Common Anal Problems
Include hemorrhoids, anal fissure,perirectal abscess and anal fistula.
Hemorrhoids are dilated veins involving the lower rectum(internal) and anal canal(external). Internal hemorrhoids are insensate until they become prolapsing into the anal canal where they become sensitive. Painless bleeding from internal hemorrhoids may respond to rubber banding since they are insensate. Once they are prolapsing they generally need to be excised if they do not respond to conservative management with hydrocortisone and sitz baths. Presently there are sutureless ways of excising hemorrhoids which cause less pain than older suturing techniques. External hemorrhoids or skin tags may become enlarged with repeated trauma of constipation, bicycle, motorcycle, and horseback riding, and can thrombose where they develop a painful blood clot which may respond to conservative measures but generally are incised and drained of the blood clot to provide more immediate relief.
Anal fissure is a painful tear through the mucosa down to the internal anal sphincter which is associated with pain with each bowel movement and may be associated with a small amount of blood on the toilet paper(as opposed to more painless bleeding from internal hemorrhoids) initial conservative care includes sitz baths , hydrocortisone cream/suppository. After a few weeks this condition becomes chronic and may require relaxing the sphincter with Botox or surgically to relieve the cycle of pain and spasm.
Perirectal abscess is initially caused by an obstructed/infected gland at the junction of the rectum and anal canal which is used to lubricate stool. The infection tracks into the peri-rectal space and down to the perirectal skin. Incision and drainage is used to treat the abscess however the communication to the rectum may not heal which leads to a fistula from the rectum and a recurrent abscess or chronic fistula. The tract can be opened if low and below the external sphincter or plugged with an absorbable collagen plug if involving the sphincter muscle.