What is an Anal Fissure?
An anal fissure is a tear in the skin around the anus. It can be terribly painful when passing a bowel motion, and the pain can last for some time after the motion has passed. It can cause also bright red bleeding from the back passage.
It can be caused by passing a large, hard motion, where the skin of the back passage has been stretched. It can also happen if you are passing loose, frequent bowel motions, where the skin becomes fragile and weak.
Can fissures heal without treatment?
Superficial tears can sometimes heal in a couple of weeks. However, what can happen, is that the muscle that keeps you continent, the anal sphincter, can go into spasm due to the pain. This results the blood supply to the skin of the anus, being reduced. If the blood supply isn’t good, the skin then fails to heal properly. The fissure then becomes a chronic problem that can be miserable to live with.
What treatments are there for anal fissures?
The most common treatment is a cream called GTN, or another agent called diltiazem. They are used on the skin of the anus twice a day for 8 weeks. We would also prescribe a laxative to make sure that your motion is soft and easy to pass. The creams increase the blood supply to the skin around the anus and we can often get the fissure to completely heal.
If the fissure is still causing symptoms after this time, my practice would be to do a small day case procedure, under an anaesthetic. During this operation, I would inject botox into the muscle of the back passage. This has the effect of reducing the spasm in the back passage, allowing a good blood supply to get to the anal skin, so that it will heal. This procedure can be repeated if the fissure recurs.
Rarely, these measures fail, and then I would discuss the other options available.
What should I do if I think I have a fissure?
If you have symptoms of pain or bleeding from your back passage, it is totally appropriate to see your GP, so you can be examined. Your GP can start first line treatment, if they are able to see an obvious fissure. If it isn’t obvious what the cause of your symptoms are, then your GP will refer you to a specialist, like myself, for further investigation and treatment. Your GP can also refer you to a specialist, if first line treatment has failed.
What are the symptoms of bowel cancer?
Unfortunately, the symptoms of bowel cancer are not very specific. Some symptoms can be signs of totally harmless conditions that do not need urgent treatment. However, I would advise that if you suffer from any of the following problems, you should see your GP and discuss with your doctor about seeing a specialist:
– bleeding from your back passage
– a change in your normal bowel habit
– unexplained weight loss
– the feeling that you still have poo in your back passage, even after you’ve fully opened your bowels
Diverticular Disease
What is diverticular disease?
Diverticular disease is the presence of pockets in the bowel wall. It is really common, and in this country, about 50% of the population will have diverticular disease by the time they are in their 80’s.
It is thought to be caused by a lack of fibre in the diet, which means that the large bowel has to work hard to push motion through to the back passage, forcing these pockets out. Once you have the disease, the diverticulae cannot be removed in any way, apart from surgery to remove the affected bowel. However, the vast majority of people who have diverticular disease do not have any symptoms, or very mild symptoms, like bloating or mild tummy pain.
Diverticular disease does not predispose to bowel cancer, but it can get inflamed, requiring antibiotics. Rarely, people can have serious complications, that do require an operation to sort out.
How is diverticular disease diagnosed?
We can see the presence of diverticular disease on a camera test of the bowel (colonoscopy or flexible sigmoidoscopy). It can also be seen on CT scans of the abdomen.
Here’s a useful link to find out more information:
What is Irritable Bowel Syndrome (IBS)?
This syndrome is very common and causes tummy pain as well as diarrhoea and/or constipation. Every person who suffers with the problem, can have a very different combination of symptoms. Common triggers are certain foods and stress.
We don’t really know what causes IBS, but it is thought that in affected people, the bowel is very sensitive to wind, stress or certain foods.
How is IBS diagnosed?
Unfortunately, there isn’t a test for IBS. You can only say that you have IBS, if we have ruled out other causes for your symptoms of tummy pain and altered bowel habit. That normally involves a test to look at the inside of your bowel (a colonoscopy or flexible sigmoidoscopy), plus some blood tests and sometimes a sample of your motion, to rule out infection.
Although IBS does not cause any sinister problems like bowel cancer, some of the symptoms of IBS can also be symptoms of bowel cancer. That is why, if you have persistent problems, you should see your GP and possibly get referred to a specialist.
Another point to note, is that Irritable bowel syndrome does not cause bleeding from your back passage, so if you have this symptom, you need to seek medical advice.
Here’s a link for more information, and some helpful ideas on how to cope with the symptoms:
Haemorrhoids
What are piles/haemorrhoids?
Absolutely everyone has anal cushions in their back passage. These cushions are there to help you decide if you are going to pass wind or a motion, and help control things until you are in a convenient place to open your bowels. These anal cushions have blood vessels in them, which can become swollen or engorged, causing pain. They can also become fragile, causing bleeding.
When these anal cushions cause a problem, they are called piles or haemorrhoids. Haemorrhoids can be external, where they come out of the anal canal, or internal, where you may not notice anything on the outside of your bottom.
What symptoms can you get with piles?
The commonest problem is that piles can bleed and sometimes this can seem quite dramatic. It is usually bright red blood, like if you had cut yourself, and can be on the toilet paper when you wipe, or in the toilet bowl after passing a motion. It is usually painless. They can also cause itching around the anus or a mucous discharge, which can feel like you a leaking motion from your back passage, without any control.
When the piles prolapse out of your back passage (anus), they can then get engorged and uncomfortable. Sometimes a blood clot can develop in them, called a thrombosed pile, and this can be very painful.
What should I do if I think I have piles?
The first point to make clear is that piles do not become anything sinister or cancerous if left alone. However, when you have problems as described above, they can also be symptoms of something more serious like a bowel or anal cancer. You could also have inflammation of your bowel called colitis, which does need medical treatment.
It is recommended that you seek medical advice from your GP or a specialist, to make sure there are no sinister causes for your symptoms and to start treatment, should it be needed.
What happens when I see a specialist for piles?
A doctor will ask you about your symptoms and medical history. You will then have an examination of your tummy and back passage which does not need you to have your bowels cleared out first.
In most cases, we would organise a formal camera test (flexible sigmoidoscopy or colonoscopy) to look further into your bowel to make sure we are not missing any other diagnosis. It does involve having your bowels cleared out with an enema or a preparation taken by mouth, so we can see the inside of your bowel clearly. If the camera test shows that you have piles and no other problem, the specialist would then advise you on treatment.
What treatments are there for piles?
If your tests are normal and your symptoms have eased, you don’t need to do anything further. If your symptoms are mild, for example, occasional bleeding that’s on the paper when you wipe, this often responds to increasing your fibre and water intake. This softens your motion so that it is easy to pass and can prevent you from straining. Taking a regular laxative can also be helpful.
If you have internal piles with itching, mucous discharge or bleeding, we would recommend banding your piles. This can be done in clinic or when you have your camera test and you would normally be able to resume normal activity straight afterwards.
When internal piles do not respond to changes in diet or banding, I would perform a Haemorrhoidal Artery Ligation Operation (HALO). This stitches the main blood vessels that supply the piles and is done while you are asleep under a general anaesthetic. We would usually perform this as a day case procedure, where you would be back at home on the day of surgery.
For the external piles that prolapse out of the anus, we would perform an operation where we remove the most prominent piles. This is called an open haemorrhoidectomy and again, is carried out under a general anaesthetic as a day case procedure. For both the HALO procedure and the open haemorrhoidectomy, you would be expected to have some time off work to recover.
Inflammatory Bowel Disease
What is Crohn’s Disease?
Crohn’s disease is an inflammation of the digestive tract. It can affect anywhere along this tract from your mouth to your back passage. It causes you to feel unwell in a variety of ways, but commonly it can cause diarrhoea, often with blood mixed in, and you can have quite severe tummy pain.
We don’t know what causes Crohn’s disease, but we do know that smoking can make it worse. We also can’t cure the disease at present, but our treatments are getting a lot better.
How do you diagnose Crohn’s Disease?
We often diagnose Crohn’s by doing a colonoscopy, getting into the end of your small bowel, and sending (samples of tissue) biopsies to the lab. Sometimes, the only way we can pick up the problem, is with a special MRI scan.
Can an operation cure the disease?
Unfortunately, because Crohn’s can affect any part of the digestive tract, you can’t completely cure the disease with an operation. There are definite indications for surgery in Crohn’s, however, particularly when medical treatments have failed. That’s why most professionals who deal with Crohn’s, work as part of a team which includes a medical gastroenterologist and specialist nurses, to ensure that you get the best care.
Here is a link for more information:
What is Ulcerative Colitis?
Ulcerative Colitis is an inflammation of the large bowel. It can cause tummy pain, as well as diarrhoea mixed with blood and/or slime. It is a chronic condition which can be treated with medication and sometimes surgery. We still don’t know exactly what causes Ulcerative Colitis, but the treatments are improving every day.
How do you diagnose ulcerative colitis?
We often diagnose ulcerative colitis by doing a colonoscopy, and sending (samples of tissue) biopsies to the lab.
Can an operation cure the disease?
As ulcerative colitis affects just the large bowel, an operation to remove the large bowel and the back passage, can cure the disease. However, this would usually not be considered as first-line management, and we would only consider this option if other medical treatments had failed. That is why we take a team approach in dealing with patients affected by the disease, and we work closely with a medical gastroenterologist and specialist nurses, to ensure that you get the best care.
Here’s a link for more information:
What is an Anal fistula (fistula-in-ano)?
This is a small track between inside the back passage and the skin around the back passage. They are normally a result of having a blocked anal gland. This would have led to an abscess, which has drained onto the skin around the back passage.
What are the symptoms of a fistula?
It can cause pain and discharge around the anus. Typically, there can be a small opening that drains, but it can heal over, causing a build up of pus underneath. This gets very painful, until it discharges again.
How is a fistula treated?
The mainstay of treatment is surgery, as there isn’t any other way of getting rid of this track. If the track is shallow, I would normally lay the track open, which takes a couple of weeks to heal.
If the track runs through the sphincter muscle, which is the muscle that keeps you continent (keeps you in control of passing wind and motion), then the surgery is more complex and can involve a couple of stages. I will not know how deep the track is until I have examined your back passage under an anaesthetic.
What should I do if I think I have an anal fistula?
You should seek medical advice from your GP, as they can examine you and make a diagnosis, then refer you for specialist care.
What is the pelvic floor?
Basically, your pelvic floor is the “hammock” or sling of muscle that supports your pelvic organs (bladder, back passage and womb).
What are pelvic floor disorders?
When this sling of muscle becomes weak or damaged, it can give symptoms that are together called pelvic floor disorders:
– Lack of bladder control
– Lack of bowel control, or difficulty evacuating your bowels
– Prolapse of pelvic organs, where the womb, bladder or bowel can sag down though the vagina or anus.
The commonest cause of pelvic floor disorders is childbirth, but anybody, men or women, can be affected. You also are more at risk if you are overweight, or had surgery or radiotherapy to the pelvis.
What conditions of the pelvic floor do you treat?
I help people who have problems with control of their bowel (faecal incontinence) or have trouble effectively emptying their back passage (obstructive defaecation). The treatment often starts once I have made sure there are no other causes for the change in your bowel habit.
If you have problems with bladder control, it is best to see a gynaecologist, and your GP can refer you to an appropriate specialist.
Here’s a link to more information
What is a Pilonidal Sinus?
A pilonidal sinus is a small hole or “tunnel” in the skin. It usually develops at the top of the cleft of the buttocks, where the buttocks separate. More than one hole may develop, and often these are linked by tunnels under the skin.
It is normally diagnosed on examination of the area, and further testing is not usually required.
Why do pilonidal sinuses occur?
The exact cause of a pilonidal sinus is not fully understood, but is very likely to be caused by loose hair piercing the skin.
Certain things can increase your chances of developing a pilonidal sinus, such as being overweight, having a large amount of body hair, and having a job that involves a lot of sitting or driving.
What symptoms can you get with this condition?
If the sinus becomes infected, an abscess can develop. An abscess is a painful collection of pus that causes symptoms such as pain and swelling under the skin, often along with a temperature. This is an acute problem and needs to be seen in hospital as an emergency. You would usually be taken to theatre for a small day case procedure to drain the pus. You would then be left with an open wound which would be packed on a regular basis till it heals. It would be normal practice to arrange for the nurse at you GP Surgery to do the dressings, and the wound takes about 2-3 weeks to heal.
However, the other way that a sinus can present, is with pain and discharge from the cleft between your buttocks. If this is the case, you can be referred by your GP to a general surgeon, to be seen in clinic and your treatment can be planned from there.
How are pilonidal sinuses treated?
Unfortunately, there isn’t any medication that will make the sinus go away, and the only way to cure the disease is with surgery.
However, the first concept to understand, is that this sinus is probably caused by hair that has broken off and pierced the skin of the cleft between your buttocks. If the area around your buttocks is particularly hairy, I would normally go through methods of hair removal with you, so that you can pick the one that will suit your lifestyle the best.
The next concept to understand, is that whatever operation is decided on, this area is particularly difficult to get to heal. This is because it is hard to avoid pressure on the area, as most people will need to sit down for periods during the day, and because it is an area that is relatively close to your anal canal, where there are quite a few bugs around that could potentially infect the wound. For this reason, I do not perform this operation on people who are current smokers, as this is known to reduce wound healing even further.
What are the operations for Pilonidal Sinus Disease?
Excision and primary closure:
It is my practice to excise the area that is affected and try to get the area closed with stitches. This is often done as a day case, so you will be home on the same day as your surgery. Sometimes you are left with a drain, which collects any fluid or blood that can form after the surgery. In this situation, I will make arrangements for your drain to be removed by your practice nurse in a couple of days. I will normally also arrange for your stitches to be removed in 14 days.
Wide excision
In some situations, I may cut out the section of skin that contains the sinus, then leave the wound open, to be packed with a dressing.
The advantage of having a wide excision is that, after the procedure, the chances of the infection returning are low. The disadvantage is that the wound will take a longer time to heal and your dressings will need to be changed daily for some weeks after.
What should I do if I think I have this condition?
The best thing to do is to see your GP who will then refer you to a surgeon for your definitive treatment.