Contact Us

Many patients request help with rectal problems because of “hemorrhoids.”  However, a rather large percentage of these patients are suffering from other rectal conditions.  Let’s review the common causes of rectal symptoms.

Hemorrhoids

Hemorrhoids are dilated varicose veins in and around the anus.  They occur in two types, internal and external.  The internal ones are located just inside the anus, (Fig. 1) where the nerve endings are few; they might cause a general sensation of aching or discomfort, but they do not cause intense, acute pain.  They can get large enough that they prolapse (hang out) with each BM, in which case they can become sore from mechanical trauma.  However, what they really do is bleed in a big way.  These are big, big dilated veins, bulging and stretching the overlying tissue.  When one of these ruptures, it drips a lot of blood into the toilet.  They almost never bleed except with BM’s.  External hemorrhoids are located just outside the anus.  They are also dilated veins, but usually not as big.  They skin overlying these veins is thicker and tougher, and they are far less likely to bleed.  They are subjected to mechanical trauma with BMs and wiping and their most frequent problem is caused when they become thrombosed.  This refers to the vein literally clotting off.  There is then a large, painful, easily-palpable lump on the outside of the anus.  One of these can rupture and ooze blood, but since the vein is already clotted, there is usually not a lot of blood.  Because they are on the outside, this bleeding can occur even between BMs.

Fig. 1

Hemorrhoids are caused by straining when having a bowel movement, and by nothing else.  Heavy lifting, prolonged sitting – these things have nothing to do with it.  Straining while lifting may cause the veins on the head and neck to bulge, but those on the anus don’t bulge because the anus is closed tightly, which squeezes the veins, keeping them from dilating.  If the anus wasn’t shut tightly, straining while lifting would result in a mess in your pants!  However, on the toilet, the anus is deliberately relaxed.  Straining here, not only pushes a stool out, it causes the anal veins to bulge.  Eventually they bulge more and more, and varicose veins (hemorrhoids) result.  Constipation is not the only cause of hemorrhoids.  People grunt and strain when they sit on the toilet with cramping diarrhea.  In fact, just sitting on the toilet and relaxing the anus, causes a modest amount of increased pressure to be transmitted to the anal veins, pressure to which they are not accustomed.  The single worst thing you can do for your anal health is to have a prolonged session of reading the newspaper while sitting on the toilet.

Perianal Abscess

This is essentially a pimple on the anus.  It occurs out of the blue, for no particular reason.  It can be pea sized, or egg sized and occasionally even orange sized!  It causes one or the other side of the anus to be exquisitely tender, and can be associated with fever if large.  Early on, it can develop deep in the tissues where it causes intense pain that is constant, even worse with BMs, but never goes away.  Until the abscess gets large enough to make it to the surface, it might not be an easily palpable lump.

Anal Fissure

A fissure is a tear of the lining of the anus.  (Fig. 2) When a person goes for an extended period of time having very soft, small stools, the anus essentially shrinks.  Then, if something disrupts the usual dietary habits, like going on a trip, the person might become constipated.  Grunting and straining, a large, hard, dry stool, that is too big for the anus, is finally passed.  The anus is overstretched and tears.  This causes intense pain and usually just a small amount of bleeding.  The pain lasts for an hour or two, but slowly subsides and stops.  However, the anus “remembers” this event, and doesn’t want to relax for the next stool.  The person quickly learns to do something, anything, to soften the stools in order to have a painless BM.  The stools then become quite soft, the anus doesn’t open much for each BM, and it shrinks even more.  The next medium sized stool stretches it again.  Where do you think it tears this time?  Right in the same spot, which is the weak link in the chain.  Over time, scar tissue accumulates at this site, much like a callous with a crack in it.  It will tear over and over at this same spot with any solid stool of any size at all.  Each time there is intense pain.  Eventually it hurts all the time, but the person never forgets that it is the large stools that really cause the pain.  So this person always keeps the stools soft.  There is often a small anal tag protruding from the anus at the site of the tear, but the tear itself is up inside the anus and cannot be seen.

Fig. 2

Anal Fistula

An anal fistula (Fig. 3) occurs when a perianal abscess is located deep in the tissues.  As it expands and works it way to the surface, it may find itself just as close to the surface inside the rectum as it is to the surface outside the anus.  If it bursts through on its own to both sides as it drains itself, it can create a tunnel that connects the rectum to the outside world.  Even though the outside opening may close and look healed, the tunnel and inner opening are still present and there is continuing contamination with stool and bacteria.  A smoldering infection continues.  The hallmark of this problem is what appears to be a perianal abscess that keeps recurring in the same spot.

 Fig. 3

Rectal Cancer

Many unfortunate people with this problem will have no symptoms at all until the tumor is quite large, and has spread beyond our ability to accomplish a cure.  The lucky ones have a tumor that bleeds early on in the stages of its growth.  This is almost always painless bleeding and the stools are not affected.  Blood can drip into the toilet or it can be seen on the surface of the stool, and on the toilet paper.

“Itchy Anus”

This is a condition characterized by intense burning and itching.  It is caused by a wet, soiled anus.  The anus is actually a canal of about 1.5 inches in length, surrounded by the anal sphincter muscles, and lined with a special type of tissue. (Fig. 4)  The special skin of your lips can tolerate wetness more than the skin on the cheeks of your face, but it cannot tolerate as much wetness as the lining of your mouth.  The lining of the anus can also tolerate more wetness than the skin on your buttocks, but it cannot tolerate as much wetness as the lining of your rectum.  These patients almost always have stools that are too soft, and have difficulty wiping themselves clean.  Many wipes are required.  Having a BM and wiping clean usually eliminates the symptoms for a while.  However, not too long after, the itching and burning, and even painful spasms return.  At this point, if the person wipes again, it becomes clear that the anus is soiled with stool all over again as though it oozed out by itself.  These people often stain their shorts.  The problem here is that prolonged contact of the anal skin with the harsh chemicals in the stool causes a chemical irritation to the skin.  It’s made much worse in hot weather when a lot of sweating keeps the area wet.  Most patients try a medicated ointment of some type, which seems to help at first.  However, because all of these ointments are wetting agents, no matter what medication they have in them, they make the problem worse after being used for just a short period of time.  The anus can become so raw that it oozes blood.  Usually this results in seeing blood on the toilet paper.  There’s almost never enough blood to drip into the toilet or even be visible on the stool.  The basic problem here is that the stools are too soft.  This never happens to people who suffer from constipation.  They almost don’t have to wipe at all.

 Fig. 4

Review:

Treatment

Relatively small, thrombosed, external hemorrhoids can be treated by removing the clot with minor surgery in an office setting.  Though they can be painful, most small, acute hemorrhoidal problems will go away by themselves if left untreated.  Major external hemorrhoid problems and all internal hemorrhoids need to be treated in an operating room.  Rubber banding, infrared heaters and even cryosurgery have all proven to be worthless in my experience.  These things only “work” when nothing needed to be done anyway, and when something really needs to be done, they fail miserably.  They cause more pain than if the small problem was just left to heal on its own.  When a real problem needs to be dealt with, a laser hemorrhoidectomy is the procedure of choice.  This involves a thermal injury to each hemorrhoid, with the treated part being almost completely removed, and a small rim of treated tissue left behind.  This keeps the end of the varicose vein from bleeding, and avoids the need for sutures to accomplish this.  Sutures in the anus are extremely painful.  The laser treatment isn’t exactly painless, but every patient seems to be able to go home after the treatment and adequately control the pain with pills.  Suture-type hemorrhoid surgery almost always requires hospitalization for several days to control the pain with shots.  Whether suturing or using a laser, the major complication of hemorrhoid surgery we want to avoid is having the anus heal with a stricture.  This is a narrowing caused by scar tissue from surgery.  It is less likely with laser surgery.  We prevent this by having the patient adjust the dietary fiber so that the stools are not too hard, but firm enough to require the anus to open up widely when having a BM.  If this is accomplished within the first week or two after surgery, stricture is almost never seen. 

Abscesses and fistulas need to be surgically drained.  Anal fissures are treated by removing the fissure and its surrounding scar tissue, and then dilating the anus so that a normal size BM can pass without causing a new fissure to occur.  These treatments are usually also done in an operating room setting. 

“Itchy Anus” is treated in two ways.  First, cut way back or eliminate fiber in the diet, or anything else that makes the stools too soft (salsa, cayenne pepper, fruit, excessive and regular alcohol intake).  Second, dry out the anus.  Instead of ointments, the anus should be gently washed whenever it is bothersome. Baby-wipes are excellent for this.  Then it should be dried with baby powder.

The treatment for rectal cancer is beyond the scope of this publication, but suffice it to say that it usually requires rather major surgery.  The important thing to note here is that rectal cancer can mimic many symptoms of the more benign rectal conditions.  Anyone having any kind of rectal bleeding should have a colonoscopy to insure that rectal/colon cancer in not present, before being treated for any other rectal condition which they might also have at the same time.

Diet

Diet is a major factor in the cause and management of rectal disorders.  In essence, the less fiber in the diet, the larger, harder and drier the stools will be.  The more fiber in the diet, the softer, smaller and wetter the stools will be.  It is a common misconception that drinking a lot of water will make the stools soft.  Actually, the gut receives 20 to 30 quarts of liquid a day in the form of bile, pancreatic juice, saliva, gastric secretion, and small intestinal secretion without the need for you to drink a drop of water to make this happen!  Almost all of it is reabsorbed, leaving just a small amount in the stool.  Fiber in the diet acts like a sponge in the stool, causing the stool to retain a bit more water and therefore be softer and wetter.  Drinking four quarts of extra water a day results in extra water being absorbed from the gut into the bloodstream, expanding the blood volume, which in turn causes four quarts of extra urine to be made to get the blood volume back to normal. 

Fiber is the nondigestible residue that is left after all the digestible nutrients have been absorbed from the food.  Some things have a lot more fiber than others.  If you take a cup of wheat bran, you have a cup of fiber.  If you take a head of lettuce, dry it out in a food drier, then crumble it up, you have perhaps a quarter cup of fiber!  Fruit pulp is fiber, but it contains other compounds that really make it potent.  Eating a lot of fruit will make a person have loose stools that go way beyond just the effect of the fiber in the fruit.  Eating a high fiber diet, with lots of raw vegetables, fruit, salads, whole grains, and bran will soften the stools, sometimes too much.  In fact, if you eat enough fiber, you can cause diarrhea.  The effect of fiber on people is variable.  What does absolutely nothing for one person may cause diarrhea for the next.  Experimentation is necessary.

I've spent over 25 years studying and perfecting ways to turn big operations into small operations

Minimally Invasive Treatments For

Acid Reflux, Hernia, Varicose Veins, Hemorrhoids, Gallstones

Endoscopy, Laser, Radiofrequency, Ultrasound, Lithotripsy, Laparoscopy

Working towards a small practice

901 N. Curtis Rd., Suite 401    -    Boise, ID 8370    -    208-367-7580