Hemorrhoids can also be caused by:. Although the most common symptom of hemorrhoids is blood in the stool or blood on the toilet paper after wiping, there are other warning signs. Some other common symptoms of hemorrhoids are:. Hemorrhoids can be completely painless, as with internal hemorrhoids, or they can be quite painful if they are located outside of the anus.
Depending on your toilet habits, you can exacerbate irritation and cause more bleeding and itching. Excessive rubbing or cleaning of the affected area can make it worse. Be proactive about your health. Make a commitment to regular visits to your doctor. If you are experiencing pain and rectal bleeding, speak with your doctor about having a colonoscopy, even if you are under 50 years of age. Although the rate of colon cancer in adults aged 50 or older is declining, there is an increase in young-onset colon cancer.
Patients with a wide variety of anorectal lesions present to family physicians. Most can be successfully managed in the office setting. A high index of suspicion for cancer should be maintained and all patients should be questioned about relevant family history or other indications for cancer screening. Patients with condylomata acuminata must be examined for human papillomavirus infection elsewhere after treatment of the presenting lesions. Their sexual partners should also be counseled and screened.
Both surgical and nonsurgical treatments are available for the pain of anal fissure. Infection in the anorectal area may present as different types of abscesses, cryptitis, fistulae or perineal sepsis.
Fistulae may result from localized infection or indicate inflammatory bowel disease. Protrusion of tissue through the anus may be due to hemorrhoids, mucosal prolapse, polyps or other lesions. Patients frequently present to family physicians for evaluation of lesions in the anorectal area. Pathologic findings are often discovered during a routine examination or during assessment of symptoms.
A thorough physical examination should be performed to detect and evaluate all anorectal lesions. This examination must include abdominal examination, visual inspection of the anal and perineal areas, digital rectal palpation and anoscopic visualization, preferably using an Ive's slotted anoscope see part I: Symptoms and Complaints. Further testing and examination, including sigmoidoscopy or colonoscopy are indicated in select patients.
It is a grave error to automatically assume that every patient who presents with common, mild or occasional symptoms has only a benign condition such as hemorrhoids. Cancer can coexist with benign lesions, so complete assessment is necessary. Colorectal cancer can be cured only if found early. Once cancer is ruled out, more than 90 percent of anorectal complaints can be managed in the primary care physician's office using simple techniques.
Patients are often unaware that condylomata can arise around the anal area Figure 1. Condylomata represent a focal manifestation of a diffuse infection and occur in only a minority of those infected with HPV.
Although those who engage in anal intercourse have a higher frequency of perianal condylomata, the majority of patients with perianal condylomata have not engaged in anal intercourse. Infection is believed to occur due to pooling of secretions in the anal area. Condylomata can reach substantial size, and multiple lesions are common. If one lesion is present, a complete genital and anorectal examination is indicated to detect additional growths.
Extensive perianal condyloma acuminata arrow. This condition is generally caused by infection with human papillomavirus 6 or The entire affected area should be soaked for three to five minutes with 3 to 5 percent acetic acid vinegar.
The abnormal warty tissue turns white and can be better distinguished from normal tissue. Magnification devices, such as a colposcope, allow the clinician to observe small lesions that may not otherwise be readily identified. Magnification helps assure that an entire lesion is removed or treated. A variety of agents or modalities can be used to successfully treat condyloma acuminatum. It is not necessary to protect the uninfected area with petroleum jelly because it is difficult to apply and often inadvertently protects the warty tissue.
The acid is applied with either the wooden or cotton-tipped end of a cotton swab, depending on the size of the lesion. It burns for about five minutes and must be reapplied after 10 to 14 days.
Treatment with TCA is inexpensive and has an 80 percent efficacy with experienced application. The acid costs less than 50 cents per application. The treated area may swell significantly after this treatment. Skin may be sloughed off following treatment, but scarring is uncommon.
Cryotherapy is efficacious 63 to 88 percent cure , but several treatments may be needed, especially with large lesions. Laser therapy can provide cure rates of 60 to 90 percent, but a laser is not readily available to most physicians. Radiofrequency using the same units that are used for the large loop electrical excision procedure [LEEP] under colposcopic magnification resolves approximately 80 to 94 percent of condyloma with one treatment.
A small wire loop can be used to excise the lesion, or a ball electrode can be used to coagulate the wart. Surgery and electrodesiccation achieve the highest cure rates of all treatments. Interferon and fluorouracil Efudex are other treatment options. Imiquimod Aldara , a new immune modifier, is applied three times a week for up to 12 weeks.
It is effective in perhaps 50 percent of cases of condyloma acuminatum, with a recurrence rate of 20 percent.
It is applied twice a day for three days, followed by four days of no treatment. This pattern is repeated for six to 12 weeks. Whichever treatment modality is used, follow-up anoscopic examination is generally not performed until the external lesions have completely resolved.
There is always concern that the virus may be introduced into new and proximal areas by instrumentation. A follow-up anoscopic examination must, however, be performed because occult intra-anal warts are a common cause of recurrence after treatment.
The long-term consequences of HPV infection are of major concern. Infection with HPV has been associated with an increased risk of cervical and anal cancers. Verrucous carcinoma can appear to be a wart. The anal lesion of syphilis condyloma latum is usually flat but, if raised, may resemble condyloma acuminatum. Serologic testing for syphilis helps distinguish lesions.
Because HPV infection itself indicates exposure to sexually transmitted disease, testing for syphilis and other sexually transmitted diseases maybe indicated. A fissure is a small cut or split in the anoderm Figure 2. It may be induced by a hard bowel movement or straining at stool. Fissures are most commonly located anterior or posterior to the anus. When fissures are found laterally, syphilis, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, herpes, acquired immunodeficiency syndrome AIDS or inflammatory bowel disease should be considered as causes.
The physical examination is classic in the presence of a fissure. Sphincter tone is markedly increased, and digital examination produces extreme pain. Most fissures can be observed with gentle lateral retraction around the anus. If the patient can tolerate anoscopic examination, a tear may be seen in the mucosa, and frequently there is bleeding. Treatment for a fissure is quite simple when it is identified within three months of onset Figure 2. Most patients respond well to rectal suppositories containing a topical corticosteroid and a local anesthetic.
As the rectal suppositories melt, the medication soothes the inflamed area, providing symptomatic relief and promoting healing. Some authorities believe that creams are more appropriate than suppositories because suppositories cause pain on insertion and lodge in the pain-insensitive area above the fissure and the dentate line. Whichever modality is selected, adequate relief of pain is essential, and topical xylocaine ointment Lidocaine 5 percent may be a useful adjunct treatment.
It is also extremely important to keep the stool soft with a high-bulk diet to avoid aggravating the fissure. Acute posterior fissure arrow. Anterior and posterior fissures are most common.
If fissures are located laterally, other etiologies must be considered see text. Fissures can often be identified by merely spreading the glutei but generally require anoscopy. Chronic fissure. Chronic fissures may present as an external perianal tag, or sentinal tag black arrow. The proximal end may also have granulation tissue that appears as an anal polyp white arrow. When the condition is this advanced, a lateral sphincterotomy is usually required.
Once a fissure has become chronic Figure 3 , it is more difficult to obtain complete resolution. The proximal end of the fissure may contain granulation tissue that is often confused with an anal polyp. The area around the fissure becomes sclerotic and appears white. The sphincter musculature can frequently be visualized at the base of the fissure. Chronic fissures usually require surgical treatment with lateral sphincterectomy. The internal sphincter is totally involuntary.
In a person with an anal fissure, the internal anal sphincter goes into spasm, and this hypertonicity of the muscle results in pain. Persistent elevation in sphincter tone requires more forceful evacuation of stool, resulting in repeated trauma to the fissure. This vicious cycle forces the fissure open and prevents healing, which in turn exacerbates the sphincter hypertonicity. The external sphincter is under voluntary control; however, it differs from all other voluntary skeletal muscles in that it maintains a constant tonic contraction at rest.
Lateral sphincterotomy procedures incise only the lowest fibers of the internal sphincter. This allows the anal musculature to relax, and the fissure invariably heals. The intact external sphincter maintains continence. Earlier procedures, such as digital stretching, could result in fecal incontinence because of excessive muscular disruption.
Appropriately performed surgical lateral internal sphincterotomy has a very low incidence of incontinence. A nonsurgical treatment for anal fissure is nitroglycerin ointment. The ointment must be rubbed into the area, not just applied superficially. In one study, 14 the application of 0. External site of perianal fistula. The wooden end of a cotton-tipped applicator was inserted 3 cm see Figure 5 , confirming a fistula, and the patient was referred for surgery.
Blood on the end of a cotton-tipped applicator being withdrawn from a fistula that could easily have been missed. An experimental treatment is botulinum toxin Botox. This therapy is expensive, and the results of clinical trials are pending. The most common cause of anal fistula Figure 4 is cryptoglandular infection. Infections that begin in the anal glands can evolve and present as either abscesses or fistulas. Fistulas are common in patients with Crohn's disease. The track of anal fistulas can be extensive Figure 5.
Flexible sigmoidoscopic examination is indicated to evaluate the mucosa of the distal colon for signs of inflammatory bowel disease. The index of suspicion for Crohn's disease is increased by a history of episodes of diarrhea, abdominal cramping and weight loss, and the appearance, location and multiplicity of the fistulas.
Patients with fistulas are generally referred to a specialist for treatment. In addition to simple fistulotomy treatments include cutting or draining setons, endo-anal mucosal advancement flaps, sliding cutaneous advancement flaps, fistulectomy with muscle repair and fibrin glue injection. Abscesses also begin as an infection in the anal glands. The suppurative process then tracks through the various planes in the anorectal region Figure 6.
The infection can present at the anal verge as a perianal abscess. These abscesses are easily drained in the office under local anesthesia. The infection may track through the internal and external sphincter muscles to enter the ischiorectal space.
These large ischiorectal abscesses are visible on the surface of the buttocks and are best managed by surgical drainage accomplished in the operating room.
The patient complains of anal pain, and the most significant finding is a highly painful bulge that is palpated within the rectum. These abscesses are difficult to diagnose and require a high index of suspicion. Treatment options include surgical drainage into the rectum. Finally, a supralevator abscess can arise from cryptoglandular anal disease or from an abdominal suppurative condition.
This brochure addresses minor rectal bleeding that occurs from time to time. Continuous passage of significantly greater amounts of blood from the rectum or stools that appear black, tarry or maroon in color can be caused by other diseases that will not be discussed here. Call your doctor immediately if these more serious conditions occur. Because there are several possible causes for minor rectal bleeding, a complete evaluation and early diagnosis by your doctor is very important.
Rectal bleeding, whether it is minor or not, can be a symptom of colon cancer, a type of cancer that can be cured if detected early. Hemorrhoids also called piles are swollen blood vessels in the anus and rectum that become engorged from increased pressure, similar to what occurs in varicose veins in the legs.
Hemorrhoids can either be internal inside the anus or external under the skin around the anus. Hemorrhoids are the most common cause of minor rectal bleeding, and are typically not associated with pain. Bleeding from hemorrhoids is usually associated with bowel movements, or it may also stain the toilet paper with blood. The exact cause of bleeding from hemorrhoids is not known, but it often seems to be related to constipation, diarrhea, sitting or standing for long periods, obesity, heavy lifting and pregnancy.
Symptoms from hemorrhoids may run in some families. Hemorrhoids are also more common as we get older. Fortunately, this very common condition does not lead to cancer. Medical treatment of hemorrhoids includes treatment of any underlying constipation, taking warm baths and applying an over-the-counter cream or suppository that may contain hydrocortisone. If medical treatment fails there are a number of ways to reduce the size or eliminate internal hemorrhoids.
Each method varies in its success rate, risks and recovery time. Your doctor will discuss these options with you. Rubber band ligation is the most common outpatient procedure for hemorrhoids in the United States. It involves placing rubber bands around the base of an internal hemorrhoid to cut off its blood supply. This causes the hemorrhoid to shrink, and in a few days both the hemorrhoid and the rubber band fall off during a bowel movement.
Possible complications include pain, bleeding and infection. After band ligation, your doctor may prescribe medications, including pain medication and stool softeners, before sending you home.
Contact your doctor immediately if you notice severe pain, fever or significant rectal bleeding. Laser or infrared coagulation and sclerotherapy injection of medicine directly into the hemorrhoids are also office-based treatment procedures, although they are less common.
Surgery to remove hemorrhoids may be required in severe cases or if symptoms persist despite rubber band ligation, coagulation or sclerotherapy. Tears that occur in the lining of the anus are called anal fissures.
This condition is most commonly caused by constipation and passing hard stools, although it may also result from diarrhea or inflammation in the anus. In addition to causing bleeding from the rectum, anal fissures may also cause a lot of pain during and immediately after bowel movements. Most fissures are treated successfully with simple remedies such as fiber supplements, stool softeners if constipation is the cause and warm baths.
Your doctor may also prescribe a cream to soothe the inflamed area.
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