Anorectal woes

Content provided by the Faculty of the Harvard Medical School

Anorectal woes

Anorectal problems usually bring up the rear in polite conversation, but they can turn your priorities upside down. Symptoms range from itching to bleeding, to pain, or even leakage of stool (fecal incontinence). In most cases, the causes are mild disorders that you can manage on your own. But you should know when to call your doctor, what tests and treatments are available, and when to expect referral to a specialist.

The normal structures

It may not be a top priority for students of anatomy, but the lower end of the gastrointestinal tract is actually a busy little world of its own (see figure). The anus is the final portion of the tract; it is a mere inch and a half long, whereas the rectum above it occupies the final 6–8 inches of the colon, the large intestine. The rectum is lined by the same type of mucous membrane as the rest of the colon, whereas the anus is covered by skinlike tissue.

A look inside Hemorrhoids develop when the channels that carry blood away from the anus and rectum become dilated (widened). They are classified according to their location. External hemorrhoids develop in the anus, internal hemorrhoids in the rectum. Many people have both.

The anus and rectum have two functions: to hold back stool until it's time to defecate, then to allow the fecal material to pass easily. A pair of muscles called sphincters circle the anus. They relax and contract to open or close the passageway. The upper internal sphincter does its job automatically, but the lower external sphincter is under conscious voluntary control. Mucous glands provide lubrication, and blood vessels keep the tissues healthy. Finally, nerves coordinate the muscular function, sending signals to the brain when the rectum is full; nerves in the anus also transmit the message of pain that accompanies various rectal disorders.

In healthy men, the rectum goes about its business without calling attention to itself. But a surprisingly large number of things can go wrong, from infections to tumors. The main problems that affect the intestinal tract's bottom are itching, hemorrhoids, fissures, and incontinence.

Anal itching

Perhaps the most frequent anorectal complaint, itching is more common in men than women. It can range from an occasional sensation to a persistent maddening itch that can disrupt normal routines, particularly at night.

Doctors have identified dozens of problems that can cause anal itching. They range from excessive moisture and poor hygiene to skin disorders (such as psoriasis and contact dermatitis), infections (pinworm in children or adults exposed to their infected kids, yeast in diabetics, viruses in people who practice receptive anal sex), hemorrhoids, fissures, medications (such as laxatives and antibiotics), foods (such as spices), and mental stress. In at least 75% of cases, though, the cause of itching is unknown. And since most causes are mild problems, you should try treating yourself before calling your doctor when itching is your only symptom. Here's what to do:

Keep your stools soft, bulky, and easy to pass. That means a high-fiber diet, with a fiber supplement (such as psyllium) or a stool softener (such as docusate) if needed. Drink plenty of water. Avoid any beverage or food that seems to cause irritation; some people feel better if they cut down on coffee, colas, alcoholic beverages, dairy products, chocolate, tomatoes, spices, or citrus fruits.

Practice meticulous hygiene — but don't irritate your rump with overzealous measures or complicate your life with elaborate rituals. Use unscented white toilet paper or moistened wipes after bowel movements. Use unscented soap when you shower or bathe; be gentle and pat yourself dry afterward. Dryness is very important; some men find a handheld blow-dryer helpful. To maintain dryness, place a piece of cotton torn from a cotton ball outside your anus in the morning and at bedtime. Wear loose cotton underwear.

For additional cleansing and itch relief, you can use glycerin-witch hazel wipes (Tucks). Zinc oxide ointment may be soothing. If itching persists, you can apply 0.5% or 1% hydrocortisone ointment to the area of the itch. An antihistamine tablet at bedtime can also help.

In most cases, your annoying itch will fade away with this care. If it doesn't, or if you have other symptoms, see your doctor. He'll inspect the skin between your buttocks and around your anus and perform a digital rectal exam. Often, he'll also look inside with a small plastic instrument called an anoscope. And he may well give you an additional piece of advice that's important but difficult to follow: Don't scratch.

Hemorrhoids

Although they are often blamed for anal itching, uncomplicated hemorrhoids don't usually cause itching — but they can certainly cause plenty of other problems.

What are hemorrhoids? Hemorrhoids develop when the channels that carry blood away from the anus and rectum become dilated (widened). They're often thought of as varicose veins of the rectum. It's a useful concept although it's not technically correct, since the vascular channels are actually venous sinusoids or cushions rather than true veins. In any case, hemorrhoids are classified according to their location. External hemorrhoids develop in the anus, internal hemorrhoids in the rectum (see figure above). Many people have both.

The blame game. Long-haul truckers and deskbound executives often blame their hemorrhoids on too much sitting, but they're probably wrong. In most cases, the cause is excessive pressure on the venous channels. Men are spared the most common cause, pregnancy, but they are affected by low-fiber diets, constipation, and excessive straining to defecate.

Symptoms. Straining is also responsible for a common symptom of internal hemorrhoids, bulging through the anus to produce a swelling or mass that people can feel when they wipe or wash. The other common symptom of internal hemorrhoids is rectal bleeding. Because small arteries feed directly into the swollen venous channels, the blood is bright red. The amount varies; often there are just small streaks of blood on the outside of the stool or on the paper used for wiping. Sometimes the water in the toilet is tinted red; it looks like a lot of blood, but usually it's just a small amount diluted by the water.

When hemorrhoids are responsible for rectal bleeding, the stool itself is brown. If the blood is mixed with the stool, if the stool is maroon or black, or if clots are present, hemorrhoids are not to blame. All cases of rectal bleeding warrant a medical evaluation, but typical hemorrhoidal bleeding can wait until it's convenient. Other types of bleeding, however, should be reported promptly and evaluated thoroughly (see below).

Internal hemorrhoids bleed because the fragile channels are open but have been injured by hard stools, the pressure of straining, or both. But the same factors can also produce blood clots inside external hemorrhoids. Such thrombosed hemorrhoids don't bleed, but they sure do hurt. Because the pain flares with bowel movements, patients often hold back, producing constipation, which makes the problem even worse.

Help yourself. If you have rectal swelling, bleeding, or pain, you should see your doctor. But if the symptoms are mild or if your condition has previously been diagnosed as hemorrhoids, you can treat yourself. To keep your stools bulky and soft, eat lots of high-fiber foods and add fiber supplements and stool softeners as needed. Bulk laxatives such as psyllium (Metamucil and other brands) or methylcellulose (Citrucel and others) are fine, but you should avoid irritating laxatives. If burning, itching, or pain is present, sitz baths can help; soak your bottom in warm water two to four times a day. And yes, over-the-counter hemorrhoid creams and suppositories can reduce discomfort, though it's not clear that they also fulfill their claims of reducing swelling. Creams or suppositories that contain hydrocortisone may do a better job, but they are best suited to short-term use.

Medical measures. If your symptoms persist despite a good program of care, or if your hemorrhoids flare over and over again, you may need medical treatment. In most cases, a general surgeon or rectal specialist (proctologist) will do the deed.

Several options are available:

• Clot removal. It's a simple office procedure that provides a temporary fix when the pain of an external hemorrhoid is severe and does not respond to conservative treatment. The surgeon opens the hemorrhoid and removes the clot.

• Sclerotherapy. The doctor injects an irritating solution into the tissue around the hemorrhoid. The solution triggers scarring, which shrinks and closes the hemorrhoid. An experienced physician can perform sclerotherapy in his office in just a few minutes, for it causes surprisingly little discomfort and does not require anesthesia. The procedure is effective but is suitable only for small internal hemorrhoids that bleed.

• Rubber band ligation. This office procedure is the first-line surgical treatment for medium to large internal hemorrhoids that don't settle down with conservative treatment. Working through an anoscope, the surgeon uses a special instrument to pull down the hemorrhoid and place a rubber band around its base. Deprived of its blood flow, the hemorrhoid tissue dies and falls away in five or six days, leaving the tissue to heal itself. It's an excellent technique, but it's useful only for internal hemorrhoids, which lack pain nerves, and it can only be used for one or two hemorrhoids at a time.

• Hemorrhoidectomy. The surgical removal of hemorrhoids is the traditional definitive cure — but it's definitively a pain in the you-know-what. It requires general anesthesia, but patients can go home the same day. Postoperative pain requires medication, but complications such as bleeding, infection, and rectal dysfunction are uncommon. A new technique, stapled hemorrhoidectomy, appears to be less painful and may have fewer complications than the traditional operation.

Few men will lament the passing of the surgical hemorrhoidectomy. And all men should reduce their risk of requiring any form of treatment by keeping their stools easy to pass with high-fiber eating.

Anal fissures

Although they are nothing more than small, superficial tears in the tissue of the anus, anal fissures are the most common cause of severe rectal pain in adults. In other tissues, a tear this small might produce only mild discomfort. In the anus, though, the pain is severe because the tear triggers intense spasms of the strong sphincter muscles around the anus.

In most cases, the fissure is caused simply by the trauma of a large hard stool forcing its way through the anus. When that's the problem, a man's fissure is nearly always at the rear of the anus; if a doctor spots a fissure in another location, he'll think of an infection, bowel inflammation, or even a tumor as a possible cause.

Pain is the major symptom. It can begin abruptly with a burning or tearing sensation or it can build gradually. Because bowel movements are terribly painful, constipation is typical, and it adds to the cycle of straining, spasm, and pain. Other symptoms can include bright red rectal bleeding, which is usually scant, and a discharge of mucus.

In theory, diagnosing a fissure is simplicity itself: The doctor just has to look. In practice, though, the pain is often so severe and the spasm so strong that a detailed rectal exam may require anesthesia.

New fissures respond well to high-fiber diets and bulk laxatives, stool softeners, and warm sitz baths. Anesthetic creams can soothe the pain. But treatment is much more difficult for persistent fissures. The main job is to reduce the spasms of the sphincter muscles. Until recently, that meant surgery. Fortunately, doctors have found that medications developed for very different uses can help enormously. Nitroglycerin relaxes the muscles in the coronary arteries of patients with angina, and it will also relax the anal muscles when it's applied in an ointment. And if that doesn't work, an injection of Botox will often succeed, at least for the short run.

Infections

Rectal abscesses are deep infections caused by bacteria from the patient's own colon. A wide range of viruses and other microbes can cause superficial anal infection, most often to individuals who practice receptive anal intercourse.

Infections begin in the mucous glands around the anus, but bacteria can rapidly track into the deep tissues. Abscesses produce throbbing pain that can feel like the intense pain of a fissure, but in this case, fever and general aching and fatigue are also present. Rectal discharge and fecal soilage can also occur, particularly when an abscess is complicated by a deep tract, or fistula.

A detailed rectal exam will usually establish the diagnosis; CT scans can help determine the extent of abscesses that have burrowed deep into the tissues. Prompt surgical treatment is mandatory; antibiotics have a secondary role.

Polyps and tumors

A man who develops rectal bleeding, pain, or protuberant tissue usually hopes for a hemorrhoid but fears cancer. Although his hopes are usually realized, anal cancer is diagnosed in 1,900 American men annually. That's a fraction of the 23,500 rectal cancers and 49,200 colon cancers, but it's one reason that anorectal symptoms should be taken seriously, particularly after the age of 40.

Anal polyps and cancers are usually painless. Some bleed; others don't. A swelling or mass is the most common symptom, but soft tumors can be difficult to feel, even by a doctor's digital exam. People with chronic anal infections are at increased risk. New programs of radiation and chemotherapy have eliminated the need for surgery in many patients.

Rectal cancers can produce bleeding, narrow stools, or pain on defecation. Like many colon cancers, though, many don't produce any symptoms at all. Surgery is the mainstay of treatment.

Anorectal cancers that are diagnosed early respond well to treatment. It's why everyone older than 50 should be screened and why people with risk factors such as a positive family history should be tested earlier and more intensively.

Fecal incontinence

Urinary incontinence is extremely distressing, but fecal incontinence can be downright devastating. Shame and embarrassment prevent many sufferers from discussing the problem with their physicians, depriving them of treatments that can often help. And although few people acknowledge the problem, an estimated 7–10 million Americans suffer from it. Most are older than 65, and because childbirth can damage anal sphincter muscles, the majority are women.

The symptoms range from mild soilage and poor control of rectal gas to large-volume incontinence. The causes range from excessively liquid stools to disorders of the nerves and muscles that control defecation. Nerve problems can result from diabetes, strokes, Alzheimer's disease and other types of dementia, and multiple sclerosis. Previous rectal surgery is a leading cause of sphincter muscle damage in men. Fecal incontinence is an uncommon complication of the radical prostatectomy operation for prostate cancer.

The first step in diagnosis is a digital rectal exam. The doctor will test for rectal sensation, asking the patient to squeeze down so he can check the strength of the external sphincter muscle (see figure above). The rectal exam may reveal the most common cause of fecal soilage in the elderly — fecal impaction, in which hard stool blocks the rectum, causing liquid feces to trickle down around it. If nerve damage is suspected, a detailed neurological exam is mandatory, and if fecal impaction is the potential culprit, an abdominal exam and x-rays are important. Most patients will have a sigmoidoscopy or colonoscopy.

More specialized tests are also available. The most useful is the anal ultrasound, which uses sound waves to evaluate the sphincter muscles. Tests that measure nerve conduction or anorectal pressure patterns can sometimes help.

Therapy is most successful when abnormal stool consistency is the problem. Fecal impactions must be removed, and patients should receive good hydration, bulk agents, and stool softeners to prevent recurrences. Diarrhea can be controlled with over-the-counter or prescription medications such as loperamide (Imodium), but doctors should first test for specific causes of diarrhea, then treat any they uncover. And although it may seem paradoxical, bulk agents and fiber can help some patients with diarrhea by providing stool texture that improves control.

More complex problems require more sophisticated treatment. Biofeedback and behavioral therapies can help retrain weakened sphincter muscles. Sacral nerve stimulation has been helpful for selected patients with intact (or repaired) sphincter muscles. If that fails, surgeons can sometimes help by repairing damaged muscles, transferring healthy muscles to where they're needed, or implanting an inflatable artificial sphincter that is opened by pumping air in from a small reservoir placed in the scrotum. As a last resort, fecal material can be surgically diverted into an external colostomy bag worn on the abdomen.

Fecal incontinence is most common in the elderly, but other anorectal problems occur at any time of life. Many are mild, others serious. Some respond to self-treatment, others need prompt, even aggressive medical or surgical therapy. And since all of these problems are embarrassing, many are neglected.

Don't ignore anorectal symptoms; problems with your bottom belong at the top of your medical priority list.

Last updated:	September 05, 2008