PROCTOLOGY

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PROCTOLOGY

Proctology is branch of medicine which deals which conditions affecting anal canal (Back passage) and Rectum. Common conditions piles (Haemorroids), Anal fissure, Anal fistula, Pilonidal Sinus or pilonidal abscess and Pruritis Ani (Itiching around back passage)

PILES/HAEMORROIDS

Does Everyone Have Piles?

While most patients come with self diagnosis of suffering from piles/haemorrhoids, I reassure them it’s normal part of every human being and we are all born with them. Another myth is pain from piles. Piles are painless and cause bleeding, itching and some time jelly like secretions but they very rarely cause pain.

Do we need piles?

Yes. Contrary to belief Haemorrhoids (piles) are necessary for everyone. They have a role in continence (once ability to control/postpone defecation). 

Does Piles cause cancer?

They will never cause cancer or turn into one. 

How much blood is lost because of bleeding from piles?

Most people are concerned about the huge amount of blood they have lost but in most cases it’s very little (mls). It looks more as it is mixed with water and water has turned red. It is very rare for one to loose excess amount of blood because of bleeding from piles. This is very rare to cause anaemia (Low blood count) and if found one might need Colonoscopy to rule out other causes of bleeding.

Bleeding from the piles is bright red in colour and is never mixed with stool. It is usually self limiting lasting few days.

If Piles are normal what causes piles to enlarge?

Causes of enlarged piles/bleeding are associated with increased abdominal pressure. Some of them being
1. Constipation requiring people to put pressure to pass motion.
2. Chronic cough
3. Weight lifting
Other rare causes include soft tissue disorders.

How are piles classified?What are different stages of piles?

Depending on size they are classified into 4 categories. (see the picture)
1st Degree—mildly enlarged
2nd degree— big enough to meet opposite side inside anal canal
3rd degree — come out but go back in on their own/can be pushed back
4th degree— always outside and stay outside

What is the treatment of piles?

If piles are bleeding intermittently then treating aggravating factor which is constipation in most of the cases will solve the problem.

If persistent bleeding is the problem then haemorrhoids can be dealt with proctoscopy and rubber bands in the clinic for 1st and 2nd degree haemorrhoids.
3rd and 4th degree haemorrhoids need haemorroidectomy.

Treatment Options:

Open Haemorroidectomy: In this procedure haemorroids are cut either using scissors or diathermy (Current). Bigest disdvantage in this procedure is open wound and severe pain. One migt not be able sit comfortably for atleast 2 weeks.
Stapled haemorroidectomy is as good if not better to open haemorroidectomy for treating piles. It’s big advantage is considerably less pain compared to open haemorroidectomy. Pain is considerably less compared to open and is biggest advantage is that there is no wound.

Haemorroidal artery ligation & Mucopexy: In this procedure there is no cut (Wound) and haemorroids are treated by cutting off blood supply to them and part of haemorroid coming out is pulled inside with suture.

Laser Surgery is also available where LASER is used to treat haemorroids.

ANAL FISTULA

What is an anal fistula?

It is an abnormal connection between your anal canal (back passage) to the surrounding skin which can happen due to various reson explanied below.

What causes anal fistula?

Most fistulas are caused by simple hair follicle infection which was not treated completely/properly.
There are millions of hair follicles in one’s body. Any one of them around anal canal can get infected. Infection is more in people who sit for long time and more so who sit in unhygienic or hot/sweating environment (ex: long distance drivers). When the infection happens and there is pus collection if it is drained appropriately then chances of fistula formation decreases drastically.

If pus is not drained then body has to discharge the pus and there are only two directions. If it bursts out of skin and infection gets completely cured then fistula does not form. If it bursts into anal canal then fistula is formed or worst case it bursts into skin but residual infection spreads slowly in different directions then complex fistula is formed. There are certain conditions like Crohn’s which predisposes one to having fistula. These conditions are rare in India.

Are there different kinds of fistula?

Fistula’s can be classified depending on the involvement of sphincter muscles and internal opening as shown in the picture.

What are the symptoms of Fistula?

 Recurrent discharge of pus around the back passage which stops and starts . People end up taking antibiotic each time and with time fistula will become more complex and difficult to treat. If there is collection of pus then it cam present at abscess in which case abscess needs to be treated first then fistula at a later stage.

How is Fistula treated?

Only way to cure the fistula is by surgery. Most of fistula are simple and do not involve sphincter muscles so cutting it out fully will cure the fistula. If fistula involves sphincter muscles then cutting out fistula in one operation is not solution as it might cure fistula but it will one with incontinence. If sphincters are damaged one would loose control over the passing the stool and might have to run to toilet every time one gets sensation or there is prospect of passing on its own. So in these scenarios patient will need to have patience and might need two/three operations.

Is there LASER surgery for anal fistula?

Yes now there is laser which is safe and very effective.

ANAL FISSURE

What is Anal fissure

Anal fissure is the most common cause for painful defecation (Opening bowels). Most times it is also associated with bleeding but not all the time. It is a small cut in the anal canal upto skin.

Pain while passing motion which can last upto few hours afterwards is the commonest complaint. This is usually associated with Constipation (Passing hard stool/pushing hard to open bowel). At times it is seen after episode of loose motion.

***Pain while passing stool is never caused by piles/haemorroids***

How is such severe pain caused?

Easiest way to understand is, if you sustain a small cut while cutting vegetables, pain will persist till the cut healed and get aggravated when ever anything touches is — including clothes. Similarly pain get stimulated when the stool passes through the anal canal touching the fissure.

What is the treatment of anal fissure?

When treated appropriately in the initial stages, fissure heals upto 75% with medicines. Longer the duration less likely it is to heal with creams and might need simple surgery to relax the sphincters so that fissure can heal.

1. Main stay of treatment includes keeping stools soft. This is usually achieved by laxatives during the period of anal fissure but in the long run by eating more fruits and vegetables, drinking at-least three lts of water in a day and exercise.
2. Local anesthetic cream applied 20 mins before passing the motion will help in relieving the pain.
3. Second cream (2% Diltigesic) helps to relax the muscle which helps in the healing of the fissure. With this treatment usually 50-60% of fissures heal.

Next step should be injection of BOTOX into sphincters if patients are affordable. This will increase the chances of healing upto 75-80%. This is more so recommended in females as they have weak and small sphincters compared to men and more over they can also be damaged at the time of vaginal delivery. BOTOX injection causes only temporary relaxation of muscles (upto 6 months) so that fissure can heal.

Other wise in patients in whom fissure does not heal by conservative management simple surgery is required (LATERAL SPHNCTEROTOMY) . This will reduce the pain significantly within 24 hrs.

Yes there is with good results and is safe.

Any anal fissure which has not healed even after 6 weeks is called chronic anal fissure. Conservative measures are unlikely to work and one might need surgery most of the times.

A small skin tag (Sentinel skin tag) can develop in chronic fissures. Otherwise some patients can experience itching.
Fissure will never lead to cancer.

PRURITIS ANI (Peri anal Itching)

What is pruritis ani?

It’s a condition which is characterised by excessive itching around anal canal. Even though it is not serious it is socially emberassing at the least. Problem is compounded by the fact patients feel emberassed to sek help from doctors at the early stage. This makes treatment even more difficult as patients seek at late stage. By this stage there might be skin damage.

What causes pruritis Ani?

There are many causes which might lead to pruritis Ani. Most common cause is incomplete cleaning or minor leakage of faeces from anal canal.  This can also be caused by 3rd and 4th degree haemorroids (piles) (See
Piles blog). This can also be caused by certain skin conditions which might have already affected different parts of the body.

What is the treatment of Pruritis Ani?

Pruritis Ani gets better with identifying and treatment of cause. If no cuase found then simple measures will outlined below will help.

What are the home remedies?

Though it is not a serious condition its difficult to treat. This is because it might be difficult to identify the
condition which is causing the pruritis ani. After identifying it needs both patience and persistence. This might be complicated as we might not be able to remove aggravating factors like (Work condition, weather etc).

Home remedies include

  1. First and the most important is personal hygiene. The area must be kept as clean as possible. After passing each motion the area should be washed with water and dried with soft clothe.
  2. Avoid using paper to clean after passing the motion.
  3. Some people might feel better after cold than warm water.
  4. Do not use soap/antiseptics/perfume. Any artifiicial agent can lead to skin irritation. Some might find emolient solution helpful.
  5. If water is not available then use wet baby wipes/soft toilet paper after opening bowel.
  6. Avoid scratching at all cost.
  7. After cleaning with water after passing motion dry the area with soft towel. Do not rub the area. You might find hair dryer with low setting helpful.
  8. Loose cotton underware and changing it twice a day will be helpful.
  9. Avoid tight trousers/jeans. Less friction is helpful in most conditions.
  10. Avoid sittind in one place for long time especially on plastic chair.
  11. undergrments should be washed with non-biological washing powder.  Make sure there is no traces of dettergent on undergarments.
  12. Avoid constipation at all cost.

If you have tried all measures at home and symptoms are resolved then consultation with proctologist for further assessment and treatment will be helpful.

PILONIDAL SINUS & ABSCESS


Pilonidal is a condition in which hair grows/collected under the skin in nata cleft (Space between two buttocks).

Pilonidal sinus is a abnormal track from deeper infection below to the skin. The track usually travels vertically which may progress with time.

The exact cause of the pilonidal sinus is not known. Some people are born with a pit where hair is trapped between buttocks and with age sinus develops. In some cases the pit may develop with constant pressure.
Some of the conditions which increases the incedence include
A job involving a lot of sitting (a sedentary occupation)
Being overweight (obesity)
A previous persistent irritation or injury to the affected area
Having a hairy, deep natal cleft
A family history of the condition
Drivers

Treatment options:

I follow a simple alogorithm for traetment of pilonidal condtions

1. When the abscess develops in a short span of time (Acute abscess) and pain and infection are not severe then it can be treated with course of antibiotics for 5 days and planned defenitive surgery with in 6 weeks.

2. When the abscess develops in a short span of time (Acute abscess) and pain and infection are severe then it can be treated with immediate excision

3. When it’s a recurrent chronic condition then planned surgery is done.

I offer the following surgical options depending on the condition

1. If infection is less and there is no contamination of surgical site then excision and primary closure.

2. If surgical site is contaminated then excision and healing by seconday intention.

Both above procedures are simple with no other added complications and will be enough to treat about 90% conditions so I would always prefer to perform simple wide excision +/- primary closure for all the pilonidal conditions as a first choice.

If condition reccurs then a advanced procedure which involves mobilising and closure with flap can be performed.

Pilonidal sinus is minor condition but problomatic because of the place it affects.