There is a long list of conditions that can cause persistent pain in the anal region. This discussion will focus on the most common of these - which are hemorrhoids, peri-anal abscesses/fistulas and anal fissures.

Hemorrhoids

Also known as “piles”, hemorrhoids occur when the blood vessels under the lining of the anal canal swell and bulge out. Initially the bulge is small and located within the anal canal but in time, the bulging piles protrude out of the anus. Swollen piles can bleed, sometimes quite profusely. Pain occurs when the swelling is severe or the blood vessels inside the piles become clotted up (thrombosed).

Hemorrhoids are very common, and it is estimated that about half of the population will develop hemorrhoids. Many patients suffer in silence for long periods before seeking treatment.

The exact cause of hemorrhoids is unknown. Excessive straining during bowel movements and chronic constipation are well known to be associated with piles. Sitting for prolong periods, especially reading, on the toilet, is another factor. Pregnant women frequently develop large piles during the later stages, especially around the time of delivery.

Small piles can be treated with medications and creams combined with relieving constipation and improving bowel habits. Increasing fluids and fiber in the diet also help.

More severe cases require some form of surgical treatment. This can range from simple rubber band ligation to formal surgery (hemorrhoidectomy) depending on the severity of the swelling.

Hemorrhoidectomy, or the surgical removal of piles, is a relatively minor operation. It takes about 15 to 30 minutes, and can be done with just one day’s stay in hospital. The main risk is bleeding after the operation, which is not common. Pain from the wound is variable and easily controlled with analgesic tablets. Although some discomfort during bowel movements may be present initially, evacuation of bowels is not affected usually. Most patients are ambulant immediately and are able to return to full normal activities in about 1 to 2 weeks.

A perianal abscess is an infection with pus collection near the anal canal. The presence of pus causes a painful swelling on the skin near the anal canal. If the infection is severe enough, patients can also have fever and feel generally sick.

The anal canal has small glands along it’s lining, which secrete a lubricant to help in the defecation process. These glands can get blocked and become infected (something similar to pimples on the face). The infection can worsen with the formation of pus.

The reason why people get perianal abscess is unclear. It is not related to personal hygiene or bowel habits.

The treatment of perianal abscess is surgical drainage. This requires an anesthetic, usually general, and an incision is made over the abscess. The pus is drained and the abscess cavity washed and left open. Daily dressing of the wound needs to be done till the abscess wound heals completely, which may take several weeks.

Leaving a perianal abscess alone or treating with antibiotics alone is not appropriate. Often this leads to worsening of the infection and other complications.

About 50% of perianal abscesses will heal and never recur. However, in the rest, while the abscess cavity and the skin over it may heal, there can still exist a connection from within the anal canal, at the site of the original blocked gland. This can re-infect the area causing another abscess or it can form into a persistent tunnel called a fistula.

A perianal fistula is a connection or tunnel linking from within the anal canal to the outside skin. Fecal material and anal secretions will discharge through this tunnel and cause staining of the patient’s underclothes. Fistulas can appear to heal only to reopen again. Often they are associated with recurrent abscess formation.

The only way to cure a fistula is by surgery. The problem with fistulas is that the tunnel passes through the muscles that control the function (continence) of the anus. If the tunnel is nearer the surface (known as a “low” fistula), then surgery is simple and with a high chance of permanent cure. However, if the tunnel is deeper (“high” fistula), surgery is more complex and there is a higher chance (50%) of failure to cure.

This is the least common of the three conditions. It usually causes a deep seated pain in the anal canal, made much worse during bowel movements. In severe cases, patients can’t even sit properly. Bleeding during defecation can also occur.

Anal fissure is a small ulcer or wound in the anal canal that does not heal. It usually starts as a tear of the lining of the anal canal, usually caused by passing hard dry stools or sometimes even by diarrhea. The wound causes spasm of the anal muscles and this leads to tightening of the anal canal which results in a vicious circle difficulty to evacuate the bowel, leading to increase force used leading to more injury and then more spasm.

The majority of patients with anal fissure can be treated with making the stool more formed and softer with high fibre and liquid in the diet and using stool softeners, together with some analgesic medications and creams.

If the fissure fails to heal despite adequate conservative treatment, then surgery may the only option. This is a minor procedure, done under anesthesia, as a day surgery, where the anal muscles are loosened with a small cut (lateral sphincterotomy).