Ano-rectal
The rectum is the lower part of your large intestine. The anus is the opening of the rectum through which stool passes out of your body.
Problems with rectum and anus are common. The most common include haemorrhoids, abscesses, fissures and fistulas; all of these are benign but may cause considerable discomfort. Symptoms of more serious diseases such as inflammatory bowel disease, colonic and anal cancer may be similar to those of the more common benign diseases therefore although many people are embarrassed to talk about anal or rectal troubles, seeing your doctor about problems in this area is important.
What are the common symptoms of ano-rectal disease?
The most common symptoms are:
- Rectal bleeding
- Pain
- Discharge
- Incontinence
- Itch (Puritis ani)
- Change in bowel habit.
Rectal Bleeding
Bleeding from the back passage is always abnormal. In most cases it will be due to benign conditions but it may also be a symptom of colonic cancer or other serious disease therefore it is important that medical attention is sought at an early stage. Although the pattern of bleeding may point to the site of bleeding it is important to recognise that symptoms are often atypical and that it is not possible from taking a history to say what the cause of bleeding is and an examination is required.
Many patients will feel reassured that they have undergone screening test that are normal i.e. have submitted stool samples for testing of microscopic blood. It is extremely important to note that even if these were normal and a patient does have rectal bleeding this should be investigated as negative tests only indicate there was no bleeding at the time the test was taken.
Pain.
Pain in or around the anus is usually a symptom of diseases at the anal margin – most commonly a fissure or an abscess. Rarely an anal cancer may present with pain and it is also important to realise that pain in the perianal region may be related to intra-abdominal diseases.
An anal fissure is a crack in the skin at the anal margin – most commonly it occurs at the 6 o’clock position and may be associated with a small skin tag which is easily felt. The most common symptom of a fissure is pain related to passing stool. Typically the patient complains of a sharp, searing, pain that comes on with going to the toilet and lasts for sometime thereafter. This pain is in part due to spasm of the anal sphincter. Anal fissures may be associated with fresh rectal bleeding and often relate to constipation. Treatment is most often possible with local ointments but if this is not successful injection with Botox or a sphincterotomy (surgically cutting the underlying muscle) may be required.
An abscess is a collection of pus, often under pressure and is extremely painful until it is drained by making a surgical incision overlying it. In this region abscesses are classified according to their position - the commonest are: Ischio-rectal, perianal and pilonidal. An ischiorectal and periananl abscess may relate to a connection between the anal canal and the external skin (Fistula-in-ano). To prevent a further abscess developing this will require treatment in its own right once the abscess has been drained. A pilonidal abscess is located in the natal cleft between the buttocks and is due to a hair that has become entrapped under the skin.
Discharge
An abnormal discharge from the anus may relate to diseases of the bowel producing excess mucous, difficulty controlling the bowel or a fistula (as above). Mucous (or slime) is normally produced by the bowel lining to lubricate the stool however any inflammation may lead to excess mucous production which is apparent as a discharge. Some growths of the rectum such as polyps and tumours may produce large qualities of mucous. In situations where part of the lining of the bowel prolapses to the exterior i.e. haemorroids or rectal prolapse there may be a large amount of mucous produced.
Incontinence
Incontinence of stool is much more common than most people think; probably because most sufferers are embarrassed and reluctant to come forwards with the problem. It should also be remembered that there are different degrees of continence and some patients may experience a mild discharge that they are unable to control while others have faecal soiling. In general the causes of incontinence can be divided into:
- Problems with the bowel causing excess stool i.e. if there is excessive diarrheoa even if there is no problem with the anal sphincter mechanism many patients will soil themselves.
- Problems with the mechanisms of controlling continence i.e. weakness of the anal sphincter mechanism possibly from previous injury – the most common relating to child birth
- Problems with perception i.e. if a patient is unaware that there is stool in the rectum they may become incontinent – this may relate to chronic conditions affecting sensation or be temporary related to their conscious state.
Initial investigations will be to ensure that there is no underlying bowel disease and it is likely that a sigmoidoscopy will be required. Further investigation may require measurement of the strength of the anal muscles.
Itch (Purities Ani)
Again this is a relatively common condition and it may relate to problems with the bowel resulting in diarrhoea and /or discharge which irritates the skin around the anus. Any problems encountered with cleaning the area around the anus may lead to an itch – this is most commonly encountered in patients with skin tags which may make cleaning after a stool difficult. Alternatively it may be due to irritation of the surrounding skin from an unrelated cause i.e. skin conditions such as dermatitis.
Change in bowel habit
There are many reasons for a change in bowel habit. It may be acute due to gastroenteritis or more insidious relating to diseases of the bowel. In many patients it may relate to a change in diet, lifestyle or even medications. In most situations it will turn out to be a fairly innocent problem but it is important to rule out more sinister causes such as inflammatory bowel disease or tumours.
