Haemorrhoids / Piles
Digital Rectal Examination – DRE
Problems with your bottom, anal pain or bowels are yet another part of ageing which results in possibly seeking help or at least reading about it. “Problems downstairs” is one we don’t usually like to discuss let alone go and see anyone about; however statistics state that over 50% of Plus Fifty year olds suffer from at least one bout of haemorrhoids with some people going on to developing an on-going condition. Anal fissures and anal fistulas are just a couple of the many conditions affecting our bottoms let alone our bowels.
It is important to state that the information provided on this site is by no means a way of self-diagnosis. If you experience anal pain you need to consult your doctor for a comprehensive diagnosis and appropriate treatment.
If you have blood or mucous coming from your rectum it will need to be investigated, also if you have black stools (faeces/poo) this is not normal and will require exploring,( note: iron supplements can give you black stools) be aware of your diet / medication. Bleeding of unknown origin needs to be investigated by a qualified healthcare worker, below is a link to a stool chart.
Kings College London has developed a stool chart which can be used by patients as well as clinical staff as an aid for the description and consistency of stools. Please click here if you would like to download the pdf file
The King’s Stool Chart was developed by:
Dr. Kevin Whelan, Lecturer in Nutritional Sciences, King’s College London.
Dr. Moira Taylor, Associate Professor of Human Nutrition, University of Nottingham.
Prof Patricia Judd, Professor of Nutrition and Dietetics, University of Central Lancashire.
The King’s Stool Chart is under copyright by King’s College London (2001) and it must not be amended.
If you treat unknown anal bleeding believing it to be haemorrhoids prior to diagnosis from your doctor you could be missing a more serious condition.
What is an Anal Fissure?
An anal fissure is a split in the skin around the anal skin. It is usually at the back of the anus where the cleft of the buttock lies, although can occur anywhere around the anus. Men and women equally suffer from this condition and it is quite common in the 20+ age group.
Symptoms of Anal Fissure
A sharp pain is experienced when passing bowel motions, the pain can last for some time after passing the stool. Fresh red blood will be noticed on the toilet paper, and the area can become itchy as the fissure tries to heal.
The pain has been described as:
As if the skin is splitting
Like a knife cutting the skin
There are two types of anal fissure:-
Primary – no evident cause but thought to be caused by constipation and the passing of a hard stool
Secondary – Inflammation of the bowel lining i.e. Ulcerative Colitis and Chrohn’s
Your symptoms can be acute – less than six weeks or chronic – long term or reoccurring
Treatment of Anal Fissure
A high fibre diet can be very useful in relieving symptoms, if the problem is chronic your doctor may prescribe medication or in some cases surgery
What is an Anal Fistula?
This is a distressing and painful condition where a very thin channel opens up from inside the anal canal to the outer skin edge, near the anus. This fistula can discharge small amounts of faecal fluid, pus and or blood when you have your bowels open.
There are two main categories of anal fistula
Simple – which is one single tract goes from the anal canal to the skin surface
Complicated – This may have many tracts some which open onto the skin surface others that are blind or go through the sphincter muscles around the anus.
Symptoms of Anal Fistula
A temperature of 38 degrees
Itching around the anus
Blood, pus or faecal fluid when passing stools
Throbbing pain around the anal area especially when you sit or exert yourself
Cause of Anal Fistula
This is a condition which can result from a pre-existing condition such as Crohn’s disease, HIV or IBS- irritable bowel syndrome.
The condition may also develop after having an anal abscess, this may have burst but if the condition is not treated efficiently a small amount of infection will continue creating a channel.
Treatment for Anal Fistula
This will require treatment at your local hospital your doctor will refer you after examination. Investigations may include MRI , anal ultrasound or a CT scan all of which will give the surgeon a more comprehensive image of how best treat your condition.
What is Anal Pruritus?
This is also known as anal itch, pruritus ani, and itchy bottom or Itchy bum, which is probably the most explanatory of all of the terms!
This can be very distressing as it is the constant urge to scratch your bottom specifically just round the anus.
The itchiness can be made worse under certain circumstances:-
After you have had your bowels open
Heat, moisture in the air
By wearing nylon underwear
The skin can become very irritated and sore due to scratching and is at risk of becoming infected. It primarily seems to affect men between 40 – 60 years old but it can affect woman and children.
Causes of Itching
Often the cause of the itchiness is unknown, called Idiopathic Pruritus but sometimes it can be attributed to conditions such as thread worms, eczema, allergic reactions to substances such as soap, ointments, even toilet tissue.
You may suffer from an infection which is causing the pruritus such as a fungal infection like thrush (Candida albicans) scabies, genital warts, herpes and other STI’s (sexually transmitted) diseases can also cause itching.
Treatment for Pruritus
You will probably need to visit your doctor if the itching does not resolve on its own after three or four days. The causes for the itching are many and varied therefore you may require investigation and treatment.
Self-help for Pruritus
Hygiene is paramount – wash your anal area after you have evacuated your bowels using either, a non- perfumed simple soap and water or just water.
Dry your bottom, patting not rubbing the area – do not apply any talc to ensure dryness – this is counterproductive – if you sweat a lot consider wearing a discreet absorbent pad
Wear cotton underwear not nylon
Scratching makes it worse, sometimes referred to as the itch, scratch, itch syndrome. Try not to and if possible wear cotton mits at night to prevent you inadvertently scratching.
What are Haemorrhoids?
The condition in UK is spelt haemorrhoids but in America it is spelt hemorrhoids common misspellings include heamorrhoids, hemroids, hamorhoids, hemmerhoids hamerroids, hemmoroids and is often referred to as piles. All these different ways of spelling the condition doesn’t take away the discomfort and embarrassment that many people feel when they experience this for the first time.
In the anal canal exists spongy layers which are called the mucosal cushions. These cushions are soft and have a good blood supply, when parts of these cushions become enlarged and bulge they are called haemorrhoids. There are two types of haemorrhoid internal and external.
The primary reason they become engorged is down to passing stools which are hard in form. This in turn causes you to strain when opening your bowels. This repeated straining can cause these sensitive vessels to become swollen, and each time this happens the walls of the blood vessels become stretched and begin to become baggy and bulge. If this is occurring on a regular or daily basis the natural ability of the vessels to reshape becomes diminished and the walls become thinner. When the hard stool passes the thinned vessels they can tear and blood will be on the excreted stool as well as the toilet paper when you wipe your bottom.
Inside your anus there is a line which is referred to as the dentate line below this line there are nerves and pain receptors; above the line further into the anal canal there are no pain receptors. This is why you can have had internal haemorrhoids for a long time but not know about them until they start bleeding or become strangulated (where the blood supply is cut off).
The blood on the stool and the toilet paper will be a bright red as if you have just cut yourself not a dark or black blood, if your stools are this colour you will need to see your doctor for investigations immediately.
Symptoms of Haemorrhoids
There are a variety of symptoms which you may suffer from you may not suffer from all of them, or all at the same time
Anal itching and discomfort
Bleeding after you have evacuated your bowels
An lump which may be engorged and tender around the anus
Pain when passing your stool
Straining to pass a stool
Faecal discharge of liquid/mucous/slime
Feeling as if your bowels are not empty after passing a stool
Leaving stool marks in your underwear
Causes of Haemorrhoids
It appears to be one yet another of these conditions which tends to affect people Plus Fifty although it is known in younger people.
People who are obese can also suffer from haemorrhoids due to the extra pressure being exerted; you can do something about this by losing weight.
People who have anal sexual intercourse are at a higher risk of developing hemorrhoids due to the friction on the mucosal layers of the bowel causing the vessels to thin and engorge.
People who suffer from a chronic (constant) bowel conditions which cause either diarrhoea or constipation are at risk.
Diet tablets which cause you to have loose watery stools can exacerbate hemorrhoids.
People who regularly suffer from constipation and have to strain to push the stool out are more likely to suffer.
- There is a medical grading system used when it comes to the assessment of internal haemorrhoids from 1-4 or First to Fourth degree
Grade 1: First Degree – These haemorrhoids are relatively small up inside the anal canal and are more like bulges in the mucosal layer of the rectum. They can be felt on rectal examination by a doctor.
Grade 2: Second Degree – These are larger haemorrhoids and will remain inside your rectum. They will occasionally protrude when a stool is passed but return inside once you have completed the evacuation of your bowels.
Grade 3: Third Degree – These originate inside the rectum but actually suspend out of the anus. They can be gently returned back inside the anal canal with your fingers.
Grade 4: Fourth Degree – These become large protrude outside the anal sphincter. They are not able to be pushed back inside. You will need to see your doctor about these and the haemorrhoids will require active treatment.
- These hemorrhoids are fortunately not as common and are found on the outer rim of the anal sphincter (the tight band of anal tissue). These can become irritated by mucus, creams, and fungal infections, causing pruritus. Occasionally these haemorrhoids can become thrombosed – which means a clot has formed inside them. This can be extremely painful and requires urgent medical attention
Rectal Examination or Digital Rectal Examination – DRE
This is something which may need to be performed as part of your appointment with your doctor if you are consulting them about a rectal problem. It will involve the doctor doing what’s called a rectal examination. The doctor will explain exactly what you will need to do prior to the examination and ask for your consent to undertake the procedure.
The Internal Rectal Examination Procedure
You will be asked to remove your underwear in privacy and lie on your side on the doctor’s couch. The doctor will ask you to lie on your side with your knees drawn up to your chest with your bottom towards the doctor. The doctor will gentle part your buttocks and examine your external anus to see if you have any external hemorrhoids, skin tags or rash. You may be asked to push gently as if you were going to have a bowel motion, this can reveal haemorrhoids. The doctor will then lubricate the gloved finger which will be gently inserted into your anus. The doctor will be able to feel around inside the rectum to feel how your anal sphincter functions (this is the tight band around your anus which relaxes when you excrete your stool). The doctor will feel to check if you have internal hemorrhoids, lumps, or restriction of the lumen.
Occasionally after a digital/ rectal examination the doctor may wish to examine your rectum with a proctoscope. This is generally done when the doctor wishes to look inside your rectum rather than just feel for lumps. The doctor will explain exactly what you will need to do prior to the examination and ask for your consent to undertake the procedure.
The Proctoscopy Procedure
This is a usually a disposable plastic conical shaped instrument with a rounded end which can be removed so that the doctor can see into the rectum. They may have a separate light which they will place in position to help with the visibility. The proctoscope is lubricated then gently inserted, it may feel tight initially but the anal sphincter will relax to make it feel more comfortable. The doctor will then move it around to get a good view of the inside of your rectum. Once the procedure is complete they will either wipe off the excess lubricant or offer you tissues to do this yourself in privacy with the curtains around you. You will then be able to get dressed the doctor will then discuss their findings with you. This is not done during the procedure as you will have you mind on other thoughts.
Once the doctor has made a diagnosis they will offer you appropriate treatment. However, if they feel that a Colorectal surgeon should take a look and /or an endoscopy is appropriate for further investigations this will be arranged and you will be sent an appointment.