• Piles
• Anal fissures
• Itching of the anus

What are piles?

• Hemorrhoids are swollen veins that are normally present just inside the anus.
  • They can be considered to be normal “cushions”.
  • They can enlarge (because of increased pressure in the veins) simply as the result of straining or frequent defaecation.
  • They are often worse during pregnancy.
  
  
• Gradually this high pressure can lead to enlargement of the veins.
  • Then there is the possibility of some protusion (proplase) of the hemorrhoids at the time of passing a bowel motion.
  • They usually withdraw back again but can stay out (sometimes causing discomfort) and may need to be pushed back.
  
  
• The main symptom of hemorrhoids is bleeding.
  • This is bright red bleeding noted on the toilet paper.
  • Or there is a “dripping” or ”squirting” of blood that can splatter in the toilet bowl.
  • If there is some protusion of inflammation of the hemorrhoids there can be discomfort or pain of defaecation.
  • Usually there is bleeding without pain.
  • Another type of problem is the external hemorrhoids.
    • There can be a clot forming in the vein and this gives a painful firm lump that is easily felt.

Diagnosis and treatment.

• Rectal bleeding should never be dismissed as simply hemorrhoids without a proper examination.
  • This requires passing a tube into the rectum to examine the bowel (sigmoidoscopy).
  • For people older than 40 years it is important to perform a colonoscopy to have a complete inspection.
  • Colonoscopy may be required at an earlier if there are concerns about the nature of the bleeding or other symptoms.
  • Specialist review may be required.
  
  
• The use of cream and/or suppositories can reduce the associated inflammation and may reduce discomfort and reduce bleeding.
  • Anusol onitment and suppositories are commonly given.
  • Some continued bleeding can be accepted so long as a thorough examination has been performed.
  • Discomfort around the anus may be an associated symptom (see pruritis ani).
  
  
• Reducing straining by treatment of constipation is the important approach.
  • Increased fibre is usually the best approach.
  • However there are other ways of improving bowel habit if fibre causes problems such as bloating.
  • If diarrhoea and bowel frequency is the problem then appropriate diagnosis and treatment is requires.
  • Avoid prolonged sitting and straining on the toilet.
  
  
• If the bleeding continues then surgical treatment is required.
  • This can be simple injection treatment or banding which can be performed in an office setting.
  
  
• If there is significant prolapse of the hemorrhoids or failure of simple treatment then an operation under general anaesthetic may be required.

Anal fissure

• An anal fissure is a split in the lining of the anus.
  • There is pain on passing a bowel motion and bright red bleeding at the time of passing a bowel motion.
  • The diagnosis is usually obvious with careful examination of the anus.
    • A more complete examination by sigmoidoscopy and colonoscopy may be required.
  • Treatment involves the avoidance of straining and hard faeces.
    • This is best achieved with fibre supplements such as Metamucil or Normacol.
  • Relieve of discomfort and some improvement in healing can be achieved with cream and suppositories.
  
  
• If these simple measures do not achieve healing then specialist advice is required from a gastroenterologist or Colorectal Surgeon.
  • Studies have shown that high pressure in the anal sphincter is the main underlying problem.
  • The first option is usually Rectogesic cream.  This contains a compound that relaxes the muscle of the anus.
    • Applying too much cream results in headache because absorption of the medication results in relaxation of muscles in blood vessels(especially those to the head).
    • It is important that fibre supplements are continued as well as suppository treatment.
  • The next option that could be considered is BoTox injection to the anus.
    • This is expensive but effective.
    • There will be a degree of paralysis of the anal sphincter for 6-12 months.
    • Healing rates are 70-80% but recurrence is possible once the effect wears off.
  • If these "conservative measures" fail then surgery can be considered.
    • Dilatation of the anal canal under GA is rarely done now as this is uncontrolled and excess damage occurs.
    • The most common operation is a lateral sphincterotomy.
    • This is very effective long-term treatment but have a small risk of incontinence in the longer term (approx 5%).

Pruritus ani (itching around the anus)

• The skin around the anus is delicate and sensitive. Itching can occur with constipation or diarrhoea or if there is contact between skin and stool.
  
• There are many causes - specialist is often required. Some causes are listed below:
  • Excessive wiping (because of diarrhoea or faecal seepage).
  • Excess moisture - sweating /tight clothes / overweight / change to hot climate.
  • Some foods may aggravate the problem.
    • Coffee/caffeine.
    • Tomatoes.
    • Spicy food.
    • Citrus.
    • Beer.
    • Chocolate.
    • Dairy products.
  • Skin conditions - dermatitis, psoriasis.
  • Rectal conditions - prolapse, fissure, fistula.
  • Infections - pinworm, scabies, fungal infections.
  • Cancers of the anus.
  • Diabetes.
  • Topical applications - soaps, perfumes.
  • Generalised (whole body) itching is a different problem and different range of possible causes.
  
  

• Some suggestions for treatment are:

  • Wash the area with water, but not soap, after a bowel movement.
    • Soap can dry out the skin, making discomfort worse.
  • If possible, wash in the shower with lukewarm water or use a salt bath.
  • Try not to use toilet paper to clean up—rubbing with dry toilet paper will only irritate the skin more.
  • Pre-moistened, alcohol-free towelettes are a better choice (wet wipes).
  • Let the area air dry after washing. If you don't have time, gently pat yourself dry.
  • Use a moisture barrier ointment.
    • This is a protective ointment (not cream) to help prevent skin irritation from direct contact with stool.
    • Zinc oxide with balsam (Anusol ointment) is a good choice but there a range of options.
    • Moist creams with steroids or antifungal may be aggravating (Proctesedyl).
  • Try using non-medicated talcum powder to relieve anal discomfort.
  • Wear cotton underwear and loose clothes that "breathe." Tight clothes that block air can worsen anal problems. Change soiled underwear as soon as possible.
  • If you use pads or disposable undergarments, make sure they have an absorbent layer on top.
    • This will help protect the skin by pulling stool and moisture away from the skin and into the pad.
  • Consider dietary changes.
  • Specialist examination will be required to check for some of the diagnoses listed above.
    • The reassurance from a normal examination can be a major help.