Columbia Surgical Specialists

Anorectal Conditions

Colon and rectal diseases comprise a broad range of conditions and ailments, the severity of which can vary from mildly irritating to life threatening. Colon and rectal surgeons are experts in the surgical and non-surgical treatment of cancer of the colon, rectum and anus, as well as benign conditions like diverticular disease, inflammatory bowel disease including Crohn’s disease and ulcerative colitis, various causes of colonic obstruction, a multitude of anorectal conditions, fecal incontinence and pelvic floor disorders. They complete residencies in general surgery in additional to surgical training fellowships dedicated to colon and rectal surgery; board certification requires completion of intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery.

Our colorectal group of board certified surgeons serves as the tertiary referral center for Eastern Washington and the surrounding tri-state region for both emergent and nonemergent colorectal conditions. Patient care is closely coordinated with local and regional medical and radiation oncologists, radiologists, gastroenterologists and primary care physicians along with general surgeons, gynecologists, gynecology oncologists and urologists as patient conditions require. Alongside clinical duties, our colorectal surgeons participate in state and national quality improvement projects, clinical research and leadership at the national level within the American Society of Colon and Rectal Surgeons.

Patient care is provided at Providence Sacred Heart Medical Center and Holy Family Hospital as well as MultiCare’s Deaconess Hospital.

Appointments  (509) 747-6194

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Anorectal Conditions Treated

ANAL ABSCESS AND FISTULA

An anal abscess is an infected cavity filled with pus near the anus or rectum. 

An anal fistula (also called fistula-in-ano) is a small tunnel that tracks from an opening inside the anal canal to an outside opening in the skin near the anus. An anal fistula often results from a previous or current anal abscess. As many as 50% of people with an abscess get a fistula. However, a fistula can also occur without an abscess. 

CAUSES

Small glands just inside the anus are part of normal anatomy. If the glands in the anus become clogged, this may result in an infection. When the infection is serious, this often leads to an abscess. Bacteria, feces, or foreign matter can also clog the anal glands and cause an abscess to form. Crohn’s disease, cancer, trauma and radiation can increase the risk of infections and fistulas.

SYMPTOMS

A patient with an abscess may have pain, redness or swelling in the area around the anal area or canal. Other common signs include feeling ill or tired, fever and chills. Patients with fistulas have similar symptoms, as well as drainage from an opening near the anus. A fistula is suspected if these symptoms tend to keep coming back in the same area every few weeks. 

DIAGNOSIS

Most anal abscesses or fistulas are diagnosed and managed based on clinical findings. Occasionally, imaging studies such as ultrasound, CT scan or MRI can help in the diagnosis and management of deeper abscesses and may be used to visualize the fistula tunnel.

TREATMENT

The treatment of an abscess is surgical drainage under most circumstances. It is important that your surgeon be very familiar with treating abscesses and fistula. Colorectal surgeons are experts in this area. For most patients, an abscess can be drained surgically through a simple procedure. An incision is made in the skin near the anus to drain the infection. This can be done at your surgeon’s office with local anesthetic or in an operating room under general anesthesia. Some patients with more severe disease may require multiple surgeries to take care of the problem. Patients who tend to get more severe infections due to diabetes or immunity problems may need to be hospitalized

Surgery is nearly always needed to treat an anal fistula. In many patients, if the fistula is not too deep, a fistulotomy is performed. During this surgery, the fistula track will be opened to allow healing from the bottom up. The surgery may require dividing a small portion of the sphincter muscle. A large amount of the sphincter muscle is not divided as this could lead to problems with bowel control (fecal incontinence) in some patients. If the fistula track does involve a large portion of the sphincter muscle, other more involved surgeries are done to treat the fistula without harming the sphincter muscle. More difficult cases may require multiple surgeries. 

Antibiotics alone are not effective in treating abscesses or fistula. Antibiotics may be needed, in addition to surgery, if a patient has immunity issues, specific heart valve conditions or widespread cellulitis (a bacterial infection of the skin and tissues under the skin). Providing your physician with an accurate medical history and undergoing a physical exam are important steps in deciding if antibiotics are required.

POST-TREATMENT PROGNOSIS

Your surgeon will advise you on proper postsurgical care. Unfortunately, despite proper treatment and complete healing, an abscess or a fistula can come back. If an abscess comes back, it suggests that perhaps there is a fistula that needs to be treated. If a fistula comes back, additional surgery will likely be required to treat the problem.  

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

The rectum is the last 6 inches of the large intestine (colon). Rectal cancer arises from the lining of the rectum. In 2012, more than 40,000 people in the United States will be diagnosed with colorectal cancer, making it the third most common cancer in both men and women. About 5% of Americans will develop colorectal cancer during their lifetimes. Colorectal cancer is highly curable if detected in the early stages.

Diagram taken from existing ASCRS brochure “Polyps”

WHO IS AT RISK FOR RECTAL CANCER?

No one knows the exact causes of rectal cancer. Rectal cancer is more likely to occur as people get older, and more than 90% of people with this disease are diagnosed after age 50. Other risk factors include a family history of colorectal cancer (especially in close relatives), and a personal history of inflammatory bowel disease such as ulcerative colitis, colorectal polyps or cancers of other organs.

CAN RECTAL CANCER BE PREVENTED?

Rectal cancer is preventable. Nearly all rectal cancer develops from rectal polyps, which are benign growths on the rectal wall. Detection and removal of these polyps by colonoscopy reduces the risk of getting rectal cancer. Your doctor can provide exact recommendations for rectal cancer screening based on your medical and family history. Screening typically starts at age 45* in patients with average risk, or at younger ages in patients at higher risk for rectal cancer.

Though not definitely proven, there is some evidence that diet may play a significant role in preventing colorectal cancer. As far as we know, a diet high in fiber (whole grains, fruits, vegetables, nuts) and low in fat is the only dietary measure that might help prevent colorectal cancer.

*In 2018, secondary to new data on the increased risks of colon cancer in those under 50, the American Society of Colon and Rectal Surgery changed recommendations to consider starting screening at age 45.

WHAT ARE THE SYMPTOMS OF RECTAL CANCER?

Many rectal cancers cause no symptoms at all and are detected during routine screening examinations. The most common symptoms of rectal cancer are a change in bowel habits, such as constipation or diarrhea, narrow shaped stools, or blood in your stool. You may also have pelvic or lower abdominal pain, unexplained weight loss, or feel tired all the time.  Other common health problems can cause the same symptoms. Hemorrhoids do not cause rectal cancer but can produce similar symptoms. Anyone with these symptoms should see a doctor to be diagnosed and treated as early as possible. Abdominal pain and weight loss are typically late symptoms, indicating possible extensive disease.

WHAT TESTS ARE PERFORMED TO DIAGNOSE RECTAL CANCER?

  • Physical exam and medical history
  • Digital rectal exam (DRE)
  • Proctoscopy: An office based exam of the rectum using a proctoscope, inserted into the rectum.
  • Colonoscopy: A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer.
  • Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer.

WHAT DETERMINES THE PROGNOSIS (OUTCOME) FOR RECTAL CANCER?

  • The stage of the cancer (how far advanced the cancer is).
  • Where the cancer is found in the rectum.
  • Whether the bowel is blocked or has a hole in it.
  • Whether all of the tumor can be removed by surgery.
  • The patient’s general health and ability to tolerate different treatment regimens.
  • Whether the cancer has just been diagnosed or has recurred (come back).

HOW IS RECTAL CANCER STAGED?

Distant Staging:

  • CT scan can accurately detect the presence of most cancer cells that have spread outside of the rectum.
  • PET scan
  • CEA assay

Local Staging:

  • MRI is one of the tests used for local staging. This will help determine if the tumor has spread through the wall of the rectum and if it has invaded nearby structures.
  • Endoscopic ultrasound (EUS): A procedure in which an endoscope or rigid probe is inserted into the body through the rectum.

HOW IS RECTAL CANCER TREATED?

For a complete cure, surgery to remove the rectal cancer is almost always required.  Depending on the location and stage, this may be performed through the anus (opening of the rectum) or through the abdomen. Rectal cancer surgery removes the cancer and lymph nodes, along with a small portion of the normal rectum on either side of the tumor. The creation of a colostomy (opening the intestine to a bag on the skin) is typically needed only in a very small number of patients. Trained surgeons may use minimally invasive surgical techniques depending on certain features of your cancer. Your surgeon will discuss these features with you prior to the operation. Additional treatment with chemotherapy or radiation therapy may be offered either before or after the surgery, depending on the stage of the cancer.

WHAT FACTORS INFLUENCE PROGNOSIS (OUTCOME)?

The outcome of patients with rectal cancer is most clearly related to the stage at the time of diagnosis, with cancer that is confined to the lining of colon having the best chance of success. This is one reason why early detection through screening methods like colonoscopy is crucial.

WHAT FOLLOW-UP IS NEEDED AFTER TREATMENT?

After treatment for rectal cancer, a blood test to measure amounts of CEA (a substance in the blood that may be increased when cancer is present) may be done to see if the cancer has come back. Routine CT scans, clinical examinations, and colonoscopy are also performed at intervals determined by the stage.

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

FISSURE

The anal canal is a short tube surrounded by muscle at the end of your rectum. The rectum is the bottom section of your colon (large intestine). An anal fissure (also called fissure-in-ano) is a small rip or tear in the lining of the anal canal. Fissures are common, but are often confused with other anal conditions, such as hemorrhoids.
 

CAUSES OF ANAL FISSURE

Fissures are usually caused by trauma to the inner lining of the anus from a bowel movement or other stretching of the anal canal. This can be due to a hard, dry bowel movement or loose, frequent bowel movements. Patients with a tight anal sphincter muscle are more likely to develop anal fissures. Less common causes of fissures include inflammatory bowel disease, anal infections, or tumors. 

SYMPTOMS

Anal fissures typically cause a sharp pain that starts with the passage of stool. This pain may last several minutes to a few hours. As a result, many patients may try not to have bowel movements to prevent pain.

Other symptoms include:

  • Bright red blood on the stool or toilet paper after a bowel movement
  • A small lump or skin tag on the skin near the anal fissure (more common when chronic)

NONSURGICAL TREATMENT

Your physician will discuss the benefits and side effects of treatments.

Treatment includes:

  • A high-fiber diet and over-the-counter fiber supplements (25-35 grams of fiber/day) to make stools soft, formed, and bulky.
  • Over-the-counter stool softeners to make stools easier to pass.
  • Drinking more water to help prevent hard stools and aid in healing.
  • Warm tub baths (sitz baths) for 10 to 20 minutes, a few times per day (especially after bowel movements to soothe the area and help relax anal sphincter muscles). This is thought to help the healing process.
  • Medications, such as lidocaine, that can be applied to the skin around the anus for pain relief.
  • Medications such as diltiazam, nifedipine, or nitroglycerin ointment to relax the anal sphincter muscles which helps the healing process.

Narcotic pain medications are avoided because they can cause constipation which could make the situation worse. 

SURGICAL TREATMENT

Although most anal fissures do not require surgery, chronic fissures are harder to treat and surgery may be the best option. The goal of surgery is to help the anal sphincter muscle relax which reduces pain and spasms, allowing the fissure to heal. Surgical options include Botulinum toxin (Botox®) injection into the anal sphincter or surgical division of an inner part of the anal sphincter (lateral internal sphincterotomy). Your colon and rectal surgeon will find the best treatment for you and discuss the risks of surgery. Both types of surgery are typically done as same-day outpatient procedures. 

POST-TREATMENT PROGNOSIS

Most patients can return to work and go back to daily activities a few days after surgery. Complete healing after both medical and surgical treatments can take 6 to 10 weeks. Even when the pain and bleeding lessen, it is important to maintain good bowel habits and eat a high-fiber diet. Continued hard or loose bowel movements, scarring, or spasm of the internal anal muscle can delay healing.

  • Botox® injections are associated with healing of chronic anal fissures in 50% to 80% of patients.
  • Sphincterotomy is successful in more than 90% of patients. Although uncommon, this procedure may affect the patient’s ability to fully control gas or bowel movements.

Fissures often come back. A fully healed fissure can come back after a hard bowel movement or trauma. Medical problems such as inflammatory bowel disease (Crohn’s disease), infections, or anal tumors can cause symptoms similar to anal fissures. If a fissure does not improve with treatment, it is important to be evaluated for other possible conditions. 

CAN ANAL FISSURES LEAD TO COLON CANCER?

Anal fissures do not increase the risk of colon cancer nor cause it. However, more serious conditions can cause similar symptoms. Even when a fissure has healed completely, your colon and rectal surgeon may request other tests. A colonoscopy may be done to rule out other causes of rectal bleeding.

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases, as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions, if indicated to do so.

Anal pain can occur before, during, or after a bowel movement. It can range from a mild ache that can get worse over time to pain that is bad enough to restrict daily activities. Anal pain has many causes, most of which are common and treatable. However, if anal pain does not go away within 24 to 48 hours, it is important to see your physician. If fever is present with anal pain, a more urgent appointment is needed.

COMMON CAUSES OF ANAL PAIN

1. Thrombosed External Hemorrhoid 

This is a blood clot that forms in an outer hemorrhoid in the anal skin. If the clots are large, they can cause pain when you walk, sit, or have a bowel movement. A painful anal mass may appear suddenly and get worse during the first 48 hours. The pain generally lessens over the next few days. You may notice bleeding if the skin on top opens. Nonsurgical treatment includes warm tub baths (sitz baths), pain medications, and stool softeners. Most experts recommend that the blood clots be removed surgically. This short surgery can be done in the surgeon’s office or at the hospital under local anesthesia.

2. Anal Fissure

The anal canal is a short tube surrounded by muscle at the end of your rectum. The rectum is the bottom section of your colon (large intestine). An anal fissure (also called fissure-in-ano) is a small rip or tear in the lining of the anal canal. Fissures are common, but are often confused with other anal conditions, such as hemorrhoids. The goal of all nonsurgical treatments is to make stools soft, formed, and bulky. Treatments include a high-fiber diet and over-the-counter fiber supplements (25-35 grams of fiber/day); over-the-counter stool softeners; warm tub baths (sitz baths) for 10 to 20 minutes, a few times per day; and several types of medication. Although most anal fissures do not require surgery, chronic ones are harder to treat and surgery may be the best option. The goal of surgery is to help the anal sphincter muscle relax, which reduces pain and spasms, allowing the fissure to heal.

3. Anal Abscess and Fistula

An abscess is an infected cavity filled with pus near the anus or rectum. In most cases, an abscess is treated by draining it surgically. A fistula is a tunnel that forms under the skin, connecting the clogged, infected glands to the abscess and out to the skin near the anus. Surgery is often needed to cure an anal fistula. Sometimes these surgeries are simple; however, more difficult cases may need multiple surgeries to take care of the problem.  

4. Fungal Infection or Sexually Transmitted Diseases

Patients with fungal infections or infections caused by sexually transmitted diseases (STDs) may have mild to severe anal or rectal pain. STDs include gonorrhea, chlamydia, herpes, syphilis, HPV, etc. The pain is not always tied to having bowel movements. Other signs may include minor anal bleeding, a discharge, or itching. Treatment includes topical or oral antibiotics and antifungal medications.

5. Skin Conditions

Skin disorders that affect other parts of the body (e.g. psoriasis, warts) may also affect skin around the anus. Anal itching, bleeding, and pain may come and go. In some cases, a skin biopsy is needed. Treatment is tied to the results of the skin biopsy and/or physical exam. Early diagnosis is key so treatment can begin as soon as possible.

6. Anal Cancer

While most cases of anal pain are not cancer, tumors can cause bleeding, a mass, and changes in bowel habits, as well as pain that gets worse over time. If you have pain or anal bleeding that does not go away or gets worse, see a colon and rectal surgeon as soon as possible. The first office visit includes a physical exam, exam of the anal canal with a small, lighted scope (anoscopy) to visualize any abnormal areas, and biopsy of the mass. If the pain is too bad for an exam in the office, your surgeon may need to perform an exam under anesthesia to make a proper diagnosis. Treatment of anal cancer or other anal tumors may involve chemotherapy, radiation and/or surgery.

WHEN SHOULD I SEEK HELP FROM MY MEDICAL PROVIDER?

You should see a physician if:

  • Pain comes back or doesn’t go away
  • There is ongoing rectal bleeding
  • You can feel a mass that does not get better 

WHAT IS A COLON AND RECTAL SURGEON?                                    

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

Anal warts (condyloma acuminata) are caused by the human papilloma virus (HPV), the most common sexually transmitted disease (STD). The warts affect the area around and inside the anus, but may also develop on the skin of the genital area. They first appear as tiny spots or growths, often as small as a pin head. They can grow quite large and cover the entire anal area. 

CAUSES

Sexual intercourse is a common way to get infected with HPV. However, a person can become infected with HPV without having sexual intercourse. Any direct contact to the anal area (e.g. hand contact, fluids from an infected sexual partner) can cause HPV and anal or genital warts. 

Anal Warts from ASCRS on Vimeo.

PREVENTION

The HPV virus often remains in the body without any signs. There are steps you can take to help prevent anal warts.

  • Do not have sexual contact with people who have anal (or genital) warts
  • Limit sexual contact to a single partner
  • Abstinence: Do not have any sexual contact
  • Always use condoms (this reduces, but does not eliminate the risk)
  • Sexual partners should be checked for HPV and other STDs even when there are no symptoms

SYMPTOMS

Warts are usually painless, so people may not realize they have them. The primary symptom is soft, moist bumps near or in the anus that are light brown or flesh-colored. Additional symptoms may include:

  • Itching
  • Bleeding
  • Mucus discharge
  • Feeling like there is a lump in the anal area

DIAGNOSIS

Your physician will look at the skin around the anus, as well as the entire pelvic area, including the genitals. He or she may perform an exam of the anal canal with a small, lighted scope (anoscopy) to see if there are any warts inside the anal canal (internal anal warts). 

TREATMENT

If warts are not removed, they can grow larger and multiply. Left untreated, warts may lead to an increased risk of anal cancer in the affected area. Internal anal warts may not respond to topical medications, so surgery may be required. Treatment options include:

  • Topical medication: These creams usually work best if the warts are very small and located only on the skin around the anus.
  • Topical medications that will freeze the warts (liquid nitrogen)
  • Topical medications that will burn the warts (Trichlorocetic acid, podophyllin)
  • Surgery: When the warts are either too large for the above mentioned treatments or are internal, surgery is considered. During surgery, the warts are surgically removed. The patient will be anesthetized for the procedure. The type of anesthetic depends on the number and exact location of the warts being removed. When there are many warts, your surgeon may perform the surgery in stages. An internal examination will also be performed so that any lesions on the inside can also be found and treated.

POST-TREATMENT PROGNOSIS

Mild pain and discomfort generally last for a few days. Pain medication may be prescribed. Patients treated in the clinic can return to work immediately. Those that have surgery can usually return to work the next day, while others that have more extensive surgery may stay home for several days to weeks.

Warts may come back repeatedly after successful removal. This happens because the HPV virus stays inactive for a period of time in body tissues. When warts come back, they can usually be treated at your surgeon’s office. If a large number of new warts develop quickly, surgery may be needed again.

It is important to discuss with your surgeon how often to schedule follow-up visits. During these visits, an exam will be done to make sure that all the warts are gone and no new ones have formed. 

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases, as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions, if indicated to do so.

Fecal incontinence (also called anal or bowel incontinence) is the impaired ability to control the passage of gas or stool. This is a common problem, but often not discussed due to embarrassment. Failure to seek treatment can result in social isolation and a negative impact on quality of life.

CAUSES

There are many causes of fecal incontinence such as injury, disease and age.

  • Childbirth-related injury: This is the most common cause, resulting from a tear in the anal muscles. The nerves controlling the anal muscles may also be injured, which can lead to incontinence. Some injuries may be detected right after childbirth; however, many go unnoticed until they cause problems later in life. Since it may be years after giving birth, childbirth is often not recognized as the cause of the problem.
  • Trauma to anal muscles: Anal operations or traumatic injury to the tissues near the anal region can damage the anal muscles and lessen bowel control.
  • Age-related loss of anal muscle strength: Some people gradually lose anal muscle strength as they age. A mild control problem may have existed when they were younger, but this gets worse later in life.
  • Neurological diseases: Severe stroke, advanced dementia or spinal cord injury can cause lack of control of the anal muscles, resulting in incontinence.

SYMPTOMS

Symptoms can range from mild to severe. Mild cases may only involve difficulty controlling gas. Severe cases can lead to an inability to control liquid and formed stools. A patient may have a feeling of urgency or experience stool leakage due to frequent liquid stools or diarrhea.

If there is bleeding with lack of bowel control, consult your physician as soon as possible. This may indicate inflammation within the colon and rectum, such as ulcerative colitis, Crohn’s disease, a rectal tumor or rectal prolapse. All of these conditions require prompt evaluation by a physician.

DIAGNOSIS

An initial discussion of symptoms with your physician will help determine the degree of incontinence and the effect on your life. Possible underlying factors are often found during a review of your medical history, such as:

  • Multiple pregnancies, large weight babies, forceps deliveries or episiotomies (surgical incisions to aid childbirth).
  • History of prior anal or rectal surgeries.
  • Medical illnesses or conditions.
  • Medication side effects.

A physical examination of the anal region should be performed. An exam may easily identify an obvious injury to the anal muscles. Your physician will decide if tests are needed to confirm the diagnosis. An ultrasound probe may be used in the anal area, which provides photographs of potentially injured anal muscles. Other tests may be required to assess the function of muscles and nerves that help control bowel movements.

 

TREATMENT

There are nonsurgical and surgical treatment options that vary based on the cause and severity of the problem. Your colon and rectal surgeon will discuss different treatment methods and help you decide what approach is best for you.

NONSURGICAL OPTIONS

Dietary changes: Mild problems may be treated simply by changing one’s diet.

Constipating medications: Specific medications can result in firmer stools, enabling more bowel control.

Medications: Inflammatory bowel diseases (such as ulcerative colitis or Crohn’s disease) can cause diarrhea and contribute to bowel control problems. Treating these underlying diseases may eliminate or improve incontinence symptoms.

Muscle strengthening exercises: Simple home exercises to strengthen the anal muscles can help in mild cases.

Biofeedback: A type of physical therapy to help patients strengthen anal muscles and sense when stool is ready to be evacuated.

 

SURGICAL OPTIONS

There are several surgical options for the treatment of fecal incontinence. Keep in mind that surgery is not the right choice for every patient.

Surgical muscle repair: Injuries to the anal muscles may be surgically repaired.

Stimulation of the nerves: Insertion of a nerve stimulator can help nerves that control muscles and skin of the anus work more efficiently.

Bulking agent injections: Injecting a substance into the anal canal can bulk it up and strengthen the “squeeze” mechanism of the anal muscles used during bowel movements.

Surgical colostomy: In severe cases, a colostomy may be the best option for improving quality of life. During this procedure, part of the colon (large intestine) is brought out through the abdominal wall to drain into a bag.

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

DISCLAIMER

Pelvic floor dysfunction is a group of disorders that change the way people have bowel movements and sometimes cause pelvic pain. These disorders can be embarrassing to discuss, may be hard to diagnosis and often have a negative effect on quality of life. Symptoms vary by the type of disorder.  Many general practitioners may not be familiar with pelvic floor dysfunction, and it may take a specialist, such as a colorectal surgeon, to discover the correct diagnosis.  

 

TYPES OF PELVIC FLOOR DYSFUNCTION

Obstructed Defecation: Obstructed defecation is difficulty getting bowel movements out of the body. Although the stool reaches the rectum, or bottom of the colon, the patient has difficulty emptying. This often makes patients feel that they need to go the bathroom more often, or that they cannot empty completely, as if stool remains in their rectum. Obstructed defecation may be caused by pelvic floor prolapse (discussed below), pain symptoms or muscles not functioning normally. 

Rectocele: A rectocele is a bulge of the front wall of the rectum into the vagina. Normally, the rectum goes straight down to the anus (picture). When a patient with a rectocele strains, the stool may get caught in an abnormal pocket of the rectum which bulges into the vagina. This prevents the patient from emptying the rectum completely. Generally, rectoceles do not produce symptoms. As they grow larger, rectoceles may cause difficulty going to the bathroom, or cause leakage of stool after having a bowel movement. Rectoceles are more common in women who have given birth. Rectoceles are usually caused by thinning of the tissue between the rectum and vagina and weakening of the pelvic floor muscles.

Pelvic Floor Prolapse: The pelvic floor consists of the muscles and organs of the pelvis, such as the rectum, vagina, bladder. Stretching of the pelvic floor may occur with aging, collagen disorders or after childbirth. When the pelvic floor is stretched, the rectum, vagina, or bladder may protrude through the rectum or vagina, causing a bulge, which can be felt. In addition to a rectocele, patients may have rectal prolapse, a cystocele (prolapse of the bladder) or protrusion of the small bowel. Symptoms generally include difficulty in emptying during urination or defecation, incontinence or pressure in the pelvis.  

Paradoxical Puborectalis Contraction: The puborectalis muscle is part of the control muscles that control bowel movements. The puborectalis wraps like a sling around the lower rectum.   During a bowel movement, the puborectalis is supposed to relax to allow the bowel movement to pass. If the muscle does not relax or contracts during paradoxical contraction, it may feel like you are pushing against a closed door.

Levator Syndrome: Levator syndrome is abnormal spasms of the muscles of the pelvic floor. Spasms may occur after having bowel movements or without a known cause.  Patients often have long periods of vague, dull or achy pressure high in the rectum. These symptoms may worsen when sitting or lying down. Levator spasm is more common in women than men.

Coccygodynia: The coccyx, or tailbone, is located at the bottom of the spine. Coccygodynia is pain is of the tailbone. The pain is usually worsened with movement and may worsen after defecation. It is usually caused by a fall or trauma involving the coccyx, although in a third of patients no cause is noted.

Proctalgia Fugax: Proctalgia fugax is a sudden abnormal pain in the rectum that often awakens patients from sleep. This pain may last up to several minutes and goes away between episodes.  Proctaliga fugax is thought to be caused by spasms of the rectum and/or the muscles of the pelvic floor.

Pudendal Neuralgia: The pudendal nerves are the main sensory nerves of the pelvis. Pudendal neuralgia is chronic pain in the pelvic floor involving the pudendal nerves. This pain may first occur after childbirth, but often comes and goes without reason.  

DIAGNOSIS

A complete medical history and thorough physical examination are key to evaluating pelvic floor dysfunction. The physician should ask about other pain issues in the body, as well as difficulty having bowel movements, passing urine or pain during sexual intercourse. It is important to have a full physical exam, including rectal and vaginal exams. 

The function of the various nerves and muscles involved in bowel movements is complex and the physician may need additional testing to determine the cause of the problem. The tests that may be ordered by your colon and rectal surgeon can help make a diagnosis and guide treatment.

  • Endoanal/Endorectal Ultrasound: Provides pictures of the structures of the pelvis, including the anus, rectal wall and control muscles. It may also demonstrate rectocele, rectal prolapse or enterocele (small bowel prolapse). This is generally performed in the office.  
  • Anorectal Manometry: Evaluates the ability for the control muscles and rectum to function and the strength of muscles. This is also generally performed in the office or at an endoscopy center. This test requires the patient to push and strain, so that it can correctly determine the strength of the muscles. 
  • Electromyography (EMG)/ Pudendal Nerve Motor Latency Testing: These are tests that check to determine how the nerves of the pelvic floor are working. Pudendal nerve motor latency tests evaluate just the pudendal nerve, while EMG is a more complex testing of several nerves in the anal sphincter and pelvic floor. These tests may require needles and small doses of electricity. 
  • Colonic Transit Study: A colonic transit study is a series of X-rays that evaluate the passage of stool through the colon to identify potential causes and locations of constipation. The patient takes a small pill containing metal markers, which will be seen on the X-rays over the next several days. 
  • Videodefecogram: A defogram is a special X-ray that is taken while you are having a bowel movement to test muscle movement. This test is very helpful in determining the cause of pelvic floor dysfunction. This test may include regular X-rays, fluoroscopy or an MRI machine.   

TREATMENT

Treatment is based on the cause of the dysfunction and severity of symptoms. Surgical treatment is rarely needed for pelvic floor dysfunction, except for large, symptomatic rectoceles or other pelvic prolapse. In the case of prolapse, surgery may help to restore the normal location of pelvic organs. This may be performed through the abdomen or through the bottom, depending on the specific problem. 

For pelvic pain syndromes, the goal of treatment is to relieve or reduce symptoms. In some cases, a combination of treatment methods helps reduce pain.

  • Dietary changes such as increasing fiber and fluid intake to make bowel movements easier. 
  • Biofeedback, a special form of pelvic floor physical therapy aimed at improving rectal sensation and pelvic floor muscle contraction. This may include electrical stimulation of the pelvic floor muscles, ultrasound, or massage therapy. In addition, there are exercises that may be done at home which can help improve symptoms. 
  • Injection of a local anesthetic and/or anti-inflammatory agents.

POSTSURGERY PROGNOSIS

The success rate of prolapse surgery depends on the specific symptoms and their duration. Risks of surgical correction include bleeding, infection and pain during intercourse (dyspareunia). There is also the chance of the pelvic prolapse recurring or worsening.

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum, and anus. They have completed advanced surgical training in the treatment of these diseases, as well as full general surgical training. They are well versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions, if indicated to do so.

Pilonidal disease is a chronic skin infection in the crease of the buttocks near the coccyx (tailbone). It is more common in men than women and most often occurs between puberty and age 40. Obesity and thick, stiff body hair make people more prone to pilonidal disease.

 

 

Figure 1: Pilonidal disease affects the buttock crease area. Two small openings are shown (A).

 

CAUSES

Hairs often grow in the cleft between the buttocks. These hair follicles can become infected. Further, hair can be drawn into these abscesses worsening the problem.  

SYMPTOMS

Symptoms can vary from very mild to severe.  The symptoms may include:

  • Small dimple
  • Large painful mass
  • Clear, cloudy or bloody fluid drainage from affected area
  • If infected, the area becomes red and tender and the drainage (pus) smells foul
  • If infected, may have fever, nausea or feel ill

DISEASE PATTERNS

Nearly all patients have an acute abscess episode (the area is swollen, tender and pus may drain from it). After the abscess goes away, either by itself or with medical care, many patients develop a pilonidal sinus. The sinus is a cavity below the skin surface that connects to the surface through one or more small openings. Some sinus tracts may resolve on their own, however, most patients need minor surgery to remove them.

DIAGNOSIS

Diagnosis is typically confirmed by a physician examining the buttock area.

TREATMENT

Treatment depends on the disease pattern. The primary treatment for an acute abscess is drainage. An incision is made that allows pus to drain, reducing inflammation and pain. This procedure can usually be done in a physician’s office under local anesthesia. 

SURGICAL TREATMENT

Complex or recurring infections must be treated surgically, either through excision or unroofing the sinuses. Unroofing the sinuses, as shown in Figure 2, involves opening up the abscess and tracts and trimming the edges of skin. 

 

Figure 2: Drawing B shows inflammation located deep under the skin above the tailbone. The dashed line indicates the area to be opened or unroofed. The dashed line in drawing C shows the entire inflamed tissue that will be removed.

Larger, open operations often result in better outcomes, although healing takes longer. Closure with flaps has a greater risk of infection, but may be required in some patients. Your colon and rectal surgeon will discuss all the options and help you choose the most appropriate surgery.

POSTSURGICAL PROGNOSIS

When the wound is closed, it must be kept clean and dry until the skin is fully healed. If the wound is left open, dressings or packing are used to help remove secretions and allow the area to heal from the bottom up.

After healing, the skin in the buttocks crease must be kept clean and free of hair. It is necessary to shave or use a hair removal agent every 2 or 3 weeks until the age of 30. After that age, hair shafts thin out and soften and the depth of the buttock cleft lessens. Pilonidal disease can be a chronic, recurring condition so it is important to follow your physician’s postsurgical care instructions.

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

A rectocele is a bulging of the front wall of the rectum into the back wall of the vagina. The rectum is the bottom section of your colon (large intestine). This is a very common problem that often does not produce symptoms. Other pelvic organs can bulge into the vagina, including the bladder (cystocele) and the small intestines (enterocele), producing similar problems.

CAUSES

Rectoceles are usually caused by thinning of the rectovaginal septum (the tissue between the rectum and vagina) and weakening of the pelvic floor muscles. There are many things that can lead to weakening of the pelvic floor, including:

  • Vaginal deliveries
  • Trauma from vaginal delivery (e.g. the use of forceps or vacuum during delivery, tearing or episiotomy, which is a surgical cut in the muscular area between the vagina and the anus made just before delivery)
  • History of constipation
  • Chronic straining with bowel movements
  • Gynecological (e.g. hysterectomy) or rectal surgeries

SYMPTOMS

Most people with a small rectocele do not have symptoms. When the rectocele is large, there is usually a noticeable bulge into the vagina.

Rectal Symptoms

  • Difficulty having a complete bowel movement
  • Stool getting stuck in the bulge of the rectum
  • The need to press against the vagina and/or space between the rectum and the vagina to have a bowel movement
  • Straining with bowel movements
  • The urge to have multiple bowel movements throughout the day
  • Constipation
  • Rectal pain

Vaginal Symptoms

  • Pain with sexual intercourse (dyspareunia)
  • Vaginal bleeding
  • A sense of fullness in the vagina

DIAGNOSIS

Colon and rectal surgeons as well as gynecologists are trained in the diagnosis and treatment of this condition. A rectocele is often found during a routine physical examination. However, other tests may be needed to help evaluate its severity or possible connection to symptoms. The following test may be ordered to confirm the diagnosis.

  • Defecography: A special X-ray test that shows the rectum and anal canal as they change during defecation. This study is very specific and can pinpoint the size of the rectocele and the degree to which the rectum is emptied. 

TREATMENT METHODS

Rectocele treatment is needed only when they cause symptoms that interfere with daily living. Before any treatment, your physician will assess whether all your symptoms are related solely to the rectocele. There are nonsurgical and surgical treatment options for rectoceles. Most symptoms associated with a rectocele can be resolved with nonsurgical treatment, however, this depends on the severity of symptoms.

NONSURGICAL TREATMENT

The goal is to have good daily bowel habits and softer stools. Avoiding constipation and straining with bowel movements will reduce the risk of a bulge associated with a rectocele.

Preventive and Medical Tips

  • Eating a high-fiber diet and taking over-the-counter fiber supplements (25-35 grams of fiber/day)
  • Drinking more water (typically 6-8 glasses daily)
  • Avoiding excessive straining with bowel movements
  • Applying pressure to the back of the vagina during bowel movements
  • Pelvic floor exercises such as Kegel
  • Biofeedback, a special form of pelvic floor physical therapy aimed at improving rectal sensation and pelvic floor muscle contraction
  • Stool softeners
  • Hormone replacement therapy

SURGICAL TREATMENT

The surgical management of rectoceles should only be considered when nonsurgical methods have not resolved or improved symptoms and the condition interferes with daily living. This can be done through abdominal, rectal or vaginal surgery. The choice of procedure depends on the size of the rectocele and its symptoms. The goal of surgery is:

  • To remove the extra tissue caused by the rectocele
  • To strengthen the wall between the rectum and vagina with surrounding tissue or use of a mesh patch

POSTSURGERY PROGNOSIS

The success rate of surgery depends on the specific symptoms and their duration. Risks of surgical correction include bleeding, infection and pain during intercourse (dyspareunia). There is also the chance of the rectocele recurring or worsening.

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum, and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum, and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

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