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Rectal Disease
The rectum refers to the last four to five inches of the digestive tract. The rectal outlet or opening is called the anal canal, or anus. There are many troublesome problems that can occur in the rectum. Fortunately, most are treatable when recognized early and properly diagnosed. Rectal symptoms of pain and bleeding should always be thoroughly evaluated by your physician. Sometimes your doctor may advise you to see a specialist in digestive disorders (called a gastroenterologist) or a surgeon who has received special training in diseases of the colon and rectum (called a colorectal surgeon or proctologist).

What are hemorrhoids?
Hemorrhoids are veins in the anal canal that become swollen or stretched. Just like varicose veins in the lower legs, hemorrhoids often cause no problems.

What are the different types of hemorrhoids?
There are two type of hemorrhoids: external and internal.

External hemorrhoids are swollen veins that can be seen under the skin outside the anal canal. Usually they look like a small bulge and are the same color as the skin.

Internal Hemorrhoids are swollen veins that arise from inside the rectum. When internal hemorrhoids become large they may prolapse through the anal canal. The most common sign of hemorrhoids are traces of bright red blood on toilet paper or drops of blood into the toilet. Thrombosed hemorrhoids contain a blood clot and are painful.

Burning, discomfort, and itching may result if hemorrhoids become irritated.

How do hemorrhoids develop?
Hemorrhoids are very common. About half the population have hemorrhoids by age 50 years. Hemorrhoids develop due to increased pressure often caused by straining to have a bowel movement. Hemorrhoids frequently develop in women during pregnancy when the presence of the fetus causes increased pressure on the rectal area. Chronic constipation or diarrhea may also lead to hemorrhoids as may heredity and aging.

How are hemorrhoids diagnosed?
As with all conditions involving the anal canal or rectum, diagnosis is made by examining the anus visually and by performing a digital (with a gloved finger) rectal exam. Following this, a lighted instrument is inserted into the anal canal so that the interior of the rectum may be visualized. This lighted tube may be an anoscope (a short tube which can examine the last few inches of the rectum) or a sigmoidoscope (a longer tube which can also examine the lower part of the large intestine).

How are hemorrhoids treated?

Medical Treatment
Eliminate constipation. Bowel movements should be soft not hard, and should pass without the need to strain. Constipation is usually caused by insufficient bulk in the bowel movement, creating the need to strain to pass it. Increasing water intake, dietary fiber (see table below) and exercise are often effective remedies. The average American diet is often deficient in fiber, and your doctor may advise you to take fiber supplements.

There are many medicated creams and/or suppositories that can be used to reduce swelling and discomfort of inflamed hemorrhoids, examples include Preparation-H and Anusol. It may also be helpful to sit in a tub of warm water (sometimes called a "sitz bath") several times a day, especially after a bowel movement. Cotton pads soaked in witch hazel may also provide temporary relief.

When hemorrhoids bleed excessively or are very painful, they can be treated. There are several types of treatment:
Sclerotherapy: injection of a chemical solution into the hemorrhoids causing them to shrink
Infrared coagulation: a special device used to destroy the internal hemorrhoids
Banding: a rubber band is placed around the hemorrhoid and causes strangulation followed by scarring
Hemorrhoidectomy: surgical removal of hemorrhoids

The first three are office procedures which can be done as an outpatient.

What is an anal fissure?
This is a fairly common condition in which the lining of the anal canal becomes torn. This generally produces pain or burning, especially with passage of a bowel movement. Bleeding may also occur. A fissure usually occurs with constipation or after forceful passage of a large, hard bowel movement. However, fissures also may occur without straining, since the tissue lining the anal canal is very delicate.

How is a fissure diagnosed?
When a fissure is present, a digital rectal exam is usually painful. The fissure can be usually be visualized by an external inspection of the anus, or an anoscope can be used to determine the extent of the tear.

How is a fissure treated?
Warm tub or sitz baths several times a day in plain warm water for about 10 minutes.
Stool softeners to provide a regular soft, formed bowel movement.

Creams and/or suppositories (Preparation-H or Anusol).

Most fissures will heal within several weeks, but surgery may be necessary if symptoms persist. Surgical treatment usually consists of cutting a portion of the muscle in the anal canal (sphincterotomy). This procedure reduces the tension produced by the fissure and allows it to heal. Of course, the best treatment is prevention, and ingestion of a high fiber diet to promote bowel regularity is of utmost importance.

What is an anal abscess/fistula?
An abscess is a cavity filled with pus. This usually results from a blockage of the anal glands located just inside the anus. A fistula is a connection or tunnel between the anal gland and the buttocks, usually very close to the anal opening. An anal fistula is almost always the result of an anal abscess.

What are the symptoms of an anal abscess/fistula?
An abscess produces considerable discomfort and swelling just adjacent to the anal opening. Fever may also be present. A fistula produces drainage from the anal canal to the opening of the fistula on the buttocks.

How is an abscess treated?
Treatment consists of draining the pus. A small opening is made in the skin to allow drainage of pus. In about 50% of individuals, a fistula will form after the abscess has been drained. This usually develops after several weeks, but sometimes occurs several months or even years later.

How is a fistula treated?

Surgery
Generally the sphincter muscle is cut to open the tunnel, thereby connecting the internal and external openings of the fistula. A groove is formed which then slowly heals and forms scar tissue. During the healing process individuals are given stool softeners to lessen the risk of irritation from passing bowel movements. Sitz baths are also frequently recommended.

What is pruritus ani?
This refers to itching around the anal area. It is often most troublesome at night or following a bowel movement.

What causes pruritus ani?
Excessive cleaning or wiping of the anal area is frequently the culprit. Excessive sweating in the area around the anus is another cause. Certain beverages, including alcohol, citrus drinks, and caffeine-containing drinks may aggravate the problem and highly-spiced foods, chocolate, nuts and popcorn may be irritating as well. Rarely, infections and skin conditions can produce pruritus ani. Poor hygiene is usually not a cause.

Unfortunately, when the problem develops, individuals often compound the problem by excessively washing and cleaning the anal area. This leads to a cycle of increased irritation.

How is pruritus ani treated?
	avoid irritating soaps (often those containing perfumes)
	gently blot the area clean with a moist wash cloth
	never excessively rub or scratch the area
	eliminate irritant foods and beverages (coffee, alcohol, spicy foods)
	keep the area dry with powder (avoid perfumed or deodorant powders)

What is rectal prolapse?
Rectal prolapse refers to a condition where the very end of the rectum protrudes out of the anal canal. This protrusion may be temporary, but may become permanent over time when the end of the rectum cannot be pushed back into the anal canal. This condition often results in constant leakage of stool and/or mucus. While the symptoms may be similar to those produced by hemorrhoids, in this condition there is protrusion of the rectum itself and not just swollen hemorrhoids.

What causes prolapse?
This is often caused by a longstanding habit of straining to have a bowel movement. In some cases there is a genetic predisposition. Still others may have weakness of the pelvic muscles and loss of control of the anal sphincter, the muscle which controls the release of stool. In some cases, a neurological condition leads to prolapse.

How is prolapse treated?
Unfortunately, once prolapse develops, surgical correction is often necessary. The type of operation performed often depends upon the severity of the prolapse, the age of the individual, and the presence of other health problems. As with most disorders of the anorectal region, prevention is best, and a high fiber diet and good bowel habits are most important.

Information Courtesy of
The American College of Gastroenterology