28-03-2021 / Digestive Disease & Gastroenterology
Anal Disorders are pretty painful and uncomfortable disorders, and most of the time, patients cannot discuss Piles, Fissure, and Anal Fistula with anyone. Here are few details about these disorders and how we distinguish between them.
Anal disorders, also known as anorectal disorders are quite common. It is important to have a basic understanding of the structure of the anal region to get a grasp over the different anal disorders.
The anus is the opening of the large intestine to the outside. Rectum is the terminal portion of the large intestine. Together, it is called anorectal region as few pathologies of both the regions occur together. This region is about 4-5 cm long and is divided into parts, each part having its own blood supply and nerve supply.
However there are a few disorders that are exclusive to the anal region. These include: Piles or hemorrhoids, Anal Fissures and Anal Fistula. These anal disorders are actually very common in occurrence and cause great disruptions in the day-to-day lives of the people affected.
Further cancer of the anal region and the rectum can also occur. Colorectal cancer involving the rectum and the preceding part of the large intestine (colon) is also very common in occurrence.
Piles are enlarged or dilated blood vessels ( veins in specific) that are felt as a knots or lumps around the anal opening. These vessels normally cannot be felt, but when they become engorged as in Piles, they can be felt by the patient.
There are two different types of hemorrhoids - External and internal. The names do not always suggest if they are present outside the anus or inside. They are classified based on the site where they arise in the anal region. Internal piles arise in the proximal portion of the anus, whereas external ones arise closer to the outside opening. Internal piles can enlarge and appear outside and external piles can stay inside and vice versa.
Hemorrhoids can also be graded based on their size and severity of complaints.
Whenever you hear the word ‘piles’, do not always imagine a scary reddish blue lump. In the initial stages, the piles look like a discolored rubbery mass that is soft to touch.
Since piles are caused by the enlargement of veins, all the factors that could increase the pressure over and within the veins could cause them:
Straining at stools, due to constipation.
Passing hard stools.
Persistent coughing, as in chronic smokers or Tb patients.
Pregnancy and childbirth, where the enlarged uterus is compressing the distal veins.
Lifting heavy objects frequently.
Old age, which causes weakness of the pelvic floor muscles.
In the early stages, piles are mostly asymptomatic and do not cause any trouble. However as they progress, they can cause complaints like:
Blood in stools which drips or stains the toilet paper.
A mucus like discharge that stains underwear.
Excess itching around the anus.
Pain and discomfort during defecation.
Pain during prolonged sitting.
A lump felt around the anus.
Tiredness and weakness if the patient becomes anemic due to prolonged bleeding.
Even though these symptoms can be seen in piles, they are not exclusive here. A similar picture can be seen also in other anal disorders like fissures or fistulae. Hence let’s talk about the difference between piles and fissure and fistula.
An anal fissure is a small tear in the lining of the anal canal. This is an extremely painful condition and can bleed rarely.
Fissures can either be acute or chronic. Acute fissures are recently developed ones, usually due to injury and can easily be treated by simple home remedies and painkillers.
Chronic fissures are long-standing ones which usually occur as a result of an underlying medical condition. These require medical or surgical assistance to heal.
Anal fissures are visible as a small tear during a physical examination by the surgeon. However, usually the patient will not be able to visualize or feel it.
Again, the clinical picture of anal fissures can resemble that of hemorrhoids.
Sentinel skin tags or anal skin tags are excess folds of skin that are seen clumped around the anal opening, usually seen in relation to an anal fissure. These can be confused with either external piles or with warts caused by papilloma viral infections.
These tags are benign. When a patient has a long-standing fissure, the skin around the anus becomes very inflamed and forms a tag. These tags can worsen with constant itching or scratching around the anus.
They could be very painful if associated with fissures and could cause a foul smelling discharge. Once the underlying fissure is treated, the tags gradually reduce in size.
Most of the causes are the same as that of Hemorrhoids.
However in addition to the above, practice of anal sex and insertion of foreign objects and sex toys into the anus can increase the risk of developing painful fissures.
Further, any underlying medical disorders like inflammatory bowel disease, HIV, tuberculosis of the intestine, cancers etc. can also increase the risk of fissures.
Even though the presentation can be similar between them, there are a few differences between fissure and piles:
Piles are swollen vessels whereas fissures are a tear
Piles are usually asymptomatic and painless, but fissures are extremely painful right from the beginning. This pain caused by fissures persists for a long time after defecation.
Now let’s talk about anal fistula and the difference between fissure and fistula and the difference between fistula and piles.
Anal Fistula is a tunnel or a connection between the anal canal and the skin surrounding the anus.
There are plenty of mucus glands in and around the anus. These are meant for keeping the area moist and protected. Sometimes, if the openings of these glands get blocked, they are not able to drain their secretions, thereby developing into abscesses. If they rupture, it creates a tunnel between the anal canal and the outside skin. However this rupturing is rare.
Now these infected, foul smelling secretions start oozing out of this tunnel.
Also sometimes fistulae could develop because of radiation therapy and surgeries or even during pregnancy.
All those factors that can lead to blockade and infection of anal glands and cause anal abscesses can cause anal fistulae. These include:
Inflammatory bowel disorders like Crohn’s disease.
Sexually transmitted infections.
Tuberculosis of the intestine.
Diverticulitis (a condition where small outpouchings would be formed in the intestinal wall ).
In addition to those, other factors that could lead to a fistula include:
6. Trauma and injury.
7. Surgical injuries.
8. Injury to mother’s anus during childbirth.
9. Radiation when given as cancer therapy.
Pain & swelling around anus.
Severe irritation and itching.
Bloodstained foul smelling discharge coming from a small opening on the skin. This opening is actually connected via the fistula tunnel to the anal canal. So even stool matter could leak through this opening. This could cause discomfort and embarrassment to the patient.
Pain during defecation.
Weakness and fever due to the infection.
Fissure is a tear in the inner lining of the anal canal whereas fistula is a cross-connection between the inner lining of the anal canal and the outer skin. This is the main difference between fissure and fistula.
Piles are caused due to engorged veins and do not have an infective origin, unlike fissures. Further piles can be silent for a long time. But fistula itself is a complication of a long-standing abscess. So fistulae present with severe pain and oozing discharge right from the beginning. This is the difference between fistula and piles.
Whenever you experience any symptoms of anal disorders, it’s important to meet with a surgeon because all of them are treatable and treatment could improve your quality of life. Your surgeon may one or many of the following tests to arrive at a diagnosis:
Per-rectal examination is done by the surgeon after application of topical anesthetic cream and lubricant where he/she inserts a finger into your anus to feel for any piles or lumps.
This is a per-rectal examination done after insertion of a proctoscope, a speculum-like instrument that helps in visualizing the lowermost 10-13 cm of the large intestine. This may help to detect any fissures or the inner opening of a fistula as well.
These examinations may sound terrifying and painful, but they are important to arrive at a diagnosis to help you get better. Further they are done very gently and under topical anesthetic creams that could numb the pain completely. However during any point in the examination if you feel any pain or discomfort, it is very important to convey the same to the surgeon and they’ll immediately stop.
3. Sometimes you may be advised an ultrasound scan or an MRI scan to trace the track of the fistula tunnel.
4. Usually if a skin tag is found, this could be a pointer for an underlying fissure which is an extremely painful condition. So the surgeon won’t perform a per-rectal examination. However if needed, he may shift you to the operation theatre to examine under anesthesia.
5.If these complaints are frequently recurring even after treatment, your surgeon may advise you to take a colonoscopy (a scope that’s inserted into your anus and guided inside to image and study the entire large intestine) to detect any underlying issues like cancers or inflammatory bowel disorders.
A good thing about anal disorders like fistula piles and fissures is that they could be treated, both by medical and surgical options.
Gastroenterology doctors prescribed painkillers, antibiotics in case of infections, topical anesthetic creams and stool softeners like liquid paraffin to help ease defecation. Further you may be advised enemas.
There are plenty of options to completely cure piles fissure and fistula.
In addition to the above, the patient should follow a high-fibre diet to and ease defecation. Further, plenty of oral fluids should be taken, spicy food to be avoided. Do not wipe your bottom harshly after defecation, instead use lukewarm water soaked tissues.
This is a method advised for anal disorders like fissures or piles to relieve pain. In this, the patient takes a large, shallow non-metallic bowl filled with lukewarm water and antiseptic solution. Then they have to sit in this bowl for a short while, twice or thrice a day. This provides a brief relief from pain and discomfort.
Avoid straining at stools.
Don’t hold defecation, hit the toilet as and when you feel the urge.
Eat a high-fiber diet.
Drink plenty of fluids.
Regular exercise helps improve digestion and ease defecation.
Do not misuse laxatives.
Do not sit too long, try to move around whenever you could get a chance.
Try to reduce weight if you are overweight for your height and age.
Anal disorders are very common and cause a great deal of discomfort and disruption in the day-to-day lives of those affected. But, fortunately they can be prevented or treated, hence it’s important to receive medical guidance if you are suffering from any of these complaints.
Wishes for a happy and healthy life!
Ans: No, fistula is a tunnel between the mucus lining of the anal canal and the outside skin where piles is are formed due to enlarged veins in the anal region.
Ans: Fistula and fissure difference - Fissure is a tear in the inner lining of the anal canal whereas fistula is a tunnel between the inner lining of the anal canal and the outer skin.
Ans: Yes, piles can be cured by surgical management.
Ans: Avoid spicy food and low-fiber food in piles.
Ans: Chronic constipation, obesity, lifting heavy weights, pregnancy and straining at stools.
Ans: Milk is low in fiber and if taken in excess can tighten stools. This can increase pain and discomfort.
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