Hemorrhoids, commonly known as piles refer to a condition in which the veins around the anus or in the rectum become swollen and inflamed. Majority of people may suffer from hemorrhoids at some point in their life time. It is more common in individuals aged between 45 and 65 years and in pregnant women. External hemorrhoids occur on the skin around the anus whereas internal hemorrhoids develop in the rectum. Internal hemorrhoids tend to protrude out through the anus.
Several factors are considered to as the causes for hemorrhoids and some of them include
- Chronic constipation and diarrhea
- Excessive straining during bowel movement
- Diet which lacks fibrous food
- Aging (weak connective tissue in the rectum and anus)
- Pregnancy (increased pressure in the abdomen)
Internal hemorrhoids: The most common symptom is passage of bright red blood with the stools. If the hemorrhoids have prolapsed, it causes pain, discomfort and itching around the anus.
External hemorrhoids: Blood clots may form in the swollen veins causing bleeding, painful swelling or a hard lump.
Your doctor will perform physical examination which involves digital rectal exam with a gloved, lubricated finger and an anoscope. Additional diagnostic tests may be ordered to rule out other causes of bleeding.
- Colonoscopy: Colonoscopy is a procedure in which a flexible lighted tube is passed through the anus into the rectum and the colon. The colonoscope helps to view the pictures of inside of the rectum and colon.
- Sigmoidoscopy: This procedure uses a shorter tube called a sigmoidoscope to transmit images of the rectum and the sigmoid colon (the lower portion of the colon).
- Barium enema X-ray: This procedure involves taking an X-ray after injecting a contrast material called barium into the colon.
Lifestyle modifications and dietary changes often are helpful in reducing the symptoms of hemorrhoids. A diet having high fiber content soften the stools and helps to pass them easily thereby avoids straining. Fruits, vegetables and cereals serve as a good source of dietary fibers. Fiber supplements such as methylcellulose or stool softeners can be taken. Drinking plenty of water (8-ounce glasses) and adequate exercise helps prevent constipation. Over-the-counter creams and suppositories help relieve the pain and itching. However, these are short time remedies as long-term use can cause damage to the skin.
Outpatient treatments are provided for internal hemorrhoids and include the following:
Rubber band ligation: In this technique, an elastic band is tied around the base of the hemorrhoid to cut off blood supply. The procedure is performed on an outpatient basis under topical anesthesia. Your doctor inserts an anoscope, a viewing instrument, into your anus and passes a small tool called a ligator through it. The hemorrhoid is grasped with forceps and the ligator is passed over the hemorrhoid to place a rubber band. Without blood supply, the tissue dies and sloughs off in 1 or 2 weeks.
As with any procedure, rubber band ligation may involve certain risks and complications which include severe pain, anal bleeding, infection in the anal canal and trouble urinating.
Sclerotherapy: This involves injecting a chemical directly into the hemorrhoid tissue. The solution numbs the site and hardens the hemorrhoid tissue leading to scar formation. After four to six weeks, the hemorrhoid shrinks and falls off. The disadvantage of this method is the recurrence of hemorrhoids after about a year.
Infrared photocoagulation: Infrared photocoagulation, indicated for small-to-medium internal hemorrhoids, uses infrared rays to form scar tissue from the intense heat created and cuts off the blood supply to the hemorrhoid causing death of the tissue which then falls off. Laser or electric current can be used instead of the infrared beams. Infrared photocoagulation is associated with intense pain immediately after the procedure, which can be managed with pain medication. There is a chance of recurrence of hemorrhoids.
Surgical removal becomes necessary when the hemorrhoids are large enough and do not respond to conservative treatment.
An anal fissure is a tear in the skin around the opening of the anus (the last part of the digestive tract that controls the removal of stools). An anal fissure is associated with pain and bleeding during bowel movements. The condition is more common in young infants but it can happen at any age.
Anal fissures are usually caused by trauma or injury to the anal canal while passing hard or large stools, constipation, diarrhea or childbirth.
Most anal fissures can be diagnosed by a physical examination which involves viewing the anal region and reviewing your medical history. In some cases, diagnosis is done by digital rectal examination or using an instrument called an anoscope. The anoscope is a short instrument with a lighted tube which can help the doctor view and examine the fissure.
Anal fissures usually heal on their own in a few days or weeks (acute), but in cases when it doesn’t heal even after 6 weeks (chronic), medical treatment or surgery is recommended.
Treatment usually involves adopting simple measures to keep your stool soft such as by increasing fiber and fluid intake. Soaking in warm water for 10 – 20 minutes as often as possible, particularly after bowel movements, also helps with healing and reducing discomfort. If symptoms still persist, further treatment is required which involves using steroid creams and botox injections. Topical anesthetics and pain medication may also be prescribed to control pain.
Surgery is recommended if the symptoms do not respond to conservative treatment. The surgical procedures include:
- Lateral internal sphincterotomy
- Fissurectomy which involves surgically removing the anal fissure leaving an open wound to heal naturally
- Advancement anal flaps which involves replacing broken tissue with healthy tissue derived from a different part of the body
Lateral sphincterotomy is the most common surgical procedure indicated for the treatment of anal fissures. The surgery is usually performed under the effect of general anesthesia in an outpatient setting or as an office procedure where you can go home the same day of the surgery. The surgery involves making a small cut or incision in the sphincter muscle to reduce the tension in your anal canal which allows the anal fissure to heal. The incision can be closed or left open to heal.
After the surgery, you will be given some pain killers for pain relief. Remember to remove the wound dressing before having a bowel movement. Complete recovery from anal fissure surgery might take several months, but this varies between individuals.
As with any surgery, the anal fissure surgery involves certain complications such as risk of infection and anal incontinence which includes inability to control gas and loss of solid stool.
The anus is an external opening through which feces is expelled out of your body. There are a number of small glands inside the anus. These glands may sometimes get blocked and form an infected cavity called an abscess. Often, anal abscesses further develop into an anal fistula. An anal fistula is a small channel or tunnel that develops from the infected gland and opens out onto the skin near the anus.
Some fistulae have only one opening, while others are branched out into many openings. Fistulae may sometimes be connected to the sphincter muscles, the muscles that open and close the anus. The ends of the fistulae look like holes on the surface of the skin around the anus. Anal fistulae are commonly treated through surgery.
Signs and symptoms
The commonly observed symptoms of an anal fistula include:
- Throbbing pain that may get severe when sitting
- Irritation of the skin around the anus
- Swelling, tenderness, redness
- Discharge of pus
- Pain during bowel movement
- Fever and fatigue
Your doctor may review your medical history and conduct a physical examination to find the opening of the fistula. This will help your doctor trace the path of the channel, which can usually be felt as a hard cord-like structure below the skin. A digital rectal examination (insertion of a gloved finger through your anus) may be performed to find the internal opening of the fistula, the presence of any branching and the functioning of the sphincter muscles. Further examinations may be performed with the use of a fistula probe (a tiny instrument inserted into the rectum) and a proctoscope (a lighted device). Your doctor may recommend an ultrasound, CT or MRI scan for complicated fistulae with many branches, to evaluate the exact position of the fistula channels.
Fibrin glue is the only non-surgical procedure for the treatment of an anal fistula. The fibrin glue is injected through the opening of the fistula and the opening is closed with stitches. Surgery is suggested when this does not relieve the symptoms of the fistula.
As part of the pre-surgical process, you will be advised to stop smoking, fast for about 6 hours before the surgery, and you will be given an enema an hour before the surgery to empty your lower bowel. Anal fistula surgery is performed under general anesthesia. The type of operation depends on the position of the fistula.
Fistulotomy: The surgery involves cutting open the fistula across its whole length in order to flush out the contents. It heals into a flattened scar after 1 – 2 months.
Seton technique: The seton technique involves passing a surgical thread into the fistula tract and leaving it in place for several months or permanently. This helps to keep the tract open and drain the contents of the fistula. This may be considered if you are at a risk of incontinence (inability for you to control your bowel movements), because your fistula crosses your sphincter muscles.
Advancement flap procedures: This procedure is usually preferred if the fistula is complex or if you are at a high risk of developing incontinence. The fistula tract is removed. A small piece of tissue (advancement flap) is removed from the rectum or from the skin around the anus and attached over the opening of the fistula.
Bio prosthetic plug: A cone shaped plug is developed from human tissue. It is used to block the internal opening of the fistula and is sutured in place. The plug does not completely close the opening, allowing the fistula to drain.
After the surgical procedure, your doctor will discharge you from the hospital on the same day or after a few days based on your condition. It might take 6 weeks for the wound to heal completely. The doctor may prescribe painkillers, antibiotics and laxatives. You will be advised to carefully wash, clean and dry your anal area. You are advised not to sit or walk for a long period until healing occurs.
Risks and complications
Anal fistula surgery is generally safe with no major risks. However, like most surgeries, anal fistula surgeries may involve complications such as:
- Narrowing of anal canal
- Damage of sphincter muscles
- Recurrence of fistula
Your doctor will access your condition with utmost detail and recommend the best treatment option.
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