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The intestinal tract (or bowel) ends with the rectum. The last
part of the rectum is a section about 1 1/2 inches long, known as
the anal canal. It ends with the anus - the opening to the
outside of the body. There are several common problems, including
hemorrhoids, that can occur in the area from the rectum to the
anus. While almost everyone has heard of hemorrhoids, the other
conditions are not so well known.
ANAL FISSURE
Most people have experienced a tear or fissure at the corner
of the mouth that can occur in cold weather or when yawning.
Similarly, an anal fissure is a small tear in the lining of the
anus, frequently caused by constipation. A hard, dry bowel
movement results in a break in the tissue. However, fissures can
also occur with severe bouts of diarrhea or inflammation. This
results in the anus becoming dry and irritated, causing it to
tear. Injury to the anal area during childbirth and abuse of
laxatives may be other causes.
A fissure can be quite painful during and immediately
following bowel movements. This is because the anus and anal
canal are ringed with muscles to control the passage of stool and
to keep the anus tightly closed at other times. When those
muscles expand, it stretches the fissure open. There may also be
bleeding or itching with an anal fissure.
DIAGNOSIS
A simple visual examination of the anus and surrounding tissue
usually reveals the fissure. It is quite tender when examined by
the physician. Fissures are most often located in the middle
posterior (back) section of the anus.
TREATMENT
More than half of all fissures heal either by themselves or
with non-surgical treatment. Stool softeners can help reduce pain
during bowel movements. Antibiotics may be used for a short time.
Special medicated creams may also be used, especially if the
fissure has become ulcerated or infected. It is important to keep
the anus and area between the buttocks clean and dry. After
bathing, the patient should gently pat dry with a soft towel.
Sitz baths may help relieve discomfort and promote healing. A
sitz bath is soaking the anal area in plain warm - not hot -
water for 15-20 minutes several times a day.
If the fissure is not responding to treatment, the physician
re-examines the patient. There are conditions, such as muscle
spasm or scarring, that could interfere with the healing process.
Fissures that do not heal can be corrected with surgery. It is a
minor operation that is usually done on an outpatient basis. The
surgeon removes the fissure and any underlying scar tissue.
Cutting a small portion of the anal muscle prevents spasm. This
helps the area to heal and rarely interferes with the control of
bowel movements. Complete healing takes place in a few weeks.
However, the pain often disappears after a few days.
Over 90% of the patients who need surgery for fissures have no
further problems. Patients can help avoid the return of fissures
by drinking at least eight glasses of water a day, and
maintaining adequate fiber in the diet. This prevents
constipation, which is the cause of most fissures.
ANAL ABSCESS AND FISTULA
An abscess is a localized pocket of pus caused by infection
from bacteria. It can occur in any part of the body. When
bacteria seep into the underlying tissues in the anal canal, an
abscess may develop. Certain conditions, such as Crohn's
disease (chronic inflammatory bowel disease), can increase the
risk of abscess in and around the anal canal. Patients with
conditions that reduce the body's immunity, such as cancer or
AIDS, are also more likely to develop anal abscesses.
An abscess causes tenderness, swelling, and pain. These
symptoms clear when the abscess is drained. The patient may also
complain of fever, chills, and general weakness or fatigue.
A fistula is a tiny channel or tract that develops in the
presence of inflammation and infection. It may or may not be
associated with an abscess, but like abscesses, certain illnesses
such as Crohn's disease can cause fistulas to develop. The
channel usually runs from the rectum to an opening in the skin
around the anus. However, sometimes the fistula opening develops
elsewhere. For example, in women with Crohn's disease or
obstetric injuries, the fistula could open into the vagina or
bladder. Since fistulas are infected channels, there is usually
some drainage. Often a draining fistula is not painful, but it
can irritate the skin around it. If the opening of the fistula
seals over before the fistula is cured, an abscess may develop
behind it.
DIAGNOSIS
Diagnosis of an abscess is usually made on examination of the
area. If it is near the anus, there is always pain, and often
redness and swelling. The physician will look for an opening in
the skin (a sign that a fistula has developed), and try to
determine the depth and direction of the channel or tract of the
fistula. However, signs of fistula and abscess may not be present
on the skin's surface around the anus. In this case, the
physician uses an instrument called an anoscope to see inside the
anal canal and lower rectum.
Whenever the physician finds an abscess, and especially a
fistula, further tests are needed to be sure Crohn's disease
is not present. Blood tests, x-rays, and a colonoscopy (a
lighted, flexible scope exam of the bowel or colon) are often
required.
TREATMENT FOR ANAL ABSCESS
An abscess must be surgically opened to promote drainage and
relieve pressure. This is often done in the physician's
office under local anesthesia. However, patients with a large or
deep abscess, or those who have other conditions, such as
diabetes, may be admitted to the hospital for the procedure.
Antibiotics cannot take the place of draining an abscess.
Antibiotics are carried by the bloodstream but do not reach the
pus within the abscess. However, they are usually prescribed
along with surgical drainage, especially if the patient has other
serious diseases, such as diabetes or those associated with
reduced immunity.
TREATMENT FOR ANAL FISTULA
Treatment of anal fistula often varies, depending on whether
Crohn's disease is present. Crohn's disease is a chronic
inflammation of the bowel, including the small and large
intestine. As noted, the physician will often do tests to see if
this disease is present. If it is, then prolonged treatment with
a variety of medications, including antibiotics, is usually
undertaken. Often these medications will cure the infection and
heal the fistula.
If Crohn's disease is not present, it still may be
worthwhile to try a course of antibiotics. If these do not work,
surgery is usually very effective. The surgeon opens the fistula
channel so that healing occurs from the inside out. Most of the
time, fistula surgery is done on an outpatient basis or with a
short hospital stay. Following surgery there may be mild to
moderate discomfort for a few days, but patients usually have a
short recovery period.
SUMMARY
Bleeding, pain, or drainage form the anus can occur with
several illnesses, so a physician should always be consulted.
Often the diagnosis is anal fissure, abscess, or fistula. These
are problems that are usually easy to diagnose and correct. A
variety of treatments, including surgery, are available to
correct these conditions. Working together with the physician
usually assures a good outcome.
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