Section on Colorectal Surgery, Frankford Hospitals

 

Proctology refers to the area of medicine that provides care for conditions of the anus and rectum.   A variety of different types of conditions can occur in these areas, including:

• hemorrhoids;

• polyps ;

• inflammations;

• abscesses;

• fistulas;

• fissures;

• infections;

• fecal incontinence;

• rectal prolapse;

• anorectal trauma;

• and cancer .

The proctologist (who is typically a colorectal surgeon) is a specialist trained and experienced in evaluating and treating these conditions.   These physicians can provide both medical and surgical care.

A key diagnostic procedure in this field is proctoscopy.   The specialist uses a self-lit, tube-like instrument called a proctoscope to view the interior of the rectal cavity.   During the procedure, the doctor may remove a small amount of tissue for examination under a microscope.

 

  Hemorrhoids –

Hemorrhoids are blood vessels that have become swollen and distended, often painfully, in and around the anus.   They can become inflamed or develop a blood clot (thrombus).   Often hemorrhoids will resolve on their own, although a number of noninvasive treatments are available.  

In other cases, it is necessary to treat hemorrhoids surgically. Specialists may choose from a variety of techniques to remove or reduce internal and external hemorrhoids directly.   These include:

• rubber band ligation, in which a rubber band is placed around the base of the hemorrhoid inside the rectum to cut off circulation to the hemorrhoid, so that the hemorrhoid will shrink and wither away over several days;

• sclerotherapy, in which a chemical solution is injected around the blood vessel to shrink the hemorrhoid;

• infrared photocoagulation, techniques that use special devices to burn hemorrhoidal tissue;

• or hemorrhoidectomy, a surgical procedure that permanently removes hemorrhoids by cutting them away.

Candidates for hemorrhoidectomy are usually patients who have large or extensive hemorrhoids that cannot be easily managed otherwise and that have not responded to nonsurgical solutions.   For the operation, patients may receive general or spinal, or sometimes local anesthesia, according to your wishes and the anesthesiologist’s judgment.   The surgeon will tie off the swollen vein to prevent bleeding, remove the protruding portion, and suture or leave open the wound for healing.   Typically, patients can undergo the operation as outpatients, and they will require two to three weeks for full recover.

 

Polyps –

Polyps are common masses that protrude into the colon or rectum.   Finding and treating them can reduce the risk of colorectal cancer.

 

  Inflammations –

Many conditions can cause inflammation of the lining of the rectum (proctitis) or sometimes the anus.   Symptoms of this condition are pain, feeling of rectal fullness, or passage of mucus or blood.   Causes include:

• inflammatory bowel disease (IBD) ;

• diverticulitis ;

• radiation therapy or antibiotics;

• sexually transmitted diseases ;

• trauma to the rectum or anus ;

• bacterial infections ;

• neuromuscular conditions of the rectum.

Physicians will treat the underlying cause of the inflammation and pursue medical treatments for the symptoms.   For severe, intractable inflammation, surgical removal of all or part of the rectum may be necessary.  

 

Abscess –

An anorectal abscess is an infected, pus-filled pocket in or around the anus or rectum.   When bacteria infect a gland or other area in the anus or rectum, the infection can become sequestered in a cavity and become exacerbated.   Various types of inflammations can create the conditions in which an abscess develops.

Symptoms of an abscess can include pain, swelling, irritation in the anus, pus leakage, and fever.   Colorectal surgeons are skilled at treating these conditions with minimal invasiveness.   They can drain these areas using needles or small incisions.   The physician will sometimes leave a small catheter in place in the abscess for a few days to permit it to drain completely.   Draining an abscess removes some of the bacterial infection and stimulates healing in the area.   The doctor may be able to drain an abscess in the office, using a local anesthetic.   More severe abscesses my require hospital treatment.   Properly healed, most abscesses do not return; however, they may sometimes   form anal fistulas .

 

  Fistulas –

Fistulas are abnormal openings between one organ or tissue area and another.   An anal fistula is typically an abnormal passage between the anal canal and skin.   This small tunnel usually communicates to the skin of the buttocks, near the anus.

Anal fistulas most often result from an anal abscess that has opened externally or been surgically opened.   However, the fistula may develop weeks, months, or years after the abscess is drained or has otherwise resolved.   In this case, the passage from the abscess to the external surface of the skin remains, forming the fistula.   (Much less commonly, the fistula may open internally to the vagina or other structures.)    Anal fistula symptoms include pain, fever, skin irritation, as well as pus, stool, or gas leakage.

Fistulas must be repaired surgically.   The colorectal surgeon removes the tissue around the fistula, while attempting to repair and restore the integrity of the anal canal and the skin surface, with the goal of closing the fistula tract while avoiding as much as possible damaging the function of the anal sphincter muscle.   Anal fistulas, however, are a risk factor for fecal incontinence due to potential damage to the muscles of the anus.

If a hospital stay is required for surgery to treat an anal fistula, it is usually short.   Properly healed, most fistulas are cured; however, some patients experience return of the condition and require repeat surgery.

 

Fissures –

Anal fissures are cracks or tears through the anal tissue that are a common cause of anal discomfort.   Such small cuts in the skin lining the anus can be very painful and may cause bleeding.   Pain is normally most acute during a bowel movement.   Blood may be visible in stool.  

Causes include internal rectal sphincter spasm, or friction of compacted or drier fecal matter that can split the lining of the anorectal area, or both.   Inflammation can also cause a fissure.   A fissure may linger as an uncomfortable, linear ulcer.

Most fissures will heal without invasive treatment.   Dietary changes to soften fecal matter, as well as creams and soak baths may aid healing.   Local application of chemicals to relax and relieve anal pressure is also an option.

A fissure that does not resolve may need a surgical intervention.   The surgeon may use one of several techniques:

• incising the nearby muscle to permit the fissure to heal in a more fixed position.   This incision does not compromise later bowel control.  

• removing the fissure and any other abnormal tissue around it and repairing the anal passage.  

 

  Infections –

Normally, the anus and rectum have a natural resistance to infection due to their function of passing bacteria-laden material at all times.   However, under the right conditions these areas are subject to infections from a number of different causes.   These range from viruses that cause anal warts to bacteria that spread as a result of inflammatory bowel disease , venereal or other exposures, or injury to the area .

Anal warts (condyloma) is a condition for which patients commonly seek treatment.   Also referred to as venereal warts because they can affect the genitals as well, these warts may cause no symptoms initially, when they are small, or may be mistaken for hemorrhoids.    Like other types of warts, they result from transmission of the human papilloma virus from someone infected with the condition.   When they occur in the anal or genital area, they are usually the result of sexual contact but can also result from contact with a contaminated object or surface.   Venereal warts are one of the most common forms of sexually transmitted diseases in the U.S.   Warts on other parts of the body, such as the hands, appear to be the result of a different type of human papilloma virus that is not thought to cause genital or anal warts.   (Another type of the anal wart is caused by syphilis infection and is treated with antibiotics.)

The warts can increase in size and cause irritation, or even eventually become cancerous, if untreated.   If the warts are small, the physician can apply medications or a freezing agent to destroy them in a series of treatment applications.   (Recently, immunologic agents have been added to the medications available to treat venereal warts.)   Others options are electrically cauterizing (burning) or surgically removing the warts.   These steps or some combination of them are needed if the warts are inside the anal canal, where they can obstruct the passage of fecal matter or cause other problems.   The treatments will require various levels of anesthesia depending on the position and extensiveness of the warts but are almost always performed as outpatient procedures.   Discomfort may last for a few days during healing.  

Many patients need repeat treatments to fully remove anal warts.   In addition, the virus that causes them may, in some patients, lie dormant long periods of time, only to become active and cause warts again at a later time.   In other patients, the warts never return.   Patients must be vigilant and seek repeat treatment for recurrences.

Physicians strongly urge patients diagnosed with venereal warts (as well as their sexual partners) to be fully evaluated and treated, as they are carriers of an infection that they can transmit to others.

Bacterial venereal diseases can cause can also cause infection in the anus or rectum.   Syphilis, gonorrhea, and chlamydia, among others can infect this area, typically as a result of anal sex with another infected individual.   In rare instances, tuberculosis can also infect anal-rectal tissue.   Physicians treat these infections with antibiotics.

 

Fecal incontinence –

Sometimes the nerves and muscles of the anorectal area can be compromised in ways that make it impossible for individuals to control the passing of stool or gas.   The condition can range from mild to severe enough to compromise lifestyle and, in the case of the sick or elderly who are bedridden, to require daily assistance with care.   Fecal incontinence is more common with advancing age, and often becomes more severe as a person with this condition ages.

Causes of injury to the anal muscles and nerves include childbirth or other types of traumatic injury, infection, or weakening of muscles with age.   Muscle and nerve tests can help to define the problem better.   After full examination and evaluation, the colorectal specialist may recommend a range of possible steps, including:

• change in diet or medication;

• exercises (sometimes including biofeedback) to strengthen the anal muscles;

• treatment of any underlying conditions causing the incontinence;

• surgical repair of the anal muscles.

In the past, specialists would sometimes recommend that patients with severe fecal incontinence undergo a colostomy; but this is rarely the case today.

 

Rectal prolapse –

In rectal prolapse, the sides or walls of the rectum drop down from the normal position so that they are visible through or outside the anus.   The everted rectum protrudes from the anus when the condition has worsened.   This external portion of the prolapse my be as much as several inches in length.   (A related condition is rectocele, in which a portion of the rectal wall bulges into the vagina.)

Rectal prolapse is often related to a weakening of muscles in and around the anus.   Partly for this reason, it is associated with leakage of stool or mucus.   The prolapse may also cause bowel problems such as constipation and difficulty in bowel movements. The appearance of the condition and some of its symptoms may resemble hemorrhoids.   Although these two conditions are distinct, they may have overlap in some early-stage patients.   In its initial stages, a prolapse may only be evident when the patient strains down with the pelvic muscles, as for a bowel movement, when coughing, or during certain types of physical exertion.   (Again, this is sometimes also true for hemorrhoids.)

The cause of rectal prolapse remains a matter of debate, and contributing factors in any one individual may be difficult to identify.   Individuals who develop the condition may have a history of straining in bowel movements, in a way the eventually weakens the bowel wall.   Alternatively, women (in whom the condition is more prevalent) may have experienced anatomical stresses as a result of giving birth to a child.   Still others, may lose strength in the muscles and connective tissue of the pelvic floor and anorectal area as they age.   Neuromuscular injuries or conditions, including those that affect the function of the spinal cord, can also contribute to rectal prolapse.

The physician will use physical examination and possible radiologic studies and other tests to confirm the diagnosis of rectal prolapse.   For a partial rectal prolapse, the specialist may use treatment steps similar to those for hemorrhoids , although sometimes sphincter repair is required.

Surgery is the primary approach to correcting complete rectal prolapse, and it is highly successful for most patients.   Type of anesthesia for this surgery will depend on your needs, as will the type of surgery:

• Increasingly, colorectal surgeons are able to offer laparoscopic repair for rectal prolapse.   This involves inserting special types of endoscopic instruments through small incisions, and the approach offers faster recovery times.   The surgeon pulls the rectum back into a straight position and attaches it with sutures to the sacrum (center bone of the pelvis).   For some patients, this will require removal of a segment of the rectum.

• Alternatively, the surgeon may use conventional, open, abdominal surgery.   This requires a longer incision in the abdomen, to perform the same repair steps, and longer recovery time.

• For some patients, including those unable to undergo more invasive surgery, the surgeon can use anal access to remove a section of the prolapsed bowel and gently return the bowel its normal position.

Surgical treatment may help patients to regain strength and tone in the anal sphincter muscle, if this muscle has been weakened.

 

  Anorectal trauma –

Various types of events can cause strains or tears in the muscle or tissue of the anus or rectum.   These causes of anorectal trauma include:

• physical activities causing unusual pressure or torsion in the area;

• anal sexual activity or assault;

• athletic incidents, including those that cause blunt impact with the area;

• falls or other types of accidents;

• or childbirth.

Proctologists can evaluate and offer noninvasive care for symptoms during healing.   Severe injuries may require surgical repair, which can normally be done with minimal invasiveness, with access through the anus.

 

Cancer –

Surgical care for cancer of the colon and rectum has improved significantly.   Colorectal cancer is one of the more common types of cancer.

Cancer of the anus, by comparison, is an uncommon cancer.   It arises in the cells around the anal opening or in the first inch or two of the anal canal.   Typically, these are cancerous growths of squamous cell carcinomas that arise on or near the surface lining of the anus or of mucous cells on the surface of the anal canal.   Risk factors other than age include, anal warts, anal sex, smoking, weakened immune system, fistulas or other wounds in the anus, and treatment of the pelvis with radiation therapy.   Symptoms include bleeding, lumps, pain, itching, and difficulty with bowel movement.   Diagnosis requires a biopsy.

Colorectal surgeons treat anal cancers by surgically removing them, sometimes including lymph nodes and other nearby tissue.   Adjunctive radiation therapy (and sometimes chemotherapy) is effective enough today in eradicating any remaining cancer cells that surgeons can almost always preserve the ring of muscle around the anus (the sphincter muscle) so that normal fecal continence is retained.   This is referred to as a sphincter-sparing operation.   Rarely do patients require more extensive surgery that includes a permanent colostomy, and then usually only if their cancer is discovered at a late stage.

 

Note –

Proctologists treat a variety of other conditions as well.   For more on proctologic diseases and conditions, see: http://ascrs.affiniscape.com