Piles fissure and Fistula
Piles is another term for hemorrhoids. Hemorrhoids are collections of inflamed tissue in the anal canal. They contain blood vessels, support tissue, muscle, and elastic fibers.
Fast facts on piles:
- Piles are collections of tissue and vein that become inflamed and swollen.
- The size of piles can vary, and they are found inside or outside the anus.
- Piles occur due to chronic constipation, chronic diarrhea, lifting heavy weights, pregnancy, or straining when passing a stool.
- A doctor can usually diagnose piles on examination.
- Hemorrhoids are graded on a scale from I to IV. At grades III or IV, surgery may be necessary.
Piles are inflamed and swollen collections of tissue in the anal area.
They can have a range of sizes, and they may be internal or external.
Internal piles are normally located between 2 and 4 centimeters (cm) above the opening of the anus, and they are the more common type. External piles occur on the outside edge of the anus.
In most cases, the symptoms of piles are not serious. They normally resolve on their own after a few days.
An individual with piles may experience the following symptoms:
- A hard, possibly painful lump may be felt around the anus. It may contain coagulated blood. Piles that contain blood are called thrombosed external hemorrhoids.
- After passing a stool, a person with piles may experience the feeling that the bowels are still full.
- Bright red blood is visible after a bowel movement.
- The area around the anus is itchy, red, and sore.
- Pain occurs during the passing of a stool.
Piles can escalate into a more severe condition. This can include:
- Excessive anal bleeding, also possibly leading to anemia
- Fecal incontinence, or an inability to control bowel movements
- Anal fistula, in which a new channel is created between the surface of the skin near the anus and the inside of the anus
- Strangulated hemorrhoid, in which the blood supply to the hemorrhoid is cut off, causing complications including infection or a blood clot
Piles are classified into four grades:
- Grade I: There are small inflammations, usually inside the lining of the anus. They are not visible.
- Grade II: Grade II piles are larger than grade I pile, but also remain inside the anus. They may get pushed out during the passing of stool, but they will return unaided.
- Grade III: These are also known as prolapsed hemorrhoids, and appear outside the anus. The individual may feel them hanging from the rectum, but they can be easily re-inserted.
- Grade IV: These cannot be pushed back in and need treatment. They are large and remain outside of the anus.
External piles form small lumps on the outside edge of the anus. They are very itchy and can become painful if a blood clot develops, as the blood clot can block the flow of blood. Thrombosed external piles, or hemorrhoids that have clotted, require immediate medical treatment.
In the majority of cases, piles resolve on their own without the need for any treatment. However, some treatments can help significantly reduce the discomfort and itching that many people experience with piles.
A doctor will initially recommend some lifestyle changes to manage piles.
Diet: Piles can occur due to straining during bowel movements. Excessive straining is the result of constipation. A change in diet can help keep the stools regular and soft. This involves eating more fiber, such as fruit and vegetables, or primarily eating bran-based breakfast cereals.
A doctor may also advise the person with piles to increase their water consumption. It is best to avoid caffeine.
Bodyweight: Losing weight may help reduce the incidence and severity of piles.
To prevent piles, doctors also advise exercising and avoiding straining to pass stools. Exercising is one of the main therapies for piles.
Several medicinal options are available to make symptoms more manageable for an individual with piles.
Over-the-counter (OTC) medications: These are available over-the-counter or online. Medications include painkillers, ointments, creams, and pads, and can help soothe redness and swelling around the anus.
OTC remedies do not cure piles but can help the symptoms. Do not use them for more than 7 days in a row, as they can cause further irritation of the area and thin of the skin. Do not use two or more medications at the same time unless advised to by a medical professional.
Around 1 in 10 people with piles will end up needing surgery.
Banding: The doctor places an elastic band around the base of the pile, cutting off its blood supply. After a few days, hemorrhoid falls off. This is effective for treating all hemorrhoids of less than grade IV status.
Sclerotherapy: Medicine is injected to make the hemorrhoid shrink. Hemorrhoid eventually shrivels up. This is effective for grade II and III hemorrhoids and is an alternative to banding.
Infrared coagulation: Also referred to as infrared light coagulation, a device is used to burn the hemorrhoid tissue. This technique is used to treat grade I and II hemorrhoids.
Hemorrhoidectomy: The excess tissue that is causing the bleeding is surgically removed. This can be done in various ways and may involve a combination of a local anesthetic and sedation, a spinal anesthetic, or a general anesthetic. This type of surgery is the most effective for completely removing piles, but there is a risk of complications, including difficulties with passing stools, as well as urinary tract infections.
Hemorrhoid stapling: Blood flow is blocked to the hemorrhoid tissue. This procedure is usually less painful than hemorrhoidectomy. However, this procedure can lead to an increased risk of hemorrhoid recurrence and rectal prolapse, in which part of the rectum pushes out of the anus.
What is an anal fistula?
An anal fistula is a small tunnel that connects an abscess, an infected cavity in the anus, to an opening on the skin around the anus.
The anus is the external opening through which feces are expelled from the body. Just inside the anus are a number of small glands that make mucus. Occasionally, these glands get clogged and can become infected, leading to an abscess. About half of these abscesses may develop into a fistula.
The leading causes of an anal fistula are clogged anal glands and anal abscesses. Other, much less common, conditions that can cause an anal fistula include:
- Crohn’s disease (an inflammatory disease of the intestine)
- Radiation (treatment for cancer)
- Sexually transmitted diseases
- Diverticulitis (a disease in which small pouches form in the large intestine and become inflamed)
Surgery is almost always necessary to cure an anal fistula. The surgery is performed by a colon and rectal surgeon. The goal of the surgery is a balance between getting rid of the fistula while protecting the anal sphincter muscles, which could cause incontinence if damaged.
Fistulas in which there is no or little sphincter muscle involved are treated with a fistulotomy.
In this procedure, the skin and muscles over the tunnel are cut open to convert it from a tunnel to an open groove. This allows the fistula tract to heal from the bottom up.
In the case of a more complex fistula, the surgeon may have to place a special drain called a seton, which remains in place for at least 6 weeks. After a seton is placed, a second operation is almost always performed:
- A fistulotomy, or
- An advancement flap procedure (the fistula is covered with a flap, or piece of tissue, taken from the rectum, like a trap door), or
- A lift procedure (the skin above the fistula is opened up, the sphincter muscles are spread, and the fistula is tied off).
A new treatment for Crohn’s disease fistulas is to inject stem cells into the fistula. Your colorectal surgeon will discuss all of your options before the surgery.
Fistula surgery is usually done on an outpatient basis, which means the patient can go home the same day. Patients who have very large or deep fistula tunnels may have to stay in the hospital for a short time after the surgery. Some fistulas may require several operations to get rid of the fistula.
Diagnosing Anal Fissures
What to Tell Your Doctor
In most cases, discussing your symptoms can give your doctor enough information to diagnose an anal fissure. Be sure to tell them:
- When you have pain, burning, or itching
- How bad your discomfort is
- How long the pain and discomfort usually lasts
- What type of bleeding you’ve seen
- What, if anything, improves your symptoms
Your doctor may ask about your diet, your bowel habits, and if you have any other medical conditions or intestinal problems.
The goal of treatment is to relieve pain and discomfort and heal the torn lining. Acute anal fissures — the ones that don’t last longer than 6 weeks — are common and usually heal on their own with self-care. Chronic anal fissures — those that last longer than 6 weeks — may need medicine or surgery to help them heal.
- Stay hydrated: Drink plenty of caffeine-free fluids throughout the day. (Too much alcohol and caffeine can lead to dehydration.)
- Eat a fiber-rich diet: To avoid constipation, your goal should be to get 20 to 35 grams of fiber every day. You can gradually increase the amount of fiber you eat by having more:
- Wheat bran
- Oat bran
- Whole grains, including brown rice, oatmeal, and whole-grain pasta, cereals, and bread
- Peas and beans
- Citrus fruits
- Prunes and prune juice
- Try fiber supplements if you can’t get enough fiber from food. They can help soften stools and make you more regular. To avoid gas and cramping, gradually raise the amount of any fiber supplement you take until you reach the recommended dose.
- Over-the-counter laxatives may help if adding more fiber to your diet does not. Before taking any laxatives, ask your doctor what they suggest.
- Don’t ignore your urge to go. Putting off bowel movements for later can lead to constipation; stools may become harder to pass and end up causing pain and tearing.
- Don’t strain or sit on the toilet too long. This can increase pressure in the anal canal.
- Gently clean and dry your anal area after each bowel movement.
- Avoid irritants to the skin, such as scented soaps or bubble baths.
- Get treatment for chronic constipation or ongoing diarrhea.
- Sitz baths, or hip baths, can promote healing of an anal fissure. By soaking the rectal area in a tub of warm water — two or three times a day for 10 to 15 minutes — you can clean the anus, improve blood flow, and relax the anal sphincter.
Medications for Treating Anal Fissures
- Nitrate ointment: Your doctor may prescribe one of these to help raise blood flow to the anal canal and sphincter, which helps fissures get better faster. Some side effects may include headaches, dizziness, and low blood pressure. Nitrate ointment should not be used within 24 hours of taking erectile dysfunction medicines like sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra).
- Calcium channel blockers: These are blood pressure-lowering medications. Some of the topical ones can treat anal fissures, too. Side effects may include headaches.
- Botox injections: When topical treatments don’t work, injecting botulinum toxin type A (Botox) into the sphincter is sometimes the next step. Botox injections temporarily paralyze the sphincter muscle, relieving pain and encouraging healing in 60% to 80% of patients. You may not be able to control your bowel movements or pass gas, but it’s temporary. The dose is extremely low, so there is no risk of botulism poisoning.
- You probably won’t need surgery for anal fissures unless other forms of treatment haven’t worked. The surgery, called a lateral internal sphincterotomy (LIS), involves making a small cut in the anal sphincter muscle. It reduces pain and pressure, allowing the fissure to heal.