Piles and other disorders of the bottom
Perianal Diseases explained
These are a group of conditions that affect the rectum and anus (the end of the bowel where it meets the skin at the bottom) and the skin surrounding the anus. They can be broadly grouped into four different categories based on symptoms: •
- Bleeding (bright red blood)
- A lump
Most of these symptoms can readily be explained after a careful history and examination by a doctor. In unusual circumstances more invasive tests such as examination of the inside of the bowel (endoscopy) may be required.
Also known as pruritus ani, itchy bottom is common and can be socially embarrassing. It is usually related to too much moisture, irritation through scratching or chemical soaps (which leads to further scratching) or infection (such as worms). Washing the area with warm water and avoiding harsh soaps is helpful. If moisture is a problem a pad between the buttocks may help and if the skin is dry moisturising creams could be tried. Carrying a pack of moisturised wipes to clean the anus without scrubbing may be useful. Avoid rubbing too hard when using a towel, and consider using a hair dryer on a low setting to dry yourself after washing. If simple measures are ineffective your doctor should be consulted as antifungal or other creams may be indicated or other diagnoses considered.
Pain around the anus is often associated with the passage of stools; either during or afterward. It is often related to being constipated. Proctalgia fugax is an intense, self-limited pain felt in the area between the anus and the genitals. It often comes on at night. The cause is unknown, but the condition is harmless and management is generally aimed at relieving symptoms. Avoidance of constipation with a high fibre diet and drinking adequate amounts of water may help. Your doctor may prescribe an anaesthetic cream which relaxes the muscles around the anus but this can cause headaches. Anal fissures are small tears in the lining of the anal canal which can be both painful (especially when passing hard stools) and may bleed, leading to bright blood on the toilet paper. Fissures usually cause problems in people of 30–50 years of age. The pain may continue after opening the bowels as the anal muscles go into spasm. Again, a cream to help relax the anus muscles may help. Avoidance of constipation is crucial. Abscesses are collections of pus around the bottom and are felt as very tender areas which may be red, hot and swollen. People with abscesses may feel unwell with fevers and chills or the problem may be localised to the bottom. Sometimes these ‘burst’ and a smelly, sticky liquid may leak with relief of pain. Otherwise abscesses need to be incised and drained as soon as possible to relieve the pressure caused by pus. In some circumstances they may continue draining, suggesting they have formed a track or passage to the bowel called a fistula. All abscesses and persistent anal discharge should be seen by a doctor.
There are many causes of bleeding from the bottom, most of which are harmless. In some cases bleeding can be due to tumours or inflammation in the bowel which if acted upon early have a better outcome, so all bleeding from the bottom should be reported to a doctor. As mentioned above, anal fissures can lead to bright blood on the toilet paper, usually associated with pain. Haemorrhoids are the commonest cause of bright bleeding from the bottom related to veins that line the anal canal stretching under pressure and bleeding. Uncomplicated haemorrhoids usually cause no symptoms. Sometime they can protrude out of the anus (prolapse) and may be felt as a small lump which may be tender to touch.
If haemorrhoids are painful it is likely that a clot has formed in the vein but other causes of anal pain (see above) are possible and medical advice should be sought. The most common symptom is bright bleeding that is on the outside of the stool, on the toilet bowl and on the paper. About half the population have haemorrhoids by the age of 50. They are very common among pregnant women and are also often related to excessive straining when passing stools. Treatment begins with increasing intake of water and fibre to soften the stool. If such conservative methods are unhelpful a referral to a specialist may be needed. Surgeons can treat haemorrhoids by snaring them with rubber bands (banding), injecting chemicals into them to cause them to shrivel up and disappear (sclerotherapy), and as a last resort remove them during an operation (haemorrhoidectomy).
Most lumps around the bottom are skin tags and warts. Painful and bleeding lumps have been described above. Rarely, lumps around the bottom are tumours, but all lumps of this kind should be examined by a doctor. Skin tags are painless fleshy folds of skin found in the anal area. They are benign and in most cases require no treatment. Sometimes they can reflect an underlying problem such as anal fissure or inflammatory bowel disease. In those situations it is likely other symptoms would draw your attention to the underlying problem (bleeding, change in bowel habit, pain or frequency). Anal warts are caused by a virus which is usually passed on through sexual contact. These can be treated at home with a cream (imiquimod) which promotes the body’s natural immune function to kill off the virus. In some cases they may need to be treated in a specialist clinic. Anal cancer is rare and is 20–30 times less common than colorectal cancer. It may present with itch, pain, bleeding or a lump that doesn’t respond to the standard treatments. Diagnosis can be made by taking some tissue (biopsy) and examining it under a microscope. Treatment is likely to be by removal at a surgical operation.
Having asked you about the nature of the problem and taken down the details you’ve described, the doctor is likely to want to examine the area. This usually involves undressing you and having you lie on your left hand side on the examining couch. This can be embarrassing for some patients but doctors are used to dealing with such problems and it is an essential step in making the correct diagnosis and instituting treatment. If you wish, the doctor will provide a chaperone. An inspection of the anus will be made by parting the buttocks. The doctor may ask you to bear down to mimic straining as this may cause a haemorrhoid to become visible. Following inspection a lubricated, gloved finger will usually be inserted into the rectum (digital rectal examination) and the entire rectal wall will be examined to feel for lumps and check for blood. Some doctors will then carry out a proctoscopy or rigid sigmoidoscopy. This involves inserting an illuminated hollow plastic tube into the rectum through which air can be blown to distend the bowel and increase the amount of bowel lining which is visible. Assessment can then be made of the lining of the bowel and a search for lumps and haemorrhoids can be carried out. Many GPs will need to make a referral to hospital for these procedures to be carried out.
Tests to examine the bowel further up may be ordered if an explanation for the symptoms is not found in the surgery. These include flexible sigmoidoscopy and colonoscopy which are performed as a day case in hospital. They usually involve a light sedation and the insertion into the rectum of a fibre-optic camera, in the form of a long tube, which is passed a variable distance into the large bowel. Biopsies can be taken. Special X-rays such as Barium enema or CT scans may be requested.
It is often impossible to determine the nature of the problem from the symptoms alone so all cases of bleeding from the bottom, new pain and lumps should be notified to your doctor for assessment. In most cases it is possible for the GP to provide reassurance that the problem is harmless, but in a small minority of patients in whom the symptoms or signs could represent a more serious problem, an urgent referral to a bowel specialist will be required.