Benign Anorectal Disease

Hemorrhoids

Hemorrhoids are blood vessels that are found around the anal canal. There are two sets of hemorrhoidal vessels known as internal and external hemorrhoids. When the hemorrhoidal vessels get engorged or enlarged with blood, symptoms can occur. External hemorrhoidal symptoms are due to a blood clot (thrombosis) in the external hemorrhoidal vessels. The blood clot causes swelling and stretching of the overlying skin, which has sensitive nerve fibers, resulting in discomfort and pain. If the overlying skin breaks down, the external thrombosed hemorrhoid may bleed. Internal hemorrhoidal symptoms are due to swelling of the internal hemorrhoidal vessels. These enlarged vessels can protrude from the anus causing itching, discomfort, and painless bleeding.

Causes of hemorrhoids

Anything that increases the pressure on the pelvic veins can cause the hemorrhoidal vessels to become swollen and enlarged. Common causes of hemorrhoids include:

Straining during bowel movements
Pregnancy
Chronic constipation or diarrhea
Prolonged sitting on the toilet bowl (due to reading)
Heavy lifting, strenuous exercise
Heredity
Aging

Mild hemorrhoids are most often treated with lifestyle and dietary changes. Increasing one’s dietary fiber intake to about 30 grams/day with fiber supplements and increasing one’s fluid intake to 64 ounces of water/day can greatly improve hemorrhoidal symptoms in most patients. Prescription topical creams may also help to reduce the size of enlarged internal hemorrhoids. Pain from external thrombosed hemorrhoids is usually self-limiting, but if the swelling and discomfort persists, surgical excision of the thrombosed hemorrhoid may be recommended by your doctor. Larger, more symptomatic internal hemorrhoids are usually treated with more invasive measures, such as ligation, stapling, or operative hemorrhoidectomy.

Treatment

Office-based Procedures:

Ligation: This is an office-based method that uses rubber bands to treat enlarged internal hemorrhoids. A small rubber band is placed around the enlarged internal hemorrhoid cutting off its blood supply. The hemorrhoid then scars down and sloughs off in a few days. The remaining wound heals in one to two weeks. There can be occasional mild discomfort with the application of the rubber bands, and several applications of the band may be needed for complete treatment.

Operative Procedures:

Stapled Hemorrhoidectomy (Hemorrhoidopexy): This procedure is less painful than traditional hemorrhoidectomy and consists of using a stapling device to “tack” the hemorrhoidal vessels back up to their usual anatomic position. The actually hemorrhoidal vessels are not removed in this type of surgery.

Hemorrhoidectomy: Traditional hemorrhoidectomy consists of excision of both the internal and external hemorrhoidal complexes from three sites around the anus. The vessels are surgically removed and the resulting wound is closed with absorbable suture. Although recovery from this surgery is uncomfortable and usually takes about 2-3 weeks, the recurrence rate of hemorrhoids with this procedure is negligible. The patient satisfaction rate after recovery from this surgery is high.

Anal Fissure

Anal fissures are “paper-cuts” in the lining of the anal canal. They are caused by hard bowel movements, frequent loose bowel movements, or other trauma to the anal canal. Patients with anal fissure complain of sharp anal pain and bleeding with bowel movements. This pain can persist for several hours after a bowel movement because the anal sphincter muscle, which is under the anal fissure, goes into spasm. It is thought that this spasm prevents blood, oxygen, and other nutrients from getting to the fissure to help promote its healing.

Treatment

Conservative treatment for anal fissure consists of dietary modification with fiber and bulking agents. For deeper fissures, topical creams may be prescribed that allow for relaxation of the anal sphincter muscle to promote healing of the anal fissure. If conservative measures do no heal the fissure, more invasive treatments are available, including Botox injection into the internal anal sphincter muscle and a small surgical procedure called the lateral internal sphincterotomy (LIS). This procedure may be formed in an office-based setting or operating room. Ask you surgeon about the risks and benefits of each procedure, and your surgeon will help determine which procedure is best for you.

Perirectal/perianal Abscess

Perirectal and perianal abscesses are thought to be secondary to an infection that starts in the anal glands or anal crypts that are located within the anal canal. If the glands or crypts get “clogged” with stool or bacteria, and infection can persist and abscess may form. Patients with an abscess have pain, swelling, and redness at the abscess site. They may also have difficulty having bowel movements.

Treatment

Treatment of an abscess is surgical in nature and consists of an incision and drainage of the abscess cavity. This procedure may be done in the office or the operating room. Depending on the amount of surrounding inflammation of the skin, your doctor may also prescribe you antibiotics to help treat the infection.

Anal Fistula

An anal fistula is usually secondary to a perirectal abscess that has not completely healed. It is a “tunnel” with an internal opening within the anal canal (usually at the level of the anal glands or anal crypts) and an external opening located on the perianal skin.

Treatment

Treatment options for anal fistula are based upon the anatomy of the fistula tract, but they are all surgical in nature. Your surgeon will usually perform an exam to determine the anatomy of your fistula tract before choosing the type of surgery that will be right for you. Minimally invasive treatment options such as the anal fistula plug and the LIFT (ligation of intersphincteric fistula tract) procedure are being used with good success at our institution.

Fistulotomy: This surgical procedure consists of making a small cut and unroofing the fistula tract. The fistula then heals from the base of the wound upwards.

Fibrin glue: This is a synthetic material that is injected into the fistula tract to help it close and scar down.

Fistula plug: A fistula plug is a synthetic material that is placed into the fistula tract. The material is incorporated by the patient’s tissues, and as the material is absorbed, it scars down and closes the fistula tract.

LIFT procedure (ligation of intersphincteric fistula tract): This procedure surgical identifies the fistula tract between the internal and external anal sphincters. The fistula tract is then tied closed and divided, thereby interrupting the connection between the internal and external openings.

Rectal mucosal advancement flap: This procedure elevates the lining of the patient’s rectum at the level of the internal opening of the anal fistula. The internal opening of the fistula is then sutured closed, and the flap of healthy rectal tissue is then used to cover the internal opening.

Pruritus Ani

Pruritus ani literally means “itchy anus” in Latin. There are numerous causes of pruritus ani, the most common are related to one’s diet and hygiene. Certain foods cause relaxation of the anal sphincter muscle and may allow for microscopic amounts of stool and bacteria to attach to the perianal skin, causing skin irritation. These foods include:

coffee, tea, caffeinated beverages
citrus foods (tomatoes, salsa, ketchup, lemonade, grapefruit)
alcohol
cheese, dairy products
nuts

Other causes of pruritus ani include over cleansing of the anal region with towels and wipes. This strips the perianal skin of its natural oils and may exacerbate symptoms.

Treatment

Treatment of pruritus ani consists of dietary modifications, gentle cleansing with water only, and possibly topical creams.

Pilonidal Disease

Pilonidal disease is most often seen in young patients between the ages of 16 and 35. These patients present with a swelling at their gluteal cleft, usually due to infection caused by hair burrowing into the soft tissue of that area. Patients with pilonidal disease will have small openings at the gluteal cleft, also known as midline pits, which allow hair to fall in and start a subcutaneous infection with deeper sinus tracts.

Treatment

Treatment of pilonidal disease depends on if the disease is acute or chronic, and most treatment options can be performed in an office-based setting. An acute abscess secondary to pilonidal disease is treated with incision and drainage to release the pus within the abscess cavity. Chronic pilonidal disease usually requires excision of the soft tissue and sinus tracts that are involved in the disease process. The wound is usually left open to heal from the base up. The hair around the wound is also shaved to prevent it from falling back into the wound and causing further infection.

Meet the specialists
Fadi F. Attiyeh, MD, FACS, FASCRS
Surgical Oncology/ Hepatobiliary Surgery
Professor of Surgery, Icahn School of Medicine at Mount Sinai
(212) 307-1144
Kathryn Baxter, NP
Nurse Practitioner and Certified Wound, Ostomy & Continence Nurse
Lester Gottesman, MD
Colorectal Surgery
(212) 675-2997
Nipa D. Gandhi, MD
Assistant Professor of Surgery, Icahn School of Medicine at Mount Sinai
(212) 523-7404
Richard L. Whelan, MD, FACS, FASCRS
Chief of Division, Colorectal Surgery and Surgical Oncology
Professor of Surgery, Icahn School of Medicine at Mount Sinai
(212) 523-8172

Richard L. Whelan,
MD, FACS, FASCRS

Minimally Invasive Colorectal Resection to Treat Colon Cancer
- April 27, 2010