Anal Problems


What are haemorrhoids?

What we call “haemorrhoids” or “piles” are veins whose usual location is within the anal canal, that is, well inside the backpassage. They have a role in the mechanism of anal continence, as they act as a water valve to help the two anal sphincters in keeping the anus closed.

Unfortunately, sometimes they tend to slide outwards, thus becoming a “disease”.


How does this happen?

Haemorrhoidal veins – or better, the “haemorrhoidal plexus” as they are a network of interconnected veins – are attached to the underlying rectal muscle layer by very small ligaments that keep them in the correct place. For some reasons, in some persons, those ligaments are loose, thus allowing a certain degree of movement to the plexus. An increased abdominal pressure – as with pregnancy, sedentary life, abdominal straining – does the rest, pushing the haemorrhoids out of the anus. There, the stretched veins come in contact with a “difficult” external environment, get engorged, become painful and bleed.

We should actually abandon the term “haemorrhoids” as the problem is always a prolapse of the rectum.

What are the symptoms of haemorrhoids?

Symptoms of haemorrhoids are symptoms of a rectal prolapse which carries out the haemorrhoidal plexus. The first symptom is usually a niggling feeling of a lump popping out from the anus at every bowel motion, that can be easily pushed back at the end. Prolapsing haemorrhoids bleed quite easily. It is usually a bright bleeding – although not as bright as with other anal conditions – that can be seen on the toilet paper or in the pan at each bowel motion. An important prolapse can cause continuous or occasional discomfort, ma a true stabbing pain is uncommon. When this happens, it signifies that the haemorrhoidal veins have been strangulated by the anal sphincter and the blood trapped into the vein clotted and got infected, causing a haemorrhoidal thrombophlebitis.

What should I do if I get symptoms of haemorrhoids?

The first thing to do is to book an appointment with your GP. In particular, in case of rectal bleeding it is of the utmost importance to identify the source of bleeding. Unfortunately, rectal bleeding can come from a variety of different lesions, not always benign. Your GP will visit you and if he thinks you deserve a surgical evaluation will refer you to the specialist. Most likely, the surgeon will propose you to have a camera test, just to rule out another reason for your anal symptoms.

How can haemorrhoids be cured?

Not all cases of haemorrhoids should be cured with a medical intervention, either by medications or surgery. Most likely, you will be initially suggested to modify your lifestyle and your diet, trying to keep your stools soft by increasing the amount of vegetables and fruits in your diet and by increasing your physical exercise. If these don’t suffice, probably you will be prescribed a local treatment with creams and ointments. In early cases of bleeding haemorrhoids, it is possibl to perform a rubber band ligation of the bleeding vessels. This is not a cure of your haemorrhoids, but it is just a palliative measure to reduce bleeding. In refractory cases, a surgical operation will be offered. Recent evidences demonstrate that the best surgical treatment for prolapsing haemorrhoids is the so-called stapled haemorrhoidopexy, where haemorrhoids are not removed but only pushed back and fixed in their original anatomical place, in order not to lose their function with anal continence. Resective operations – haemorrhoidectomy – are still largely performed in the UK. Haemorrhoidectomy is the excision of the prolapsing haemorrhoidal tissue. The choice of the operation is up to the surgeon, who will offer the best treatment in your specific case and will discuss with you the surgical technique and the possible outcome.

Can haemorrhoids recur after surgery?

Yes. Unfortunately in less than 30% of cases haemorrhoids can recur after surgery. Usually, this is not due to a failed operation, but mostly to the persistence of the factors which caused the prolapse at the beginning.

Perianal fistula

What is a perianal fistula?

A perianal fistula is an abnormal tract connecting the last part of the bowel, the anal canal, to the skin around the anus.

How does it form?

In the vast majority of cases, a perianal fistula follows an infection that for some reasons arises in the space between the two anal sphincters. The abscess-forming infection settles down either spontaneously or with medical treatment (antibiotics and/or surgical drainage), but usually leaves a fistula connecting the anal canal to the skin. This can be a simple single tract or a complex network of tracts and collateral branches around the anus.

What are the symptoms of a perianal fistula?

Patients with a perianal fistula have a history of one or more episodes of perianal infection, with pain, swelling and discharge. Once the fistula has established, the patients complain of continuous discharge and discomfort around the anus.

How can a fistula be cured?
The only way to cure a perianal fistula is to remove the whole inflammatory tract with a surgical operation. Unfortunately, this is not always possible. When dealing with a perianal fistula, a surgeon should take into account the anatomy of the fistula and mostly the relation the fistula established with the anal sphincters. Endoanal ultrasound or magnetic resonance imaging can be useful to delineate the anatomy of the fistula.  If only the internal sphincter is involved by the fistula, usually the operation is quick and straightforward as the internal sphincter can be easily cut with no big consequences on the anal continence, but a complex fistula involving the external sphincter can represent a real challenge for the surgeon.

Can a fistula recur after the operation?

Unfortunately this is quite frequent as sometimes it is not possible to remove all the inflammatory tissue.

Anal fissure

What is an anal fissure?

An anal fissure is a small non-healing ulcer that arises on the anal verge.

Why does it form?

Usually, an anal fissure is the result of a chronic local ischaemia due to a constant spasm of the internal anal sphincter. It is not clear why a normal sphincter decides to contract abnormally.

What are the symptoms of an anal fissure?

Anal pain – in particular during a bowel motion – and bright rectal bleeding are the usual symptoms of a fissure.

How can it be cured?

The treatment of an anal fissure is usually aimed to reduce the spasm of the sphincter. Your GP will initially suggest you to try and keep your stools soft and will prescribe a local treatment with creams and ointments. If this is not enough, he/she will refer you to the colorectal surgeon. Reducing the sphincteric hypertone is not an easy task and sometimes an operation is needed.

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