Hemorrhoids are normal components of human anatomy. External hemorrhoids arise from the inferior hemorrhoidal plexus and are covered by modified squamous epithelium distal to the dentate line. They can swell or become thrombosed, causing pain, or they may ulcerate with subsequent bleeding. Internal hemorrhoids are classified as first-degree, second-degree, third-degree, and fourth-degree.
Decision to Treat Symptomatic Internal and External Hemorrhoids
The approach to treatment depends on the patient’s symptoms. Hemorrhoidal symptoms may be a manifestation of myriad medical conditions and therefore careful evaluation of the patient must be conducted to try to determine underlying causes of the patient’s complaints. A history includes assessment of the patient’s coagulation history, the possibility of immunosuppressive disease, and the need for antibiotic prophylaxis. If possible, before initiating any therapy, rectosigmoid evaluation and anoscopy should be performed.
- MEDICAL TREATMENT FOR HEMORRHOIDS
- Symptomatic internal and external hemorrhoids can be treated medically if symptoms are secondary to suspected alterations in diet, stool consistency (diarrhea or constipation), or poor hygiene. With treatment, hemorrhoids can be alleviated. Medical treatment may include the application of warm sitz baths, correction of diet, stool modifiers, and the use of topical creams.
- SURGICAL THERAPY
- Patients with acute hemorrhoidal disease or crisis may seek attention because of pain, hemorrhage, or debilitation.
- External Hemorrhoids- Surgical removal of external hemorrhoids is indicated if symptoms require emergency intervention or if medical treatment has failed and chronic symptoms persist. External hemorrhoidectomy can be performed as an outpatient procedure.
- Internal Hemorrhoids- Surgery is indicated in chronic internal hemorrhoidal disease in the following cases:
- Patients who fail more conservative measures of treatment. These include rubber-band ligation, dilatation, infrared coagulation, laser surgery, and bipolar diathermy coagulation.
- Patients who have symptomatic hemorrhoidal disease associated with other benign anorectal conditions that require surgery. These include patients with fistula, fissure, hypertrophied, papilla, or stenosis.
- Patients who have had third- and fourth-degree hemorrhoids, with or without external components, and who have severe symptoms and signs from their hemorrhoidal disease, may be treated by elective surgery.
- Following surgical treatment of internal hemorrhoids, with or without external hemorrhoids, ambulatory or inpatient stay is judged by the operating surgeon based on the findings at surgery and the clinical condition of the patient.
- ALTERNATIVE THERAPIES- Acute or chronic hemorrhoidal symptoms secondary to internal hemorrhoids can be treated with alternative therapies:
- Injections-Traditionally indicated for first- and second-degree hemorrhoids but not for use with external hemorrhoids.
- Rubber Bands- Rubber-banding or elastic-band ligation may be indicated for the treatment of symptoms with first- and second-degree hemorrhoids. These treatments remain in many controlled trials, the treatment of choice for first- and second- degree hemorrhoids that are complicated with symptoms of bleeding and/or prolapse. The literature supports either single or multiple bands in a single treatment and the band site may or may not be injected.
- Cryotherapy- Cryotherapy is most effective with the least side effects when directed at first- and second-degree hemorrhoids. It is not recommended for use with external hemorrhoids. We have not had good results with cryotherapy.
- Infrared- Controlled trials indicate that it is useful for first- and second-degree hemorrhoids; however, first- and second-degree hemorrhoids may need multiple treatments and alternative methods may be more efficacious (i.e., rubber-band ligations).
- Dilatation- Not preferred as an alternative treatment for internal hemorrhoids due to lack of controlled trials, unfamiliarity of the technique in the United States, and significant risk of incontinence in published reports.
- Laser- Laser advocates suggest that a critical advantage of the use of laser energy is precise control over the depth of destruction. They say this translates into minimized associated tissue injury which in turn results in less scarring, more rapid healing and possibly less pain for the patient. After extensive work and reports, laser treatment of hemorrhoids has not resulted in lower pain or bleeding for the patient; therefore, we have stopped using the laser routinely.
- Bipolar Diathermy Coagulation- Alternative procedure for fixation. Significant clinical data not yet available.
An anal fissure is a small tear, which looks like an ulcer, in the lining of the anus which can cause pain, bleeding and/or itching.
Common Questions about Anal Fissures
- What Causes an Anal Fissure? A hard, dry bowel movement can cause a tear in the anal lining, resulting in a fissure. Other causes of anal fissures include diarrhea and inflammation of the anorectal area. Anal fissures can also be caused by increased spasms of the anal sphincter.
- How Can a Fissure Be Treated? At least 50 percent of fissures heal either by themselves or with nonoperative treatment, including application of special medicated cream, use of stool softeners, avoidance of constipation, and the use of sitz baths (soaking the anal area in plain warm water for 20 minutes, several times a day).
- What Does Surgery Involve? Surgery may consist of a small operation to remove the fissure and the underlying scar tissue. Cutting a portion of one of the anal muscles helps the fissure to heal by preventing pain and spasm, which interferes with healing. This cutting of muscle is more like thinning hair. The chances of losing control of bowel movements after this operation are minimal. This is sometimes done in conjunction with removal of hemorrhoids. This is usually done on an outpatient basis and is done under some local or regional anesthesia.
- Will the Problem Return? More than 90 percent of patients who require surgery for this problem have no further trouble from fissures.
- Can Anal Fissures Lead to Colon Cancer? No! Persistent symptoms need careful evaluation, however, since conditions other than fissure can cause similar symptoms.
A patient who feels ill and complains of chills, fever, and pain in the rectum or anus could be suffering from an anal abscess or fistula. These medical terms describe common ailments about which many people know little. An anal abscess is an infected cavity filled with pus found near the anus or rectum.
Common Questions about Anal Abscess/Anal Fistula
- What is an Anal Fistula? An anal fistula, almost always the result of a previous abscess, is a small tunnel connecting the anal gland from which the abscess arose to the skin of the buttocks outside the anus.
- What Causes an Abscess? An abscess results from an acute infection of a small gland just inside the anus, when bacteria or foreign matter enters the tissue through the gland. Certain conditions – colitis or other inflammation of the intestine, for example – can sometimes make these infections more likely.
- What Causes a Fistula? After an abscess has been drained, a tunnel may persist connecting the anal gland from which the abscess arose to the skin. If this occurs, persistent drainage from the outside opening may indicate the persistence of this tunnel. If the outside opening of the tunnel heals, recurrent abscess may develop.
- What are the Symptoms of an Abscess or a Fistula? Symptoms of both ailments include constant pain, sometimes accompanied by swelling, that is not necessarily related to bowel movements. Other symptoms include irritation of skin around the anus, drainage of pus (which often relieves the pain), fever, and feeling poorly in general.
- Does an Abscess Always Become a Fistula? No. A fistula develops in about 50 percent of all abscess cases, and there is really no way to predict if this will occur.
- How is an Abscess Treated? An abscess is treated by draining the pus from the infected cavity, making an opening in the skin near the anus to relieve the pressure. Often, this can be done in the doctor’s office using a local anesthetic. A large or deep abscess may require hospitalization and use of a different anesthetic method. Hospitalization may also be necessary for patients prone to more serious infections, such as diabetics or people with decreased immunity. Antibiotics are not usually an alternative to draining the pus, because antibiotics are carried by the blood stream and do not penetrate the fluid within an abscess.
- What About Treatment for a Fistula? Surgery is necessary to cure an anal fistula. Although fistula surgery is usually relatively straightforward, the potential for complication exists and is preferably performed by a specialist in colon and rectal surgery. It may be performed at the same time as the abscess surgery, although fistulae often develop four to six weeks after an abscess is drained, sometimes even months or years later. Fistula surgery usually involves cutting a small portion of the anal sphincter muscle to open the tunnel, joining the external and internal opening and converting the tunnel into a groove that will then heal from within outward. In complicated fistulas, special surgical techniques like placement of a “Seton stitch” may have to be performed to minimize chances of loss of control of the bowels. Most of the time, fistula surgery can be performed on an outpatient basis or with a short hospital stay.
- What Are the Chances of a Recurrence of an Abscess or Fistula? If properly healed, the problem will usually not return. However, it is important to follow the directions of a colon and rectal surgeon to prevent recurrence.
Pilonidal disease is a chronic infection of the skin in the region of the buttock crease. The condition results from a reaction to hairs embedded in the skin, commonly occurring in the cleft between the buttocks. The disease is more common in men than women and frequently occurs between puberty and age 40. It is also common in obese people and those with thick, stiff body hair.
Common Questions about Pilonidal Disease
- What are the Symptoms? Symptoms vary from a small dimple to a large mass. Often the area will drain fluid that may be clear, cloudy, or bloody. With infection, the area becomes red and tender and the drainage (pus) will have a foul odor. The infection may also cause fever, malaise, or nausea.
- A small number of patients develop recurrent infections and inflammation of these sinus tracts. The chronic disease causes episodes of swelling, pain, and drainage. Surgery is almost always required to resolve this condition.
- How is Pilonidal Disease Treated? The treatment depends on the disease pattern. An acute abscess is managed with an incision and drained to release the pus and reduce the inflammation and pain. This procedure usually can be performed in the office with local anesthesia. A chronic sinus usually will need to be excised or surgically opened.
- Complex or recurrent disease must be treated surgically. Procedures vary from unroofing the sinuses to excision and possible closure with flaps. Larger operations require longer healing times. If the wound is left open, it will require dressing or packing to keep it clean. Closure with flaps is a bigger operation that has a higher chance of infection; however, it may be required in some patients.
Itching around the anal area, called pruritus ani, is a common condition. An irresistible urge to scratch results. It may be most noticeable and bothersome at night or after bowel movements.
Common Questions about Pruritus Ani
- What Causes Pruritus Ani? Several factors may be at fault. A common cause is excessive cleaning of the anal area. Moisture around the anus, from excessive sweating or from moist, sticky stools, is another possible cause. In some people, a loose and/or irritating stool may be caused by a high intake of liquids. In addition, drinking certain beverages, including some alcoholic beverages – especially beer – milk, citrus fruit juices and drinks containing caffeine, such as coffee, tea and cola, may be aggravating for some people. Similarly, some foods that may be a problem include chocolate, fruits, tomatoes, nuts, and popcorn. Other rare causes of pruritus ani may include pinworms, psoriasis, eczema, dermatitis, external hemorrhoids, anal fissures, anal infections, and allergies.
- Treatment of pruritus ani may include these four points:
- Avoid further trauama to the affected area
- Avoid mositure in the affected area
- Use only medications prescribed by your physician
- Avoid excess fluid and certain foods - as recommended by your physician
Anal warts (also called condyloma acuminata) are a relatively common and bothersome condition that affects the area around the anus. They may also affect the skin of the genital area. They first appear as tiny blemishes, perhaps as small as the head of a pin, and may grow larger than the size of a pea. In early stages, they do not cause pain or discomfort to afflicted individuals. As a result, patients may be unaware that anal warts are present.
Common Questions about Anal Warts
- Where do These Warts Come From? They are thought to be caused by the human papilloma virus, which is relatively contagious. The virus can be transmitted from person to person, almost always by direct contact.
- What Treatments are Available? If warts are very small and are located only on the skin around the anus, they can be treated with medications, which are applied directly to the surface of the warts. Another form of treatment involves more rapid destruction of anal warts using electrical cautery, surgical removal or a combination of the two. Laser surgery may also be used but has no advantage over other treatments. Warts inside the anal canal usually are not suitable for treatment by medications and in most cases need to be treated by cauterization or surgical removal.
- What Can be Done to Avoid Getting Anal Warts Again? In some cases, anal warts may recur repeatedly after successful removal, since the virus that causes the warts often persists in a dormant state in body tissues.
- Tips to avoid recurrence and reinfection:
- Continue observation for several months after the last wart has been spotted to improve the chances that both the warts and the underlying virus that causes them have been eliminated.
- Abstain from sexual contact with individuals who have anal (or genital) warts. Since many individuals may be unaware that they suffer from this condition, sexual abstinence or limiting sexual contact to marriage relationships will reduce your potential exposure to the contagious virus that causes these warts. As a precaution, sexual partners should be checked, even if they have no symptoms.