of hemorrhoids in the operating room
Some hemorrhoids will require surgical treatment in the operating room and you doctor will counsel you about his/her recommendations.
Surgical excision of hemorrhoids is usually quite effective in elimination the hemorrhoid symptoms. The postoperative period is unfortunately quite painful for one or two weeks and it is important that you have pain medication at hand and that you see that you don’t get constipated.
Stapled hemorrhoidectomy and suture of hemorrhoids are two other effective treatment options in the operating room. These options are usually associated with less postoperative pain, but may have other limitations. Your doctor will discuss treatment options with you and you can then decide what option you want to proceed with.
Problems after treatment of hemorrhoids
Office treatment of hemorrhoids is usually associated with only minor pain, except for incision of thrombosed hemorrhoids when the pain may be moderate. If you experience excessive pain, unrelieved by pain medication, please contact our office immediately or go to the emergency room. The same accounts if you experience fever or chills, increasing pain after a few days, difficulties to urinate, constipation or severe bleeding or other alarming symptoms. Other risks with treatment of hemorrhoids will be discussed by your doctor before proceeding with treatment.
An abscess in the rectal region is caused by an infection, which may start in the rectum or in the skin. Irrespectively, the treatment of abscesses in this region is the same (drainage; please see below).
Abscesses that start in the skin will usually heal without any problems. A few of these abscesses will have a pilonidal cyst, which mat need to be removed at a later date.
Abscesses that start in the rectum may have an underlying fistula, which may need further subsequent treatment. The risk for an underlying fistula is approximately 50 percent the first time a patient has an abscess. If the abscess recurs several time in the same location, this risk may be even higher. It is therefore important to follow-up in the clinic after drainage of an abscess, to ensure that the abscess completely heals and there is nothing additional that will further attention.
The most common symptom is pain. The pain is continuous and not always related to having a bowel movement or not. Some patients may develop fever or a feeling of “being sick”. A few patients will notice a swollen area, sometimes with some discharge of pus or blood.
Diagnosis of perianal abscess
Most times a reliable diagnosis can be done by clinical examination only. Sometimes an endoanal ultrasound can be helpful and in a few patients a CT or MRI scan can be necessary.
Treatment of perianal abscess
Drainage of the abscess is the treatment of choice. This can usually be performed under local anesthesia in our clinic. The doctor will anesthetize the area with a local anesthetic to allow the drainage to be as painless as possible. Thereafter, an incision is made into the abscess to drain the pus. In addition to drainage, antibiotics are sometimes given to some patients, for instance immune compromised patients, patients with artificial implants or diabetes.
After the incision you will have mild to moderate pain when the local anesthesia weans off. If needed, you can take an over-the-counter pain medication, for instance Tylenol® or Advil® or a medication that your doctor will give you a prescription for. You may also notice some secretion or bleeding after the procedure. Please be careful not becoming constipated after the procedure, and we recommend that you take a mild laxative, for instance Miralax, if needed.
A few patients with more complicated abscesses may need examination and incision under general anesthesia in the operating room. If this is the case, your doctor will discuss this with you and see if you also need to be admitted to the hospital.
After treatment, you will need to follow-up in our clinic. As indicated above, some patients with a perianal abscess will have an underlying fistula that may need further subsequent treatment.
Problems after treatment of perianal abscess
Treatment of fistula is usually associated with moderate pain. If you experience excessive pain, unrelieved by pain medication, please contact our office immediately or go to the emergency room. The same accounts if you experience fever or chills, increasing pain after a few days, difficulties to urinate, constipation or severe bleeding or other alarming symptoms. Other risks with abscess surgery will be discussed by your doctor before proceeding with surgical drainage of the abscess.
A perianal fistula, almost always the result of a previous abscess, is a small passage connecting the anal gland from which the abscess arose to the skin where the abscess was drained.
An abscess is formed when a small gland just inside the anus becomes infected from bacteria or stool trapped in the gland. You did nothing to cause this infection. Certain conditions – constipation, diarrhea, colitis, or other inflammation of the intestine, for example, may make these infections more likely.
After an abscess has been drained, a passage may remain between the anal gland and the skin, resulting in a fistula. If the gland does not heal, there will be persistent drainage through this passage. If the outside opening of the fistula heals first, a recurrent abscess may develop.
Typical symptoms of a perianal fistula include frequent drainage of pus or blood through an opening in the perianal region. Sometimes there may also be some discomfort in the area. Sometimes, patients with perianal fistula may develop a perianal abscess with typical symptoms of pain, possible fever or a feeling of “being sick”.
Diagnosis of perianal fistula
A perianal fistula is usually diagnosed with a clinical examination. Fistulas usually have a draining small opening in the perianal region. Sometimes there is also a small opening found in the lower rectum, at clinical examination.
Fistulas can involve different amounts of sphincter muscle and therefore an endoanal ultrasound, and sometimes a MRI in complicated cases, can be quite useful. This may help the surgeon to advise you which type of surgery is most appropriate for you.
Treatment of perianal fistula
Surgery is usually necessary to treat a perianal fistula. The surgery is usually tailored to the extent of the fistula and how much of sphincter muscle is involved.
If there is a limited amount of sphincter involved in the fistula, the surgeon may suggest a fistulotomy. This involves cutting a small portion of the anal sphincter muscle to open the fistula. This procedure has a high rate of success, but there is some risk for continence disturbances if the fistula involves significant amount of sphincter musculature. Your doctor will discuss this with you before the surgery.
Fistulas involving more significant amount of sphincter muscle are usually treated with a sphincter saving procedure. These procedures are aimed at preserving/protecting the sphincter muscle. There are a few alternatives to choose from, including the LIFT procedure, flap procedure, plug procedure, etc. Your doctor will review these options with you to discuss which procedure will be most appropriate for you. In general, these procedures have a lower risk for postoperative continence disturbances but at the same time their healing rate may be lower.
It is unclear how much sphincter muscle is involved in the fistula, your doctor may elect placing a rubber band, a “seton” in the fistula. The doctor will then recommend you to come back to our clinic for an endoanal ultrasound to better “map” the fistula. At the same time, after the ultrasound, the doctor will discuss appropriate treatment options for you.
After fistula surgery you will have mild to moderate pain. If needed, you can take an over-the-counter pain medication, for instance Tylenol® or Advil® or a medication that your doctor will give you a prescription for. You may also notice some secretion or bleeding after the procedure. Please be careful not becoming constipated after the procedure, and we recommend that you take a mild laxative, for instance Miralax, if needed.
Problems after treatment of perianal fistula
Treatment of fistula is usually associated with moderate pain. If you experience excessive pain, unrelieved by pain medication, please contact our office immediately or go to the emergency room. The same accounts if you experience fever or chills, increasing pain after a few days, difficulties to urinate, constipation or severe bleeding or other alarming symptoms. Other risks with fistula surgery will be discussed by your doctor before proceeding with surgical repair of the fistula.