What Are Piles

Haemorrhoids, or piles, as they are more commonly known, are actually normal parts of our body. They are normal structures in the anus, comprising mainly blood vessels that help to preserve continence and prevent our stools from leaking out. They start to become bothersome when they swell and this may result in bleeding, pain, prolapse (lumps) and itching. This is termed haemorrhoidal disease. Most people will experience such problems at some point in their lives either due to straining on the toilet because of constipation, bouts of diarrhoea, during pregnancy, or as a result of poor toileting habits such as sitting on the toilet bowl for too long.

Although piles are one of the most common causes of bleeding from the anus (bright red usually), there are certain ‘red flag’ symptoms which could suggest that the bleeding may be due to a more serious condition like cancer. These symptoms include:

• Signs of ongoing blood loss, where you become pale, tired and breathless with minimal exertion such as simply walking on flat ground
• A significant loss of weight and appetite
• Passage of mucus and pain when opening your bowels
• Passage of narrow or pencil-thin stools
• Changes in bowel habits like alternating constipation and diarrhoea

One should always seek medical attention early when there is bleeding from below, especially when it is accompanied by the symptoms mentioned above, as the treatment and outcomes of piles and cancer are vastly different. A colonoscopy is the gold standard of checking the colon and rectum to confirm the cause of bleeding as it is accurate and also allows for a biopsy to confirm if any abnormality seen is due to colorectal cancer.

How Are Piles Treated

Treatment of piles comprises 3 aspects: lifestyle modifications, medications and surgery. Treatment should be individualised and dependent on the severity of symptoms, and surgery is not always needed. Treatment is aimed at reducing the swelling and returning the piles to their normal size and position in the anus and not removing them entirely, because doing so could potentially lead to faecal incontinence (involuntary loss of control of stool).

An important factor for the success of any treatment lies in identifying the underlying cause and triggers for the bleeding and ensuring this is corrected. Lifestyle modifications include relief from any existing constipation or diarrhoea, ensuring you do not strain excessively or sit for too long on the toilet bowel (usually not more than 10 minutes).

Medications usually consist of Daflon to reduce swelling as well as either stool softeners when constipated, or fibre supplements to increase stool bulk when stools are loose.

Only when the above measures fail or when symptoms are severe at the onset (eg. severe pain, swelling or bleeding) is surgery needed. Once again, the type of surgery should be tailored based on the symptoms of the piles, which can include cutting, sealing or stapling the swollen haemorrhoidal tissue.

Watch more of Dr Mark Wong’s videos and gain insights at https://www.markwongsurgery.com/media/videos/

When a cavity (space in the body) is filled with pus, it is called an abscess. When this occurs around the anus, it is called an anal abscess. This is NOT related to poor hygiene.

What causes anal abscess? Who is at risk?

An anal abscess is usually caused by a blocked anal gland (similar to how a pimple forms). The normal secretions are trapped and bacterial infection sets in to produce the pus. Other less common causes include an infected anal fissure can be associated with a weakened immune system:

1. Inflammatory bowel disease (eg. Crohn’s disease) where the body’s own immune system attacks the otherwise healthy body, particularly the digestive system.
2. Tuberculosis
3. Weaker immune system due to HIV or AIDS
4. Medications like steroids or chemotherapy drugs for cancer

Symptoms

Patients often experience a painful lump, fever or even a yellow foul-smelling discharge if the abscess should burst. It can affect your bowel movement or even walking and normal activities. If you notice any such issues, you should contact your doctor early.

Other common symptoms of anal abscess are

1. Constipation and/or difficulty with urination due to pain
2. Bleeding from the anus and rectum
3. Fever and fatigue

In more serious cases, an anal abscess can go deeper into the rectum. As a result, pain along with discomfort in the abdominal area can be felt.

Up to 50% of anal abscess is associated with a fistula, an abnormal communication from the skin into the anus or rectum. Treatment of the fistula will reduce the risk of a recurrent abscess, but this may have to be staged.

How it is Diagnosed?

An anal abscess is usually diagnosed by an expert examination the patient’s anus.

In some patients, where the abscess is deeper or pain does not allow for a comfortable examination, our specialists may order an MRI of the area.

If Crohn’s disease or Tuberculosis or other underlying disease is suspected, more tests may be ordered to confirm this diagnosis as part of the complete management of the abscess.

Treatment

The most effective treatment for an anal abscess is surgery, to remove the pus and clean the infected area. This may be accompanied by a course of antibiotics.

You will need to come to the clinic after surgery where our specialist and nurse will teach you how to take care of your wound.

Anal Fissure is a tear in the anal skin which can extend into the anal canal. A fissure is typically extremely painful and can be associated with bleeding during bowel movements. Although fissures are common, people usually get them confused with hemorrhoids.

Anal fissures can develop at any point of age and can happen to both males and females. Majority (85 to 90%) of anal fissures occur in the back midline position of the anus as it is the weakest part of the anal skin. Those who have multiple fissures or fissures located in unusual locations may have an underlying disease (eg. Crohn’s disease).

Symptoms

Pain and bleeding are the most common symptoms of a fissure. The patient classically experiences severe pain (sometimes described as passing glass shards) during the bowel movement along with some bleeding. The pain may last for a minute to several hours.

What Causes Fissures?

Usually, using excessive force (straining) at stools, accompanied by a hard bowel movement is responsible for the fissure. Occasionally excessive trauma from repeated bowel movements like diarrhoea and loose stools can also cause it.

The pain results in tightening of the anal sphincter (spasm) which causes an increase in sphincter pressure. More effort is needed for bowel movements which can cause more straining and tearing. This consequently sets up a vicious cycle, which results in more tightening and reduces the blood flow to the injured area which slows healing.

Commonly, patients may be misdiagnosed as having hemorrhoids because both have common symptoms. But these are 2 entirely different conditions requiring different treatments. As such, it is important to seek the right attention early in order to get the right treatment.

Examination

An acute fissure has the appearance of a simple tear in the anus skin, but after 6 to 8 weeks it becomes chronic and may cause swelling and scarring and an external lump along called a sentinel pile.

Treatment

The principle of treatment is to break the cycle of pain and spasms, so as to allow healing of the fissure.

If it is acute, surgery may be avoided. The most effective treatment for acute anal fissure is the use of GTN ointment to relax the anal muscle and relieve spasms. At the same time, stool softeners are prescribed to minimize trauma during bowel movements.

However, once it shows signs of chronicity (scarring and sentinel pile) or having failed the above treatment, an effective surgical technique is the Lateral Anal Sphincterotomy. In this technique, a small amount is divided in a controlled manner under anaesthesia to promote fissure healing. Occasionally, especially for chronic or recurrent fissures, botox injection may be useful.

Faecal incontinence (FI) occurs when a person loses the ability to control their anal muscles and bowel movements, resulting in leakage of faeces or gas. If left untreated or mismanaged, FI can lead to severe skin irritation as well as depression, causing affected individuals to withdraw from their families and society.

How Prevalent is FI in Singapore?

The first local prevalence study (conducted by our specialist) published in 2014 showed that approximately 4.7 per cent of the adult population – or some 200,000 individuals – may have this condition.

This is a staggering number, yet it may be an underestimate as the incidence is often even higher among the elderly staying in care facilities like nursing homes. The same study also showed that women are three times more likely to be affected by bowel incontinence, with childbirth-related injuries being the main cause. In fact, those over 50 years old are five times more vulnerable. Men are not spared from the condition.

How Does FI Affect Quality Of Life?

Most sufferers are unaware of the available treatment options, and the resulting negative effects on their overall physical and psychosocial wellbeing are often overlooked. In addition, the accompanying embarrassment and fear of social stigmatization cause the afflicted most of whom are elderly to suffer in silence, setting up a vicious cycle that perpetuates the misinformed notion that faecal incontinence is simply ‘part-and-parcel’ of ageing. Consequently, sufferers are relegated to suboptimal quality of life.

What Are The Risk Factors For FI?

The risk factors for women include instrument-assisted delivery (e.g. forceps and vacuum-assistance), and a prolonged second stage of labour.

Risk factors affecting both genders include anal muscle (sphincter) injuries due to anorectal surgical procedures e.g. for conditions such as haemorrhoids, anal fissures/fistula or colorectal cancer. Radiation treatment for conditions like cervical or prostate cancer can also contribute to faecal incontinence in women and men, respectively.

Other risk factors include surgery for colorectal cancer or benign conditions, in which part of or the entire rectum is removed, and trauma to the lower abdomen or pelvis, such as pelvic fractures after road traffic accidents or penetrating injuries.

Rectal prolapse, a condition commonly seen in the elderly female population, where the rectum/lower large intestine descends due to a loss of strength of supporting tissues, can also present with FI. Occasionally, injuries associated with sexual assault can result in faecal incontinence.

What Are The Available Treatment Options for FI?

FI results from either damage to the muscles directly, or to the nerves supplying these muscles around the anus, or both. After a thorough history taking and examination, specialised tests are performed including anorectal manometry, ultrasound and nerve stimulation tests, to identify the possible site(s) of injury so that treatment can be directed appropriately.

Regardless, the majority of sufferers can benefit from conservative measures such as dietary modification, tailored medical therapy and pelvic floor rehabilitation. Skin care and hygiene is also essential to maintain a good quality of life. However, when the above measures fail, surgery may be the only means of providing adequate relief of symptoms.

Treatment options for Faecal Incontinence

Majority of sufferers can benefit from conservative measures such as dietary modification, tailored medical therapy and pelvic floor rehabilitation. However, when the above measures fail, surgery may be the only means of providing further relief of symptoms.

The conservative treatment options offered include:

Dietary modifications: to improve stool consistency, as firmer stools can result in less ‘leaks’.

Medications: to improve stool consistency, including anti-diarrhoeal agents and stool-bulking agents like fiber supplements.

Anorectal biofeedback therapy: these are specific pelvic floor exercises, comprising a series of breathing exercises that are coordinated with anal and abdominal muscle contraction and relaxation. The aim is to condition and coordinate anal muscle movements for improving sensation and overall control.

Surgical options include: Sacral nerve stimulation (SNS), Percutaneous Tibial Nerve Stimulation (PTNS), Injectable bulking agents, Anal muscle (sphincter) repair and Rectal prolapse surgery (or Rectopexy).