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Is your bottom bleeding or paining? (March, 2006)

Many are the problems in and around the anal orifice. Quite often a lay person and sometimes even doctors tend to label all of them as “piles”. Piles or haemorrhoids as it is called in medical parlance forms a fairly large percentage of diseases in that area; but there many others, some relatively less serious like “fissure”,“fistula”, perianal haematoma or blood clot, simple skin tags or warts. However sometimes these symptoms like bleeding, pain or some discharge may be due to more serious diseases like TB or even cancer. A careful evaluation by the examining doctor can result in proper diagnosis in most instances. Simple out patient tests like a digital glove examination, proctoscopy or sigmoidoscopy would result in proper diagnosis in about 95 % of patients. Special investigations like colonoscopy and biopsy, contrast X-rays of the large bowel, ultrasound scan and C T Scan may be needed in a small percentage of cases where a firm diagnosis could not be established by other simpler and inexpensive tests. Almost all these diseases including cancer can be cured if the disease is diagnosed and treated in its early stage.

Full details of symptoms, diagnosis and treatment of “Piles” is explained in one of our earlier Newsletters and are available for your perusal. Let us now see how to diagnose other diseases.

Fissure in ano.
This condition is a very painful disease. Pain may be severe and excruciating, in and around anal region occurring at the time of passing stools or even while passing any gas. Pain may last for few minutes to sometimes hours and attacks may repeat several times a day. Generally the stools are quite solid or even hard and when the subject tries to strain for evacuation, a crack forms at the anal verge. The highly sensitive nerve endings in that region causes severe pain. Often, there would be streaks of blood along one side of the column of stools and even few more drops at the end of defaecation. In many patients with fissure, there forms a fold of skin which can be felt when washing the area after stools. The fissure may heal with some dietary regimen, laxatives, local applications or some other simple measures. But it may recur if later motion becomes hard and needs excessive straining for evacuation. Repeated such episodes would result in scarring in that area and a permanent swelling/bulge at the anal verge. It is called as “Chronic fissure in ano” in contrast to I or II episode called as “Acute fissure in ano”. Chronic fissure may lead to superadded pocket of pus formation like in “fistula” and may not respond to non operative measures. If non operative measures do not produce relief surgical operation may be needed. It may be relatively simpler “lateral sphincterotomy” for acute fissure or a slightly more elaborate “fissurectomy , fistulectomy and sphincterotomy” for chronic fissure.

Fistula in ano:
This condition is due to infection and pus formation in the perianal (around anus) region. In the early stages it starts as an abscess (collection of pus) around the anal orifice. It is quite painful and usually associated with mild or even high fever. Defaecation would be quite painful and a bulge,which originally starts inside the rectum/anal canal, becomes palpable outside under the skin sooner or later. This swelling would be very tender- painful to touch. Almost always simple surgery is needed to let out the pus giving “temporary” relief. It is temporary because it almost invariably goes on to formation of “fistula in ano”. Fistula occurs whether pus is let out by surgery or the abscess bursts spontaneously. The infection gets controlled and even the wound heals in few weeks' time. But sooner or later after weeks or months, infection and abscess sets in again in the same place and either bursts open or needs surgical incision and drainage. This kind of repeated episodes of healing and infection is the hallmark of “fistula in ano”.

“Fistula” means an area or strip of infection having communication with skin or other lining at both ends. It is like a tube lined by infective material/tissues open at both ends. The abscess starts on the inner lining of the rectum/anal canal and later the abscess bursts open or surgically drained resulting in double communication. The site of infection in a fistula may be simple and straight tube like or may have several ramifications like the branches of a tree. Surgery is essential for complete cure of a fistula. But failure of surgery and recurrence of the fistula is not uncommon. Recurrence occurs if even the minutest portion of the fistulous tube or its branch is not removed at surgery. The surgeon has to be very meticulous in this so called “simple”surgery; the entire fistulous tract and all its ramifications has to be pain stakingly searched and cut out. In this surgery, after surgery the wound is left open and complete healing takes 4 – 8 weeks or rarely much longer. In case it does not heal after several months, it most probably indicates incomplete removal at previous surgery. Sometimes recurrence occurs because there is some special kind of infection like TB. If TB infection is proved by a histopathological examination, patient has to take a full course of treatment for the disease for wounds to heal.

Other causes of perianal disease, some simple and some very serious would be explained in our forthcoming newsletter.

Be knowledgeable about health matters; be healthy,

Dr. M.Mohan Rao, MBBS,MS,FICS,MCH,

Director & Senior Surgeon (Retired but not tired),
Dr. U Mohan Rau Memorial Hospital.


Updated on 01.03.2006.

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