Piles, fissures and anal pain. Dealing with a sore behind.

Piles, fissures and having a pain in the backside.Pain in the backside is no joke.  It can make you feel self conscious – like everyone knows your problem – and just plain afraid to sit down.

In this article we’re going to look at piles/hemorrhoids (haemorrhoids), anal fissures, the causes of anal pain and what can be done to treat them.

Piles and hemorrhoids.

Piles and hemorrhoids are the same thing.  They’re swollen and inflamed veins around the anal opening and in the lower rectum.  You can see the location of these 2 parts of the body on the diagram here.

There are 2 types – internal hemorrhoids and external hemorrhoids.    The external piles are found under the skin at the anal opening itself.  The internal piles are the ones in the lower rectum and they may protrude through the anus.  This can be permanent and may need treatment to put them back inside the anus, but they often shrink and disappear of their own accord.

What are the causes of hemorrhoids?

Factors that contribute to the swelling of the veins at the rectum and anus include:

  • Long term constipation and diarrhoea
  • Straining during bowel movements, often part of having constipation
  • Lack of fibre in the diet – which can lead to constipation
  • Pregnancy – puts pressure on the lower abdomen and its blood vessels
  • Childbirth
  • Being overweight
  • Getting older
  • Chronic cough
  • Heavy lifting
  • Anal intercourse
  • Family tendency to the condition.

What are the symptoms of hemorrhoids?

  1. The first sign is often seeing blood on the toilet paper.  This can be very alarming and should be discussed with your doctor so that s/he can confirm a diagnosis and rule out a more sinister cause.

If you see blood on the toilet paper that’s caused by piles, it is usually bright red.  There may be streaks of it or so much that it drips into the toilet.  You may see blood on the outside of a stool but it won’t be mixed into the stool.

  1. Some pain in the anal area and some anal bleeding is another symptom, as is having a mucous discharge from the anus.
  2. You may see or feel a small hard, painful lump at or near the anus.
  3. Severe pain and some bleeding happen when the internal piles have prolapsed through the anus and twisted or strangulated, or thromosed (clotted).  This pain will get worse after about 2-3 days but then improve, resolving after about 10 days.

How do I treat hemorrhoids?

Treatment will depend on the severity of the piles.

Changing your diet to include more fibre and therefore prevent constipation is essential for everyone with piles.

In mild cases at-home hemorrhoid remedies may work well:

  1. Over-the-counter hemorrhoid remedies such as Anusol or Anusol HC, Anugesic HC, Preparation H etc.  Many of these come in both cream and suppository form.  The tubes of cream should have a nozzle attachment that can be used to put cream into the rectum to ease pain there.

These creams contain local anaesthetic ingredients. Creams with ‘HC’ in their names indicate that they have a low dose of hydrocortisone, a steroid which will help to reduce the swelling.  Creams with higher doses of steroid are available on prescription.

  1. You may also want to take pain killing tablets such as paracetamol and/or ibuprofen.
  2. Use hot and/or cold compresses.  Wrap ice in a small towel or cloth and apply for 10 minutes 3-4 times a day.  A hot damp compress (small towel or facecloth) applied for about 10 minutes 3-4 times a day will also help.
  3. Avoid standing or sitting for long periods during the day.
  4. Don’t be tempted to use donut or ring cushions as they can make the problem worse.
  5. Wear loose cotton undergarments as they will prevent the build up of sweat and moisture that can irritate the piles.
  6. Use baby wipes to clean yourself after using the toilet.
  7. Avoid perfumed soaps when washing.

In more severe cases:

  • Ligation may be necessary.  Ligation of piles means putting a band round the hemorrhoids to stop their blood flow which should make them die off.
  • Sclerosant therapy involves injecting the piles with a substance that stops the blood getting into the pile.
  • Haemorrhoidectomy is the surgical removal of the piles.  There are several different types of hemorrhoid surgery.

Banding treatment can be done at the outpatient clinic.  The doctor will hold the hemorrhoid with a pair of forceps and wrap a rubber band around its base.  The hemorrhoid then dies over time (because it has no blood supply) and drops off.

This procedure is usually painless and up to 3 hemorrhoids can be treated at the same time.  It has an 80% success rate at preventing the hemorrhoids from recurring.

Injection sclerotherapy:  An injection of phenol in oil is put into the base of the hemorrhoid which causes them to scar.  This in turn shuts off the blood supply to the hemorrhoid so that it dies and drops off.

Hemorrhoidectomy:  This is the traditional operation use to treat serious and prolapsed hemorrhoids.  It is done under general anaesthetic and the surgeon cuts the hemorrhoids away.  It’s usually a successful operation but can be painful in the recovery phase afterwards.

Prevent hemorrhoids by preventing constipation and not straining on the toilet.

Anal fissures.

An anal fissure is a small tear in the anus.  The pain this causes is often worse when you pass a stool (poo/poop/faeces) but it should heal itself in 1-2 weeks.

Treatment for anal fissures is for the pain they cause.

For fissures that don’t heal themselves and last for 6 weeks or more (doctors call these chronic fissures), GTN ointment to relax the anal muscle and/or surgery will reduce the anal muscle pressure.  This helps the fissure to heal better.

They’re not serious but they are very painful.

What are the symptoms of an anal fissure?

Pain when you have a bowel movement and for an hour or so afterwards, as well as seeing bright red blood on the toilet paper, on the stool or in the toilet pan are the most common symptoms.

This is similar to the symptoms of hemorrhoids but on examination, a (internal) haemorrhoid can be felt with the finger but a fissure cannot.

What causes anal fissures?

  • Most fissures are caused by passing large faeces as a result of constipation and the anus stretches and tears.
  • Spasm of the anal muscle (the sphincter) can make it difficult to pass the stools and slow down the healing process.
  • Some anal fissures are caused by very bad diarrhoea.
  • Some bowel diseases, such as Crohn’s Disease, cause fissures.
  • Anal sex can stretch and tear the anus.
  • An anal herpes infection can also cause them.

Treatment for anal fissures.

Cream or ointment containing anaesthetic will help to ease the pain, and some of these creams contain a steroid which will help to reduce swelling – see haemorrhoid treatment, above.

Warm baths will help to relax the sphincter and ease the pain.

Wash and dry the area gently after using the toilet and avoid perfumed soaps etc.

Painkillers containing paracetamol and ibuprofen will also help.

If the fissure doesn’t heal on its own after 6 weeks then see your doctor as further treatment may be needed.

Anal pain.

Anorectal pain, proctalgia, pyriformis syndrome and levator ani syndrome are all other names for anal pain.  Separate from anal fissures or hemorrhoids, it’s the pain thought to be associated with a spasm of the anal sphincter muscles (proctalgia) or the pelvic floor muscles (levator ani syndrome).

It’s not physically serious but is a relatively common and very distressing symptom that can have a number of causes.  If you have anal pain then don’t be shy about seeing your doctor.  People often suffer for a long time before seeking medical help, where as an early diagnosis and treatment would save a lot of physical and emotional discomfort.

In men, prostatitis can cause anal pain as one if its symptoms.

What does anal pain feel like?

Sudden severe cramping pain in the anus or lower rectum, which lasts for a few seconds to a few minutes but goes away on its own is typical of anal pain caused by the spasm of the anal sphincter.

These episodes may only happen a few times a year but may happen at night and wake you from sleep, or they may happen daily for a short time and then stop as suddenly as they came.

A vague ache or feeling of pressure in the rectum, made worse by sitting or lying but made better by walking indicates a pelvic floor problem.

This pain may last for a few hours or days and be quite regular.

What is the treatment for anal pain?

In both cases, your doctor will examine you – press your abdomen, do a digital rectal exam (putting a lubricated, gloved finger into the rectum), and may order blood test or a proctoscopy.  S/he may also do a gynaecological examination or feel the testicles for lumps etc.  These tests will help the doctor exclude other causes of the pain.

For a diagnosis of anal sphincter spasm, treatment is generally not needed.

Many treatments have been suggested and tried for levator ani syndrome – medical (diazepam, some heart meds, muscle relaxants etc), massage, Botox, and psychological interventions – so you will need to discuss these with your specialist to see which might work best for you.

If you’re worried about your symptoms or medical problem but don’t want to seek professional help because you feel embarrassed, silly or that it’s your fault, read this page now:  How to talk to a doctor about an embarrassing problem.

Elspeth Raisbeck

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