Do Not Confuse Anal Fissure (Pain in the Butt) with Anal Cancer

A clinical picture showing a case of anal fissure. (Dr. Noorali Bharwani)
A clinical picture showing a case of anal fissure. (Dr. Noorali Bharwani)

There are various kinds of anal and rectal problems. Some are painful and some are not. Some are serious and others are a mere nuisance – if that is the right word. But all of them are a real pain in the butt – so to speak.

Anal fissure can be really painful. On the other hand, cancer of the rectum may be painless. The only way to find the real diagnosis is to see a doctor to get a good rectal examination consisting of inspection, finger examination and some sort of a scope test depending on your age and history. The important thing is to make sure we are not dealing with cancer or Crohn’s disease.

I have written about this subject before. You can check it out on my website. Today, I want to focus on the management of anal fissure. I want to emphasize that management of painful anal fissure requires a more aggressive approach than managing a “hemorrhoid itch.”

Five steps to manage acute or chronic anal fissure:

1. Make your stool well formed and bulky with a diet high in fiber. Take psyllium (Metamucil) two to four capsules per day with lots of water. This relaxes the anal muscles, helping the healing process.

2. Sit in a hot bath for 20 minutes twice a day for several days until the pain goes away. This really helps the healing process by relaxing the anal sphincter.

3. Minimize the intake of constipating painkillers.

4. Use two per cent diltiazam or nifedipine ointment inside and outside of anal canal twice a day. You need a prescription for this. This medication is associated with healing of chronic anal fissures in 65 to 95 per cent of patients.

5. What can be done if the fissure does not heal after three to six weeks? Rule out other illness of the colon and rectum. Your colon and rectal specialist will advise you on that. Surgical options for treating anal fissure include Botulinum toxin (Botox) injection into the anal sphincter and surgical division of a portion of the internal anal sphincter (partial lateral internal sphincterotomy).  Both of these are performed typically as outpatient procedures with good results and minimal of complications.

During my surgical training, I was taught if a doctor does not put a finger in the patient’s rectum then he may end up putting his foot in it. If you have rectal and anal symptoms then get that area examined well. You do not want anybody’s foot in it!

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Anal Itch Can Drive you Embarrassingly Crazy

Anal itch or some people may call it rectal itch is also known as pruritus ani (proo-rí-tus a-ní). It is a fairly common condition. Most people think that the reason they cannot stop scratching their butt is because of hemorrhoids. But hold your breath or your gas (so to speak), there is more to itchy butt than you think.

There are several benign conditions which can cause anal itch. Conditions to keep in mind are hemorrhoids, fecal incontinence of varying magnitude and severity, anal fistulae and condyloma (anal warts). Anal fissures are very painful but may be a cause of anal itch in chronic cases.

Other benign conditions which can cause anal itch are contact dermatitis, fungal infections, diabetes, pinworm infections, psoriasis and seborrhea (dermatitis of the oil glands).

A common cause of anal itch is excessive moisture in the area. Moisture may be due to perspiration or a small amount of residual stool around the anus. Itching can be made worse by scratching, vigorous cleansing of the area or overuse of topical treatments. Use of dry rough toilet paper can be another source of itch. You might as well use sand paper (just kidding!).

In some individuals, itching can be caused by eating certain foods, smoking and drinking alcoholic beverages, especially beer and wine. Examples of food items associated with anal itch are coffee, tea, carbonated beverages, milk products, tomatoes and tomato products such as Ketchup, cheese, chocolate and nuts. That is hell of a list. If you are over indulging in any of these items then you may know where the problem lies.

Cleanliness is next to godliness, so once a person develops the itch there is a tendency to wash the area vigorously and frequently with soap and a washcloth. This almost always makes the problem worse by damaging the skin and washing away protective natural oils. God will not be happy with that.

What about cancer? Yes, we have to keep that condition in mind. You may recall, Farrah Fawcett, one of the Charlie’s Angels, was diagnosed with anal cancer in 2006. She died in June of this year.

Be aware of the condition but do not panic. Anal cancer is fairly uncommon. It accounts for about one to two per cent of gastrointestinal cancers. About 4,000 new cases of anal cancer are diagnosed each year in the U.S.A., about half in women.  Approximately 600 people will die of the disease each year.

Anal cancer is commonly associated with the human papilloma virus (HPV). This virus causes warts in and around the anus and on the cervix in women.  It is associated with an increased risk of cervical cancer in women.

If you have anal itch, then talk to your doctor and get the area thoroughly checked. This includes a good history and a physical. Visual inspection of the anal area, a digital rectal examination and a scope test should be part of the examination. A biopsy of the area and stool test may be necessary. Once this is complete then the doctor (or a specialist) should be able to give you a diagnosis of the problem.

Treatment depends on the cause of the problem. Besides that there are things you can do. Try dietary modifications. Avoid moisture in the anal area by using cotton balls, gauze or corn starch powder. Avoid further injury to the area by avoiding soap of any kind and do not scrub the area. For hygiene, it is best to rinse with warm water and pat the area dry. Use wet toilet paper, baby wipes or a wet washcloth to blot the area clean. Never rub.

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There Are Good Ways to Treat Hemorrhoids

The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BC by Hippocrates. Red-hot iron was used to cauterize the hemorrhoids. In 1815, at the Battle of Waterloo, Napoleon was defeated by the British because he was too busy treating his hemorrhoids with leeches. The treatment of hemorrhoids has come a long way since.

Hemorrhoids, also known as piles, are swollen veins around the anus or lower rectum. They are either inside the anus (internal hemorrhoids) or under the skin around the anus (external hemorrhoids). We all have hemorrhoids. We are born with them. They are in the form of small veins. Hemorrhoidal veins get bigger from straining to have a bowel movement, during pregnancy and aging, as aging process makes the supporting tissues in that area lax. Usually, people with chronic constipation or diarrhoea are affected.

Internal hemorrhoidal veins are at three locations: at three, seven and 11 o’clock. When these veins get large and stretch out (like varicose veins in the legs) we call them hemorrhoids. External hemorrhoids are in the form of redundant skin usually at the same three locations. Some internal hemorrhoids can be quite big and prolapse through the anus that they need to be pushed back. Some people have extensive circumferential hemorrhoids and redundant skin in the anal area.

It is important to remember that hemorrhoids are not always symptomatic and all problems in the rectal area are not due to hemorrhoids. It is difficult to estimate the true incidence of symptomatic hemorrhoids.

Troublesome hemorrhoids present with symptoms like bleeding, prolapse, feeling of incomplete evacuation, soiling, irritation and/or itching. Severe pain in the rectal area is usually due to thrombosed hemorrhoid, fissure, infection (abscess) or cancer.

The diagnosis of symptomatic hemorrhoids is usually made with digital rectal examination and direct visualization with an instrument. If a patient presents with rectal bleeding then other causes of bleeding should be ruled out by a scope test. All patients with symptomatic hemorrhoids do not require leeches, iron rod, Captain Hook (just kidding) or surgery. I find that about 80 per cent of my patients with symptomatic hemorrhoids can be managed by medical treatment only.

Medical treatment includes careful examination and diagnosis, detailed explanation of the problem, careful review of treatment options and monitoring progress to see if the medical treatment has worked. Detailed advice consists of high fiber diet, fiber supplement, use of hemorrhoidal ointment, hot baths and explanation on how to take meticulous care of the anal are – just like flossing and brushing your teeth!

Failure of medical treatment and patients with no external hemorrhoidal components will benefit from rubber band ligation of internal hemorrhoids in the office – a less than five-minute procedure. Patients do not require any anaesthetic for this.

Symptomatic patients with big hemorrhoids with external components require surgical excision. Duration of this procedure and post-operative recovery time depends on the extent of surgery required to fix the problem.

If you think you have hemorrhoidal problems then do not be afraid to have your butt checked out. Believe it or not, there are gentler and kinder ways to take care of the area. And you might even get a candy or a sucker after the procedure! You may even say “thank you” before you leave the office.

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