Haemorrhoids/Piles are swellings that originate in the anus/anal canal and are known as Internal Haemorrhoids at this stage. As they enlarge, they gradually extend outside the anus and will be visible and palpable. Haemorrhoids are composed of dilated blood vessels enclosed in the lining of the anal canal and are not malignant/cancerous growths.
Contrary to popular belief, bleeding from haemorrhoids is usually painless and fairly fresh and bright red in colour. Similarly, haemorrhoids are not painful even as they enlarge, though they will cause some irritation and itchiness around the anus. Haemorrhoids will become painful only when they are trapped outside the anus and are not pushed/reduced back in time. These haemorrhoids will then be known as Thrombosed Haemorrhoids and will swell to many times their usual size and be excruciatingly painful.
Haemorrhoids are not cancerous and do not lead to colorectal cancer. However, the bleeding associated with defecating can be due to a variety of causes such as colorectal cancer and is not restricted to haemorrhoids. Therefore, it is important to perform a colonoscopy for most cases of bleeding during defecation to exclude other serious conditions other than haemorrhoids.
Perianal and Ischiorectal/Buttock Abscess
An abscess is a collection of pus. A perianal abscess is a collection of pus in the immediate vicinity around the anus. It is usually visualised or felt on the skin surface as a tender lump that may be discharging pus. Less commonly, a perianal abscess can manifest as a deep-seated pain in the anus with no visible skin swelling as the abscess is located within the sphincter muscles of the anus.
An ischiorectal/buttock abscess is a collection of pus in the buttocks. It can manifest as an obvious lump on the buttock skin or as an area of pain and tenderness in the buttock with no surface swelling
Both perianal and ischiorectal abscesses will need an operation to drain out the pus. The wound is usually left open to allow drainage of any remnant pus and may require wound packing and gradual closure of the wound.
An anal fissure is a tear in the lining of the anus. It presents with acute pain in the anus that occurs after passing motion and can last for a few hours. In addition, the pain is usually associated with fresh blood on wiping or in the toilet bowl.
Anal fissures usually occur after an episode of constipation with the passage of hard stools or a bout of severe diarrhoea. The passage of the stools causes trauma and tears to the anus which do not heal, leading to a chronic/long term tear.
Treatment of an anal fissure is a step-wise approach. The first line of treatment is with GTN ointment which relaxes the anal sphincter and improves blood flow to the fissure to promote healing. Surgical options include injection of Botulinum toxin and Lateral sphincterotomy.
An Anal Fistula is an abnormal tunnel that develops between the anal canal (anus) and the external skin around the anus. A fistula usually develops after an episode of an abscess around the anal skin region.
A fistula can be felt as a small bump on the skin around the anus and this is known as the skin or external opening. A fistula will cause a recurrent discharge that is usually a combination of blood and pus. This often manifests as a wet patch on the underwear. A new abscess can also form on the site of the external opening and this will be painful and will require surgical drainage.
An Anal Fistula can only be treated with a surgical procedure. This can take the form of a Seton placement, Fistulotomy procedure, LIFT procedure or EPSiT procedure.
Anal Fistulas can recur if the treatment did not eradicate the tunnel completely.
A Perianal Hematoma is also known by the old and incorrect name of Thrombosed External Piles. A Perianal Hematoma is actually a blood clot that formed underneath the skin around the anus due to the rupture of a small blood vessel.
It presents as a painful and tender lump at the edge of the anus and is often mistaken for a Hemorrhoid. However, unlike Hemorrhoids, a Perianal Hematoma cannot be reduced or pushed back into the anus.
A Perianal Hematoma does not require any treatment as the blood clot is usually reabsorbed by the body within a month with the resolution of the lump. A drainage procedure to remove the blood clot is carried out only if the initial lump is very painful or if the lump fails to resolve after a month.
Warts, also known as Viral Warts can develop in the skin around the anus. The Warts are caused by the Human Papilloma Virus (HPV), similar to warts at other sites of the body.
Viral Warts presents as a growth resembling a cauliflower or a polyp. It can occur as a single growth or as multiple growths scattered around the anus. Viral Warts are usually painless.
Treatment of Viral Warts requires a combination of removal procedures and medications to reduce the risk of recurrence. Viral Warts can be surgically removed while the smaller warts can potentially be removed using cryotherapy with liquid nitrogen.
Anal Tumours are relatively rare tumours that occur in the anal canal. They can be Squamous Cell Carcinomas or Adenocarcinomas. These are two different cancers with different treatment options.
Anal Tumours can present with bleeding during defecation together with deep-seated pain in the anus. Changes in bowel movement habits such as diarrhoea is also a symptom. In its later stages, the tumour will be large enough to protrude through the anus or invade into the skin around the anus.
First-line treatment for Squamous Cell Carcinomas is a combination of Chemotherapy and Radiotherapy. Major radical surgery is reserved for cases that do not achieve complete resolution.
The first-line treatment for Adenocarcinoma is Radical Surgery. Prior to surgery, there will be a 6-week period of Radiotherapy to shrink the tumour and reduce the risk of recurrence.
Pilonidal Disease occurs in the region of the Natal Cleft which is also commonly known as the Buttock Crack.
Pilonidal Disease usually first comes to attention with pus discharged from either the natal cleft itself or from either side of the cleft. Another common presentation is an abscess that develops just adjacent to the natal cleft. There will usually be a few small dimples or holes in the centre of the natal cleft with occasional tufts of hair protruding from it.
There is no known exact cause for Pilonidal Disease. However, we do know that it occurs much more commonly in hairy/hirsute individuals and lengths of hair can often be found protruding from the dimples or in the abscess cavity. The idea that Pilonidal Disease is due to ingrown hair is, however, too simplistic and ingrown hair is only one factor in the development of Pilonidal Disease.
The treatment of Pilonidal Disease is a surgical procedure. The simplest treatment involves laying the pilonidal tract open and allowing the wound to heal by itself (secondary intention). Alternatively, flap procedures such as the Karydakis flap or Rhomboid flap are also good treatment options as it allows for flattening of the natal cleft which reduces the risk of recurrence. For acute abscesses, surgical drainage of the abscess is needed before other definitive and curative procedures can be done
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