Burning, itching, bleeding. A sharp pain in the rectal area that wakes you up from sleep. A feeling like hot coals during or after a bowel movement. Not easy stuff for most people to talk about with their doctor, despite the fact that these are all common conditions. Let's discuss three of the most prevalent and bothersome: hemorrhoids, anal fissures and proctalgia fugax.
Hemorrhoids are really just veins in the rectal area that everyone has. When they become engorged or inflamed we call them hemorrhoids or piles. Flare-ups are usually caused by constipation, straining, or frequent loose stools. Pregnancy can lead to hemorrhoids as a result of pressure from the enlarged uterus and increased pelvic blood flow. Hemorrhoids inside the anal canal (internal hemorrhoids) usually cause painless bleeding while hemorrhoids at the opening of the anus (external hemorrhoids) usually cause pain. Both kinds can become engorged with blood (thrombosed hemorrhoids) resulting in an excruciatingly painful swollen lump.
I find that hemorrhoids respond best to bulking up the stool so it can be more easily expelled. This can be done by increasing your fiber intake with a goal of at least 30 grams a day, accompanied by a liter or more of water to keep the stool moist. Most patients benefit greatly from a fiber supplement like psyllium husk. In addition to aiding passage of the stool and shrinking hemorrhoids, the psyllium leads to what I like to call "the clean wipe" – a big, bulky, magnificent stool that falls easily into the toilet and leaves no messy schmear on the toilet paper.
Anal fissures are caused by constipation as well as spasm of the anal sphincter, although large non-healing fissures can also be seen with Crohn's disease. Fissures are basically a tear in the lining of the anus. Signs and symptoms include blood in the stool or on the toilet paper, and pain both during and after the passage of stool. Fissures respond well to warm soaks (sitz baths), stool softeners and increasing the amount of fiber and water in the diet. I also recommend lubricating the toilet paper with petroleum jelly prior to wiping. Nitroglycerin ointment and calcium channel blockers help to relax the sphincter and for refractory fissures injection of botulinum toxin A into the anal sphincter can also help with healing.
Proctalgia fugax is manifest by deep pain in the rectum that feels like a severe muscle cramp –which is exactly what it is: a cramping of the pubococcygeus or levator ani muscles. It frequently occurs at night and may also occur after intercourse. Some patients describe an urge to defecate although the rectum is usually empty. No one knows for sure what causes proctalgia fugax but thickening of the internal anal sphincter muscles is present in many people who suffer from this condition. Although warm baths, enemas, botulinum toxin, fiber supplements, anti-inflammatories and analgesics have all been used with varying success, I find that biofeedback and other relaxation techniques are the most useful for treating this recurrent condition.
Hemorrhoids and anal fissures are visible on rectal exam - something you might be hesitant to have but should be sure to request. When people are embarrassed about having me examine their rectum, I remind them that for me it's like looking at their elbow. A carefully done rectal exam should cause minimum if any discomfort and can yield lots of useful information, so don't be shy about talking to your doctor about what's going on back there!