This article discusses how three very common benign conditions that affect the area around the anus are treated, namely, anal fissure, anal fistula and haemorrhoids, which are also known as piles.
- What is an anal fissure?
- What causes an anal fissure?
- How do you know if you have an anal fissure?
- How is an anal fissure diagnosed?
- How is an anal fissure treated?
- How can I prevent an anal fissure from occurring?
- Are there any complications from an anal fissure?
- What is an anal fistula?
- What causes an anal fistula?
- Are there different types of anal fistulas?
- What are the symptoms of an anal fistula?
- How is an anal fistula diagnosed?
- How is an anal fistula treated?
- Are there any complications from an anal fistula?
- What are haemorrhoids?
- What causes haemorrhoids?
- Are there different types of haemorrhoids?
- What are the symptoms of haemorrhoids?
- How are haemorrhoids diagnosed?
- How are haemorrhoids treated?
- How can I prevent haemorrhoids?
- Are there any complications from haemorrhoids?
The medical conditions that occur in or just around the anus (perianal) can often cause pain and frequently lead to worrying symptoms including bleeding. However, three of the most common conditions are quite benign and can be treated easily. These are anal fissures, anal fistulae and haemorrhoids (piles).
An anal fissure (fissure in ano) is a small split or tear in the thin lining (mucosa) of the anal canal. The anus is the opening through which stools (faeces) are passed from the body.
Anal fissures are very common in young children but they can occur in people of all ages.
In adults, fissures can be caused by constipation, straining to pass hard stools, or by long periods of diarrhoea. In older adults anal fissures can occur as a result of decreased blood flow to the area.
Anal fissures are also common in women following childbirth and in people with inflammatory bowel disease and Crohn’s disease.
An anal fissure causes a sharp pain whenever the bowels are opened and this can linger for several hours. The pain is often accompanied by bleeding that can be seen on the toilet paper on wiping or in the toilet.
Another sign of an anal fissure is the development of a small anal skin tag (growth) at the point of the fissure. These are probably produced by the anal skin swelling. Anal fissures can also lead to constipation as sufferers often become fearful of going to the toilet due to the pain. This is much more common in the younger age group.
An anal fissure can be diagnosed by examining the anus and lower rectum. When gentle pressure is placed on the area of the anus that contains the fissure the pain felt on defaecation will occur. If necessary a further examination using a specially designed tube (called a proctoscope) that is inserted into the anus can take place on an outpatient basis and this enables the fissure to be seen.
Anal fissures are painful because they cause a spasm of the underlying anal sphincter, which is the muscle that hols the anus closed. With the anal fissure in spasm, a sufferer will need to strain to open their bowels, which makes the fissure worse. In this way a cycle of injury and spasm occurs. Treatments for anal fissures aim to break this cycle.
There are a number of possible treatments for anal fissures that range from non-interventional to surgery. These are:
- Attempting to avoid constipation by adjusting your diet and increasing the amount of water that you drink.
- The use of topical local anaesthetic gel that reduces pain.
- The application of creams to the anus that is absorbed and relaxes the anal sphincter. This needs to be done a number of times during the day as well as before the bowels are opened. This form of treatment is governed by the patient and produces an overall 75% healing rate.
- The use of Botox (botulinum toxin A), which produces the same effect as the muscle relaxant creams but remains present for up to 3 months. The Botox is inserted either side of the fissure and this will require a general anaesthetic. This is done as a day-case procedure. The healing rates for Botox are approaching 100%.
- Finally, some fissures do not respond to any of the previously mentioned treatments and require some of the superficial fibres of the anal sphincter to be divided. This produces permanent relaxation of the short segment of the sphincter where the fissure occurs and this allows it to heal completely.
The majority of treatments take place without surgery on an outpatient basis. The treatments will be tailored to each patient and if surgery is required this will be performed on a day-case basis. An anal fissure will take six to eight weeks to be cured and heal completely.
All of the surgical procedures, namely Botox injections and the division of the superficial fibres of the anal sphincter require a general anaesthetic. The operation time can be anything from ten to twenty minutes.
To prevent anal fissures in infants, be sure to change nappies frequently.
To prevent fissures at any age:
- Keep the anal area dry
- Wipe with soft materials to avoid any trauma to the area
- Promptly treat any constipation or diarrhoea
- Avoid any irritation to the anus
Occasionally, a fissure can become chronic if not treated and will then not heal. Chronic fissures may require minor surgery to relax the sphincter.
A fistula (fistula in ano) is an abnormal connection between two surfaces within the body. The connection can involve a combination of an organ, a vessel, or the intestines and another structure. Fistulas are usually the result of injury or surgery but can also result from infection or inflammation.
An anal fistula occurs at the connection between the lower bowel and the surrounding skin of the anus.
It is not really known what causes an anal fistula. One theory is that they originate from the anal glands, which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form that can eventually point to the skin surface. If the abscess bursts through the anal skin a channel is formed by this process and this is the fistula.
An abscess can recur if the fistula seals over, allowing the accumulation of pus. It then points to the surface again, and the process repeats itself. Anal fistulas do not generally cause harm but they can be very painful and irritating.
The answer to this is yes and they are classified according to their relationship to the anal sphincter, which is the muscle at the end of the rectum that holds the anus closed.
An anal fistula can cause a variety of symptoms as follows:
- Discharge - either blood or pus
- Itching around the anus (pruritus ani)
- If the infection reaches the blood stream this can cause a fever
An examination that is carried out either in an outpatient setting or under a general anaesthetic will be required to diagnose whether an anal fistula is present. An anal fistula will be suspected in the following circumstances:
- If it is possible to see the opening of the fistula onto the skin.
- If the area is painful on examination.
- If the area is red.
- A thickened area due to chronic infection may be present.
- A discharge may be seen.
- It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula.
How the anal fistula lies in relation to the anal sphincter can be established with an MRI scan. This will confirm the diagnosis and guide suitable treatment.
There are several possible treatment options for anal fistulas; however, before the final treatment plan can be decided upon it is often necessary to treat any infection that may be present with antibiotics. If the infection has caused an abscess then this will have to be drained.
For low lying fistulas or those that involve the internal part of the anal sphincter the preferred treatment is usually surgery to open up the fistula. Once the fistula has opened it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. This option will leave a scar and it is not appropriate for fistulas that cross the entire anal sphincter.
For fistulas that involve a great portion of the anal sphincter the usual treatment will be a seton, which is a length of soft suture material that is looped through the fistula from the skin to the inside of the bowel that keeps it open and allows pus to drain out. This is called a draining seton. The stitch is put in place under a general anaesthetic and encourages healing. This makes further surgery easier.
The part of the fistula that leads to the anal sphincter is often removed (a fistulotomy) but the external portion of the anal sphincter is never cut. This removal of the fistula where the wound is created that requires regular packing.
A new method that has developed in recent years is the fibrin glue injection, which involves injecting the fistula with biodegradable glue that should, in theory, close the fistula from the inside out and let it heal naturally although the success of this process has been variable.
Sometimes the fistula will be plugged with a plug made from small intestinal submucosa that is positioned from the inside of the anus with a suture. The small intestinal submucosa stimulates the body to close the fistula from the inside out. According to some sources, the success rate with this method reaches 60%.
Another possible procedure is the endorectal advancement flap. This involves cutting a flap of mucosal tissue around the opening of the fistula, which is then lifted to expose the fistula. This is cleaned and the internal opening sewn shut. The flap is then pulled down over the sewn internal opening and stitched into place. The external opening is cleaned and also stitched. The success rates of this procedure are however variable and high recurrence rates are directly related to previous attempts to correct the fistula.
The decision on which treatment is most suitable will depend on the symptoms and the location of the fistula. All of the surgical procedures can be carried out on a day-case basis and patients can return home a few hours after surgery. The surgery will leave a small wound in the perianal region that may be painful and will require regular dressings. There are several techniques that can be used to reduce the pain at time of surgery including nerve blocks, local anaesthetic and oral painkillers. Salt baths are recommended to reduce the discomfort and inflammation following the operation. The external wounds usually take six to eight weeks to heal completely.
All of the surgical procedures that have been discussed will require a general anaesthetic. The operation time can be anything from 10 minutes to 1 hour.
The presence of an anal fistula, particularly if it involves the anal sphincter, can result in some degree of incontinence. If anal fistulas are not treated secondary tracts can develop and this can lead to the formation of a complex fistula. These are more difficult to treat and may need 2 or 3 surgeries to treat completely.
Haemorrhoids, which are also known as piles, are enlarged veins in the lower section of the anal canal. The rectum is the final portion of the large intestine. Its function is to store stool. Stool is emptied from the body through the anus. Hemorrhoids are veins that act as "cushions" of tissue at the junction of the rectum and the anus.
Haemorrhoids are one of the most common conditions of the anus and they result from an increase in pressure in the veins of the anal canal. This increased pressure causes the veins to expand and bulge enlarging the haemorrhoids. The main causes of increased pressure in the anal veins include constipation, pregnancy and chronic coughing.
Haemorrhoids can be divided into two types, internal and external. Internal haemorrhoids occur just inside the anus, at the end of the rectum. External haemorrhoids occur at the anal opening and can often be felt. On occasions internal haemorrhoids can become so big that they protrude outside the anal canal.
The most common symptoms of haemorrhoids include:
- Anal itching
- Ache or pain
- Bright red blood often on the toilet paper or in the toilet
- A ‘lump’ that can be felt on or around the anus
Haemorrhoids can be diagnosed by examining the anus and lower rectum (lower part of the large bowel). If necessary, further examination can be performed using specially designed tubes inserted into the anus (rigid sigmoidoscope and a proctoscope). All of this can be performed on an outpatient basis and it is not too uncomfortable.
There are a number of ways that haemorrhoids can be treated depending on their position and the symptoms they are causing. Haemorrhoid removal may be recommended when non-surgical treatment (increasing daily water intake, fibre rich diet, laxatives) has not proved adequate to relieve symptoms.
Outpatient treatments include injecting the base of the haemorrhoid with a sclerosing agent (injection sclerotherapy), which destroys the vessels in the haemorrhoid, causing it to fall off and be passed in the stool. Alternatively, some surgeons will apply a rubber band around the base of the haemorrhoid (haemorrhoid banding) This deprives the haemorrhoid of a blood supply, and again, the haemorrhoid will then simply fall off and be passed in the stool.
Stapled haemorrhoidectomy or PPH (Procedure for Prolapse and Haemorrhoids) avoids the need for wounds in the sensitive perianal area. The advantage of this is that it significantly reduces post-operative pain. PPH employs a unique circular stapler that removes a circumferential strip of mucosa containing the haemorrhoids from the proximal anal canal. PPH also has the advantage of reducing the degree of tissue prolapse because by removing the strip of mucosa this has the effect of pulling the haemorrhoidal cushions back up into their normal anatomical position.
A minimally invasive surgical technique is Transanal Haemorrhoidal Dearterialisation (THD), which uses a specially developed proctoscope combined with a miniature ultrasound device to identify the haemorrhoidal arteries 2–3 cm within the ano-rectal canal and to suture them. By suturing the feeding artery to the haemorrhoid (devascularising) the blood inflow is reduced and the haemorrhoid shrinks in size. This technique shows a great deal of promise for the treatment of haemorrhoids.
Formal or open haemorrhoidectomy is a procedure reserved for large external haemorrhoids. The haemorrhoid is disconnected from its attachments to the anus by diathermy, where heat is produced by a high frequency electric current (electrocautery) in order to remove the haemorrhoidal tissue completely. This will leave wounds around the anus which can be painful. These wounds will take six to eight weeks to heal completely.
Treatments are tailored to both the patient’s symptoms and the location of haemorrhoids. Outpatient treatment will produce a little discomfort and occasionally a small amount of bleeding. Simple painkillers can control the discomfort, which tends to last for a few days. A follow up appointment is usually arranged to assess treatment outcome.
Stapled haemorrhoidectomy and THD, both of which remove haemorrhoids, usually need a period of two to four weeks for full recovery. Again, there will be some discomfort but this should ease by the following day.
Open haemorrhoidectomy is painful because there will be open wounds around the anus where the external haemorrhoids have been removed. Techniques to reduce the pain at the time of surgery include nerve blocks, local anaesthetic and painkillers taken by mouth. Salt baths are advised to reduce the discomfort and inflammation post operatively. The external wounds will take six to eight weeks to heal completely.
The outpatient treatments are performed on the same day as the consultation. The surgical procedures are all carried out as a day-case procedures.
All of the surgical interventions described above, namely stapled haemorrhoidectomy, THD and open haemorrhoidectomy require a general anaesthetic. The operation time can be anything from 30 minutes to 1 hour.
The key is to avoid straining during bowel movements. You can help prevent haemorrhoids by preventing constipation. Drink plenty of water, eat a high-fibre diet of fruits and vegetables and consider fibre supplements on a daily basis. Sometime laxatives may be needed.
The blood in an enlarged vein may form a clot. If this occurs in an enlarged haemorrhoid it is referred to as a thrombosed haemorrhoid and these are very painful. Severe bleeding may also occur. This is unusual but may cause anaemia if the bleeding is prolonged.