MICHAEL H. TARLOWE, MD, FACS, FASCRS

Hemorrhoids are enlarged, bulging blood vessels in and around the anus and lower rectum which are both outside (external) and inside (internal). External hemorrhoids are just outside the anus and covered with skin which is very sensitive. These hemorrhoids are usually painless, unless they become inflamed or develop a blood clot (thrombosis) within them, and can then be very painful.

Internal hemorrhoids are just inside the anus and are located under the lining of what is called the anal canal. The most common symptoms of these hemorrhoids are painless bleeding and protrusion during bowel movements. Internal hemorrhoids can be painful if they develop a thrombosis or become prolapsed outside the anus and cannot be pushed back inside.

Contributing factors that cause hemorrhoid symptoms include:

• Chronic constipation or diarrhea
• Straining during bowel movements
• Aging
• Pregnancy
• Hereditary
• Sitting on the toilet for long periods of time

Mild hemorrhoid symptoms are usually treated by increasing fiber and fluids in the diet as well as avoiding straining. Sitting in a plain warm water bath for 10-15 minutes can help as well. A thrombosed external hemorrhoid may need to be treated by removing the clot via a small incision which can be done in the office under local anesthesia.

More severe hemorrhoid symptoms may require topical medication or other special treatments such as rubber band ligation, injection sclerotherapy and surgical hemorrhoidectomy. Please click on “Procedures” for more information.

An anal fissure is a small tear just at or inside the anus which typically causes severe pain and bleeding with bowel movements. Patients commonly confuse this condition with hemorrhoids. The classic complaint is severe pain during and after defecation which can last from minutes to hours. Bright red blood is also usually noted on the toilet paper, streaked on the stool or sometimes even in the bowl. Due to the pain, many patients are afraid to have a bowel movement and will eat less or take other measures to avoid defecation.

Anal fissures are usually caused by trauma to the area, typically a hard stool, but diarrhea can also be the cause. Less common causes are inflammatory conditions, infections or tumors. Patients with tight sphincter muscle tone are more likely to develop a fissure. The anal pain can lead to spasm of the muscle which decreases blood flow to the area, so the fissure is unable to heal. Chronic fissures may have an external skin tag that feels like a hemorrhoid.

Most anal fissures do not require surgery. The most common treatment is softening the stool via high-fiber diet (~ 25-30 grams/day), increasing water intake and using stool softeners. Warm baths several times a day for 15-20 minutes is critical as it relaxes the sphincter muscles so the fissure can heal. Special topical medications may be required to achieve this result as well. Surgical options (including Botox injection) are a last resort.

An anal abscess is an infection near the anus or rectum, usually containing a pus-filled cavity. The infection involves a clogged anal gland when bacteria or foreign material enters the tissue through the gland. Symptoms are typically pain, which can be severe, and swelling around the anus. Fevers and chills are possible if the infection has entered the bloodstream. The abscess is treated with drainage by making an incision in the skin after a local anesthetic is injected. This can usually be done in the office. Antibiotics in general are not a good alternative as they do not penetrate the abscess cavity.

An anal fistula is a small tunnel that forms beneath the skin and connects the previously infected gland to the skin around the anus. An abscess leads to a fistula approximately 50% of the time and there is really no way to predict or prevent it. It can develop weeks, months or even years later. Symptoms are usually drainage of pus, blood or both and often relieves a feeling of pressure. The skin around the anus can be irritated by the drainage. Fevers and malaise are also possible. The primary and most successful way to treat a fistula is via surgery. The operation involves opening the fistula tunnel, converting it into a groove, so it can heal from the inside out. This is almost always done as an outpatient procedure. Simple fistulas require cutting none or just a small portion of the anal sphincter, the muscle involved in bowel continence. Complex fistulas involve a significant portion of the anal sphincter and thus require more advanced techniques in order to avoid incontinence. Recovery time is usually less than a week.

Anal warts or “condyloma acuminata” are lesions around and inside the anus that look like tiny spots or growths and may grow larger than the size of a pea. They are believed to be caused by HPV (Human Papilloma Virus), a sexually transmitted disease. One can develop anal warts without ever having anal intercourse. They are usually asymptomatic, so patients may be unaware that they have them. Some patients will have itching, bleeding or mucus discharge, but most will present with feeling lumps around the anus.

It is recommended that the warts be removed as they will usually grow and spread, but more importantly, they may lead to an increased risk of anal cancer in that area. Multiple treatments are available including topical medications and freezing. The warts can be removed surgically as well and usually required for lesions inside the anal canal. The operation is outpatient and recovery time is usually quick. Recurrence of the warts is, unfortunately, a hallmark of the disease as they can live dormant in tissues that look normal. New warts that develop need to be treated so follow-up office visits are very important and may be necessary for months. As for prevention, abstain from sexual contact with people who have anal or genital warts.

A colonoscopy is an exam by which the entire inside lining of the colon and rectum is visualized using a long, flexible tube with a camera at the end of it. In addition, this instrument, or colonoscope, can perform biopsies and remove polyps or other lesions. Nearly all are done as an outpatient procedure and under anesthesia or some form of sedation. They can even be performed in an office setting. It usually takes less than an hour to complete. After the exam, there can be some mild abdominal discomfort which is normally relieved after passing flatus. Most patients fully recover in a few hours.

For the exam to be optimal, the inside of the colon and rectum needs to be clean of stool and other residue. This is usually done the day before the exam using a preparation recommended by your doctor. This will include being on a clear liquid diet and taking a laxative solution. Blood thinning medications will need to be stopped.

Routine screening colonoscopy for colorectal cancer typically begins at 50 years of age, while patients with a family history of colon or rectal cancer may start at 40 years old or even younger. Certain symptoms may prompt your physician to recommend a colonoscopy and these can include rectal bleeding, change in bowel habits, unexplained abdominal symptoms and occult blood in the stool.

Colonoscopy is considered to be a very safe procedure with complications occurring less than 1% of the time. These risks include bleeding, infection, perforation of the intestine and missed polyps or other lesions.

Pilonidal disease is a chronic skin infection in the area of the buttock crease near the tailbone. It is more common in men than women and associated with obesity and thick, stiff body hair. It is usually seen in patients between puberty and age 40. It is caused by hair follicles in the buttock crease that become infected. The problem is made worse by hairs being drawn into the infected area. Diagnosis is made on physical exam.

Symptoms can range from a small dimple in the area to a large painful mass. Drainage can occur and can be clear, cloudy or bloody. During an infection, or pilonidal abscess, the area becomes red, swollen and painful with possible drainage of pus. This can be associated with fevers and malaise. Many patients develop a sinus after an infection, which is a cavity beneath the skin that connects to the surface via one or more small openings or sinus tracts. Few patients develop recurrent infections or inflammation of these tracts.

Treatment depends on the symptoms and presentation. An acute abscess needs to be drained, which is usually done in the office with a local anesthetic. A chronic sinus tract is typically treated with surgical excision. Complex disease or recurrent infections needs surgical treatment and can involve large open wounds which need packing and involve longer healing times. After healing, the skin in the area needs to be kept free of hair to help prevent recurrence.

Fecal incontinence is the impaired ability to control the passage of gas or stool. Symptoms can range from mild difficulty in controlling gas to severe loss of control over liquid and formed stools. Causes include injuries during childbirth, decreased anal muscle strength, age and neurologic diseases. Treatment includes non-surgical options such as dietary changes, Kegel exercises, medications and biofeedback. Surgical options include repair of the anal sphincter muscle, injection of muscle bulking agents and implantation of a nerve stimulator.

Constipation can mean different things to different people. For some, it means infrequent bowel movements. To others, it is a hard, difficult-to-pass stool that requires excessive straining. Constipation may also mean a bowel movement which does not completely evacuate and leaves the person with a sense as if they “still need to go.” Constipation is often associated with a bloating sensation, mild nausea and mild cramping pain, all of which are generally relieved by bowel movements.

Constipation is usually caused by a combination of low fiber diet, poor fluid intake or lack of physical activity. Medications and medical conditions can also be a factor. It can be avoided by having a diet high in fiber (25-35 gm/day), adequate fluid intake (6-8 glasses of water/day) and some form of exercise. It can be treated by laxatives or stool softeners. Speak with your physician regarding these medications.

This type of hernia occurs when tissue protrudes through a weak point in the abdominal wall muscles. The most common areas where this can occur are the groins (inguinal), belly button (umbilicus) and a previous surgical incision (incisional). Hernias can be formed or made worse by anything that increases the pressure in the abdominal cavity such as heavy lifting, obesity, coughing and straining.

A bulge is usually seen in the area, especially with coughing, straining or heavy lifting. Pain, pressure or a burning sensation can be felt at the site, but can be painless as well. A reducible hernia is able to be pushed back (reduced) into the abdomen and usually painless to the touch, but may ache. The bulge usually increases in size with standing or by increasing abdominal pressure such as with coughing. An irreducible or incarcerated hernia cannot be reduced back into the abdomen as the fat or intestine in the hernia is entrapped. It can be occasionally painful or may be chronic, slowly growing larger over years, and be painless. A strangulated hernia is a surgical emergency. It occurs when the blood supply to the entrapped fat or intestine is cut off. Pain is always present and the bulge very tender to the touch. Nausea and vomiting may be present and can indicate an intestinal obstruction.

Treatment is surgical and almost always recommended as the hernia will not go away on its own and will get larger with time, with possible incarceration or strangulation. However, watchful waiting may be an options for certain hernias that are painless. These hernias can be repaired either open or laparoscopic. An open procedure involves making an incision over the hernia site and then repairing it, usually with mesh. A laparoscopic approach involves making several small incisions in the abdomen and then placing ports (hollow tubes) through the incisions. Carbon dioxide gas is pumped into the abdominal cavity to distend it for better visualization. A light source and surgical instruments are placed into the abdomen via the ports. The hernia is then repaired with a mesh that is stapled into place using special tacks.

These operations are almost always outpatient and general or regional anesthesia is used. Recovery time varies but typically 1-2 weeks for laparoscopic procedures and 2-3 weeks for open operations. Your surgeon will discuss all of the above with you in more detail prior to your surgery.

Pruritis ani, or “itchy anus” in Latin, is commonly caused by excessive washing or wiping around the anus. This leads to a breakdown of natural barriers, which makes the problem worse. Excessive moisture is another common cause and can be due to sweat, residual stool or mucus. Anorectal conditions such as hemorrhoids, anal fissures and anal fistulas can lead to itching as well. Certain foods and drinks such as alcohol, caffeine, dairy products, nuts, tomatoes and ketchup can be a factor. Lastly, scented soaps and powders can be irritating. In many cases, no specific issue is found to explain the itching.

Treatment primarily involves preventing further irritation by avoiding scratching and protecting the skin from moisture. Avoid all soaps around the anus and do not scrub the area with anything. The anus can be cleaned gently with unscented baby wipes by dabbing the area or use a hairdryer set to “cool”. Keep the area dry by applying cotton or 4 x 4-inch gauze to the anal area. Medications, both prescription and over the counter, are sometimes needed and should be used only under the direction of your physician.

Benign tumors of the soft tissues are not uncommon and can occur at almost any location both within and between muscles, ligaments, nerves and blood vessels. The most common of these tumors, however, are located just beneath the skin and are composed of fat and called lipomas. It is a soft, painless bulge which usually grows slowly over a period months or even years. These tumors may or may not cause pain or discomfort. Treatment is outpatient surgical excision where the tumor is usually just “shelled out” via an incision over the lump. However, many of these lipomas need not be removed, especially if they are asymptomatic. If a tumor is deeper or does not seem benign, an MRI is usually indicated prior to any surgical intervention and a biopsy may be required as well.

Skin cysts are common and are benign, closed pockets of tissue that can be filled with pus, fluid or other material. One of the most common is an epidermoid cyst, often referred to as a sebaceous cyst which is not the same thing. Epidermoid cysts can develop anywhere on the skin, but most often on the face, neck and trunk. They are slow-growing, painless and smooth to the touch. Most of these cysts do not need treatment unless they become infected, rupture or inflamed, in which case they can be painful. The cyst needs to be drained in this situation and then can be removed at a later date if needed. Some patients want the cyst excised because of cosmetic reasons. Surgical removal of the cyst is a minor procedure and can many times be done in the office. Recovery is quick and recurrence rates are low.