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		Frequently asked questions Anal Abscess/Fistula Anal Cancer Anal Fissure Anal Warts Bowel Incontinence Colonoscopy Colorectal Cancer Constipation Crohn�s Disease Diveticular Disease Hemorrhoids Pelvic Floor Dysfunction Pilonidal Disease Polyps of the Colon and Rectum Puritis Ani Rectal Prolapse Rectocele Ulcerative Colits Anal Abscess/Fistula What is an anal abscess/fistula? An anal abscess is an infected cavity filled with pus near the anus or rectum. An anal fistula, which results from a previous abscess, is a small tunnel connecting the internal anal gland from which the abscess arose to the skin on the buttocks outside the anus. What are the symptoms of an abscess or fistula? Symptoms of both ailments may include pain, swelling, irritation of the skin, drainage of pus, and fever. How is an abscess treated? Abscesses are treated by draining the pus from the infected cavity. At the St. James Center for Colon and Rectal Surgery, this may be done in the office using a local anesthetic, or in the operating room for deeper abscesses. Although antibiotics may be used following drainage, they are usually not an alternative to drainage because they do not penetrate the infected fluid within an abscess. How is a fistula treated? Surgery is necessary to cure an anal fistula. Although usually straightforward, the potential for complication exists. Surgery usually involves cutting a small portion of the anal sphincter to open the tunnel and convert it to a groove that will heal from within outward. More complicated fistulas may require fistula plugs, or staged operations. Back To Top Anal Cancer What is anal cancer? Anal cancer arises from abnormal cells within the anus that may invade surrounding healthy tissues or spread (metastatsize) to other parts of the body. Most arise from skin cells and are called squamous cell carcinomas. What are the symptoms? Symptoms may include bleeding from the rectum or anus, feeling a lump or mass at the anal opening, pain in the anal area, narrowing of the stools, discharge of mucous or pus from the anus. Many of these symptoms may be caused by less serious conditions such as hemorrhoids, but you should never assume this. Instead see your doctor for a proper evaluation. How is anal cancer treated? Most often, a combination of radiation and chemotherapy is given to destroy the cancer cell, with surgery used only for very small early tumors that may be removed without damaging the anal sphincters. Back To Top Anal Fissure What is an anal fissure? An anal fissure is a small tear or cut in the skin that lines the anus which causes pain and/or bleeding. What are the symptoms of an anal fissure? Extreme pain during defecation and red spotty bleeding on the tissue or streaking the stool. There is often a spasm of pain that remains for a time after defecation. How can an anal fissure be treated? A new (acute) fissure will heal near 90% of the time with proper medical management. Bowel habits are improved with a high fiber diet, stool softeners and plenty of fluids to avoid constipation. Medicated ointments prescribed by a colorectal surgeon ease the pain of spasm and promote healing of the fissure. Warm baths several times each day are soothing and promote relaxation of the anal muscles. A chronic fissure (lasting longer than one month) may require additional treatment. This may involve a small outpatient operation to cut a portion of the overly-tight anal sphincter muscle. This allows the fissure to heal by decreasing pain and spasm. Cutting this muscle may very rarely interfere with the ability to control bowel movements. Pain usually disappears after a few days and complete healing usually occurs in a few weeks. Back To Top Anal Warts What are anal warts? Anal warts (also called condyloma acuminata) are a condition that affects the area around and inside the anus. They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may grow larger than the size of a pea. Usually, they do not cause pain or discomfort to afflicted individuals. As a result, patients may be unaware that the warts are present. Some patients will experience symptoms such as itching, bleeding, mucus discharge and/or a feeling of a lump or mass in the anal area. What causes these warts? They are caused by the human papilloma virus (HPV) which is transmitted from person to person by direct contact. HPV is considered a sexually transmitted disease. You do not have to have anal intercourse to develop anal condyloma. Do these warts always need to be removed? Yes. If they are not removed, the warts usually grow larger and multiply. If left untreated, the warts may lead to an increased risk of cancer in the affected area. What treatments are available? If warts are very small and are located only on the skin around the anus, they may be treated with a topical medication. Warts may also be removed surgically. Surgery provides immediate results but must be performed using either a local anesthetic or a general or spinal anesthetic, depending on the number and exact location of warts being treated. Warts inside the anal canal usually are not suitable for treatment by medications, and in most cases need to be treated surgically. Will a single treatment cure the problem? Recurrent warts are common. The virus that causes the warts can live concealed in tissues that appear normal for several months before another wart develops. As new warts develop, they usually can be treated in the physician's office. Sometimes new warts develop so rapidly that office treatment would be quite uncomfortable. In these situations, a second and occasionally third outpatient surgical visit may be recommended. How long is treatment usually continued? Follow-up visits are necessary at frequent intervals for several months after the last wart is observed to be certain that no new warts occur. What can be done to avoid getting these warts again? In some cases, warts may recur repeatedly after successful removal, since the virus that causes the warts often persists in a dormant state in body tissues. Discuss with you physician how often you should be evaluated for recurrent warts. Abstain from sexual contact with individuals who have anal (or genital) warts. Since many individuals may be unaware that they suffer from this condition, sexual abstinence, condom protection or limiting sexual contact to single partner will reduce your potential exposure to the contagious virus that causes these warts. As a precaution, sexual partners ought to be checked, even if they have no symptoms. Back To Top Bowel Incontinence What is bowel incontinence? Incontinence is the impaired ability to control gas or stool. Its severity ranges from mild difficulty with gas control to severe loss of control over liquid and formed stools. Incontinence to stool is a common problem, but often it is not discussed due to embarrassment. What causes incontinence? Injury during childbirth is one of the most common causes. These injuries may cause a tear in the anal muscles. The nerves supplying the anal muscles may also be injured. While some injuries may be recognized immediately following childbirth, many others may go unnoticed and not become a problem until later in life. Previous anal operations or traumatic injury to the tissue surrounding the anal region similarly can damage the anal muscles and hinder bowel control. Some individuals experience loss of strength in the anal muscles as they age. As a result, a minor control problem in a younger person may become more significant later in life. How is the cause of incontinence determined? An initial discussion of the problem with your physician will help establish the degree of control difficulty and its impact on your lifestyle. Many clues to the origin of incontinence may be found in patient histories. For example, a woman's history of past childbirths is very important. Multiple pregnancies, large weight babies, forceps deliveries, or episiotomies may contribute to muscle or nerve injury at the time of childbirth. In some cases, medical illnesses and medications play a role in problems with control. A physical exam of the anal region should be performed. It may readily identify an obvious injury to the anal muscles. In addition, an ultrasound probe can be used within the anal area to provide a picture of the muscles and show areas in which the anal muscles have been injured. Frequently, additional studies are required to define the anal area more completely. In a test called anal manometry, a small catheter is placed into the anus to record pressure as patients relax and tighten the anal muscles. This test can demonstrate how weak or strong the muscle really is. A separate test may also be conducted to determine if the nerves that go to the anal muscles are functioning properly. What can be done to correct the problem? After a careful history, physical examination and testing to determine the cause and severity of the problem, treatment can be addressed. Mild problems may be treated very simply with dietary changes and the use of some constipating medications. Diseases which cause inflammation in the rectum, such as colitis, may contribute to anal control problems. Treating these diseases also may eliminate or improve symptoms of incontinence. Sometimes a change in prescribed medications may help. Your physician also may recommend simple home exercises that may strengthen the anal muscles to help in mild cases. A type of physical therapy called biofeedback can be used to help patients sense when stool is ready to be evacuated and help strengthen the muscles. Injuries to the anal muscles may be repaired with surgery. Back To Top Colonoscopy What is colonoscopy? Colonoscopy is a safe, effective method of examining the full lining of the colon and rectum, using a long, flexible, fiberoptic instrument. It is used to diagnose colon and rectum problems and to perform biopsies and remove colon polyps. Most colonoscopies are done on an outpatient basis with minimal inconvenience and discomfort. Who should have a colonoscopy? Colonoscopy is routinely recommended to adults 50 years of age or older as part of a colorectal cancer screening program. Patients with a family history of colon or rectal cancer may have their colonoscopy at age 40. Your physician may also recommend a colonoscopy exam if you have change in bowel habit or bleeding, indicating a possible problem in the colon or rectum. A colonoscopy may be necessary to: Check unexplained abdominal symptoms Check inflammatory bowel disease (colitis) Verify findings of polyps or tumors located with a barium enema exam Examine patients who test positive for blood in the stool Monitor patients with a personal or family history of colon polyps or cancer How is colonoscopy performed? The bowel must first be thoroughly cleared of all residue before a colonoscopy. This is done one day before the exam with a preparation prescribed by your physician. Patients receive intravenous sedation, or �twilight sleep� for this procedure. The colonoscope is inserted into the rectum and is advanced to the portion of the colon where the small intestine joins the colon. During a complete examination of the bowel, your physician will remove polyps or take biopsies as necessary. The entire procedure usually takes about 30 minutes or less. Following the colonoscopy, there may be slight discomfort, which quickly improves with the expelling of gas. Most patients can resume their regular diet and activities the same day. What are the benefits of colonoscopy? Colonoscopy is more accurate than an x-ray exam of the colon to detect polyps or early cancer. With colonoscopy, it is now possible to detect and remove most polyps without abdominal surgery. Removing polyps is an important step in the prevention of colon cancer. What are the risks of colonoscopy? Colonoscopy is a very safe procedure with complications occurring in less than 1% of patients. These risks include bleeding, a tear in the intestine, risks of anesthesia and failure to detect a polyp. Learn more: http://www.fascrs.org/patients/treatments_and_screenings/colonoscopy/ Back To Top Colorectal Cancer Colorectal cancer is the second most common cancer in the United States, striking 140,000 people annually and causing 60,000 deaths. That�s a staggering figure when you consider the disease is potentially curable if diagnosed in the early stages. Who is at risk? Though colorectal cancer may occur at any age, more than 90% of the patients are over age 40, at which point the risk doubles every ten years. In addition to age, other high risk factors include a family history of colorectal cancer and polyps and a personal history of ulcerative colitis, colon polyps or cancer of other organs, especially of the breast or uterus. How does it start? It is generally agreed that nearly all colon and rectal cancer begins in benign polyps. These pre-malignant growths occur on the bowel wall and may eventually increase in size and become cancer. Removal of benign polyps is one aspect of preventive medicine that really works! What are the symptoms? The most common symptoms are rectal bleeding and changes in bowel habits, such as constipation or diarrhea. (These symptoms are also common in other diseases so it is important you receive a thorough examination should you experience them.) Abdominal pain and weight loss are usually late symptoms indicating possible extensive disease. Unfortunately, many polyps and early cancers fail to produce symptoms. Therefore, it is important that your routine physical includes colorectal cancer detection procedures once you reach age 50. Individuals who have a first-degree relative (parent or sibling) with colon cancer or polyps should start their colon cancer screening at the age of 40. How is colorectal cancer treated? Colorectal cancer requires surgery in nearly all cases for complete cure. Radiation and chemotherapy are sometimes used in addition to surgery. Between 80-90% are restored to normal health if the cancer is detected and treated in the earliest stages. The cure rate drops to 50% or less when diagnosed in the later stages. Thanks to modern technology, less than 5% of all colorectal cancer patients require a colostomy, the surgical construction of an artificial excretory opening from the colon. Can colon cancer be prevented? Colon cancer is preventable. The most important step towards preventing colon cancer is getting a screening colonoscopy. Colonoscopy provides a detailed examination of the bowel, and polyps can be identified and removed. Though not definitely proven, there is some evidence that diet may play a significant role in preventing colorectal cancer. As far as we know, a high fiber, low fat diet is the only dietary measure that might help prevent colorectal cancer. Finally, pay attention to changes in your bowel habits. Any new changes such as persistent constipation, diarrhea, or blood in the stool should be discussed with your physician. Can hemorrhoids lead to colon cancer? No, but hemorrhoids may produce symptoms similar to colon polyps or cancer. Should you experience these symptoms, you should have them examined and evaluated by a physician, preferably by a colon and rectal surgeon. Back To Top Constipation What is constipation? Constipation is a symptom that has different meanings to different individuals. Most commonly, it refers to infrequent bowel movements, but it may also refer to a decrease in the volume or weight of stool, the need to strain to have a movement, a sense of incomplete evacuation, or the need for enemas, suppositories or laxatives in order to maintain regularity. For most people, it is normal for bowel movements to occur from three times a day to three times a week; other people may go a week or more without experiencing discomfort or harmful effects. Normal bowel habits are affected by diet. The average American diet includes 12 to 15 grams of fiber per day, although 25 to 30 grams of fiber and about 60 to 80 ounces of fluid daily are recommended for proper bowel function. Exercise is also beneficial to proper function of the colon. About 80 percent of people suffer from constipation at some time during their lives, and brief periods of constipation are normal. Constipation may be diagnosed if bowel movements occur fewer than three times weekly on an ongoing basis. Widespread beliefs, such as the assumption that everyone should have a movement at least once each day, have led to overuse and abuse of laxatives. Eating foods high in fiber, including bran, shredded wheat, whole grain breads and certain fruits and vegetables will help provide the 25 to 30 grams of fiber per day recommended for proper bowel function. What causes constipation? There may be several, possibly simultaneous, causes for constipation, including inadequate fiber and fluid intake, a sedentary lifestyle, and environmental changes. Constipation may be aggravated by travel, pregnancy or change in diet. In some people, it may result from repeatedly ignoring the urge to have a bowel movement. More serious causes of constipation include growths or areas of narrowing in the colon, so it is wise to seek the advice of a colon and rectal surgeon when constipation persists. Individuals with spinal cord injuries frequently experience problems with constipation. Constipation may be a symptom of diabetes. Constipation may also be associated with scleroderma, or disorders of the nervous or endocrine systems, including thyroid disease, multiple sclerosis, or Parkinson's disease. Can medication cause constipation? Yes, many medications, including pain killers, antidepressants, tranquilizers, and other psychiatric medications, blood pressure medication, diuretics, iron supplements, calcium supplements, and aluminum containing antacids can slow the movement of the colon and worsen constipation. When should I see a doctor about constipation? Any persistent change in bowel habit, increase or decrease in frequency or size of stool or an increased difficulty in evacuating warrants evaluation. Whenever constipation symptoms persist for more than three weeks, you should consult your physician. If blood appears in the stool, consult your physician right away. How is constipation treated? The vast majority of patients with constipation are successfully treated by adding high fiber foods like bran, shredded wheat, whole grain breads and certain fruits and vegetables to the diet, along with increased fluids. Your physician may also recommend lifestyle changes. Fiber supplements containing indigestible vegetable fiber, such as bran, are often recommended and may provide many benefits in addition to relief of constipation. They may help to lower cholesterol levels, reduce the risk of developing colon polyps and cancer, and help prevent symptomatic hemorrhoids. Fiber supplements may take several weeks, possibly months, to reach full effectiveness, but they are neither harmful nor habit forming, as some stimulant laxatives may become with overuse or abuse. Other types of laxatives, enemas or suppositories should be used only when recommended and monitored by your colon and rectal surgeon. Designating a specific time each day to have a bowel movement also may be very helpful to some patients. In some cases, bio-feedback may help to retrain poorly functioning anal sphincter muscles. Only in rare circumstances are surgical procedures necessary to treat constipation. Your colon and rectal surgeon can discuss these options with you in greater detail to determine the best treatment for you. Back To Top Crohn�s Disease What is Crohn's disease? Crohn's disease is a chronic inflammatory process primarily involving the intestinal tract. Although it may involve any part of the digestive tract from the mouth to the anus, it most commonly affects the last part of the small intestine (ileum) and/or the large intestine (colon and rectum). Crohn's disease is a chronic condition and may recur at various times over a lifetime. Some people have long periods of remission, sometimes for years, when they are free of symptoms. There is no way to predict when a remission may occur or when symptoms will return. What are the symptoms of Crohn's disease? Because Crohn's disease can affect any part of the intestine, symptoms may vary greatly from patient to patient. Common symptoms include cramping, abdominal pain, diarrhea, fever, weight loss, and bloating. Not all patients experience all of these symptoms, and some may experience none of them. Other symptoms may include anal pain or drainage, skin lesions, rectal abscess, fissure, and joint pain (arthritis). Who does it affect? Any age group may be affected, but the majority of patients are young adults between 16 and 40 years old. Crohn's disease occurs most commonly in people living in northern climates. It affects men and women equally and appears to be common in some families. About 20 percent of people with Crohn's disease have a relative, most often a brother or sister, and sometimes a parent or child, with some form of inflammatory bowel disease. Crohn's disease and a similar condition called ulcerative colitis are often grouped together as inflammatory bowel disease. The two diseases afflict an estimated two million individuals in the U.S. What causes Crohn's disease? The exact cause is not known. However, current theories center on an immunologic (the body's defense system) and/or bacterial cause. Crohn's disease is not contagious, but it does have a slight genetic (inherited) tendency. An x-ray study of the small intestine may be used to diagnose Crohn's disease. How is Crohn's disease treated? Initial treatment is almost always with medication. There is no "cure" for Crohn's disease, but medical therapy with one or more drugs provides a means to treat early Crohn's disease and relieve its symptoms. The most common drugs prescribed are corticosteroids, such as prednisone and methylprednisolone, and various anti-inflammatory agents. Other drugs occasionally used include 6-mercaptopurine and azathioprine, which are immunosuppressive. Metronidazole, an antibiotic with immune system effects, is frequently helpful in patients with anal disease. In more advanced or complicated cases of Crohn's disease, surgery may be recommended. Emergency surgery is sometimes necessary when complications, such as a perforation of the intestine, obstruction (blockage) of the bowel, or significant bleeding occur with Crohn's disease. Other less urgent indications for surgery may include abscess formation, fistulas (abnormal communications from the intestine), severe anal disease or persistence of the disease despite appropriate drug treatment. Not all patients with these or other complications require surgery. This decision is best reached through consultation with your gastroenterologist and your colon and rectal surgeon. Back To Top Diverticular Disease Diverticulosis of the colon is a common condition that afflicts about 50 percent of Americans by age 60 and nearly all by age 80. Only a small percentage of those with diverticulosis have symptoms, and even fewer will ever require surgery. What is Diverticulosis/ Diverticulitis? Diverticula are pockets that develop in the colon wall, usually in the sigmoid or left colon, but may involve the entire colon. Diverticulosis describes the presence of these pockets. Diverticulitis describes inflammation or complications of these pockets. What are the symptoms of diverticular disease? Uncomplicated diverticular disease is usually not associated with symptoms. Symptoms are related to complications of diverticular disease including diverticulits and bleeding. Diverticular disease is a common cause of significant bleeding from the colon. Diverticulitis - an infection of the diverticula - may cause one or more of the following symptoms: pain in the abdomen, chills, fever and change in bowel habits. More intense symptoms are associated with serious complications such as perforation (rupture), abscess or fistula formation (an abnormal connection between the colon and another organ or the skin). How is diverticular disease treated? Increasing the amount of dietary fiber (grains, legumes, vegetables, etc.) - and sometimes restricting certain foods reduces the pressure in the colon and may decrease the risk of complications due to diverticular disease. Diverticulitis requires different management. Mild cases may be managed with oral antibiotics, dietary restrictions and possibly stool softeners. More severe cases require hospitalization with intravenous antibiotics and dietary restraints. Most acute attacks can be relieved with such methods. When is surgery necessary? Surgery is reserved for patients with recurrent episodes of diverticulitis, complications or severe attacks when there's little or no response to medication. Surgery may also be required in individuals with a single episode of severe bleeding from diverticulosis or with recurrent episodes of bleeding. Surgical treatment for diverticulitis removes the diseased part of the colon, most commonly, the left or sigmoid colon. Often the colon is hooked up or "anastomosed" again to the rectum. Complete recovery can be expected. Normal bowel function usually resumes in about three weeks. In emergency surgeries, patients may require a temporary colostomy bag. Patients are encouraged to seek medical attention for abdominal symptoms early to help avoid complications. Back To Top Hemorrhoids Did you know... Hemorrhoids are one of the most common ailments known. More than half the population will develop hemorrhoids, usually after age 30. Millions of Americans currently suffer from hemorrhoids. The average person suffers in silence for a long period before seeking medical care. Today's treatment methods make some types of hemorrhoid removal much less painful. What are hemorrhoids? Often described as "varicose veins of the anus and rectum", hemorrhoids are enlarged, bulging blood vessels in and about the anus and lower rectum. There are two types of hemorrhoids: external and internal, which refer to their location. External (outside) hemorrhoids develop near the anus and are covered by very sensitive skin. These are usually painless. However, if a blood clot (thrombosis) develops in an external hemorrhoid, it becomes a painful, hard lump. The external hemorrhoid may bleed if it ruptures. Internal (inside) hemorrhoids develop within the anus beneath the lining. Painless bleeding and protrusion during bowel movements are the most common symptom. However, an internal hemorrhoid can cause severe pain if it is completely "prolapsed" - protrudes from the anal opening and cannot be pushed back inside. What causes hemorrhoids? An exact cause is unknown; however, the upright posture of humans alone forces a great deal of pressure on the rectal veins, which sometimes causes them to bulge. Other contributing factors include: Aging Chronic constipation or diarrhea Pregnancy Heredity Straining during bowel movements Faulty bowel function due to overuse of laxatives or enemas Spending long periods of time (e.g., reading) on the toilet Whatever the cause, the tissues supporting the vessels stretch. As a result, the vessels dilate; their walls become thin and bleed. If the stretching and pressure continue, the weakened vessels protrude. What are the symptoms? If you notice any of the following, you could have hemorrhoids: Bleeding during bowel movements Protrusion during bowel movements Itching in the anal area Pain Sensitive lump(s) How are hemorrhoids treated? Mild symptoms can be relieved frequently by increasing the amount of fiber (e.g., fruits, vegetables, breads and cereals) and fluids in the diet. Eliminating excessive straining reduces the pressure on hemorrhoids and helps prevent them from protruding. A sitz bath - sitting in plain warm water for about 10 minutes - can also provide some relief. With these measures, the pain and swelling of most symptomatic hemorrhoids will decrease in two to seven days, and the firm lump should recede within four to six weeks. In cases of severe or persistent pain from a thrombosed hemorrhoid, your physician may elect to remove the hemorrhoid containing the clot with a small incision. Performed under local anesthesia as an outpatient, this procedure generally provides relief. Depending on the severity of one�s hemorrhoids, the following procedures are performed on an outpatient basis at the St. James Center for Colon and Rectal Surgery: Rubber Band Ligation - works effectively on internal hemorrhoids that protrude with bowel movements. A small rubber band is placed over the hemorrhoid, cutting off its blood supply. The hemorrhoid and the band fall off in a few days and the wound usually heals in a week or two. Infra Red Coagulation can be used on bleeding hemorrhoids that do not protrude. It is relatively painless and causes the hemorrhoid to shrivel up. Hemorrhoid stapling or �pexy� (PPH) � this is a technique that uses a special device to internally staple and excise internal hemorrhoidal tissue. The stapling method may lead to shrinkage of but does not remove external hemorrhoids. This procedure is generally more painful that rubber band ligation, but less painful than hemorroidectomy. Hemorrhoidectomy � surgery to remove the hemorrhoids - is the most complete method for removal of internal and external hemorrhoids. It is necessary when (1) clots repeatedly form in external hemorrhoids; (2) ligation fails to treat internal hemorrhoids; (3) the protruding hemorrhoid cannot be reduced; or (4) there is persistent bleeding. A hemorrhoidectomy removes excessive tissue that causes the bleeding and protrusion. It is done under anesthesia, and may, depending upon circumstances, require hospitalization and a period of inactivity. Laser hemorrhoidectomies do not offer any advantage over standard operative techniques. They are also quite expensive, and contrary to popular belief, are no less painful. Do hemorrhoids lead to cancer? No. There is no relationship between hemorrhoids and cancer. However, the symptoms of hemorrhoids, particularly bleeding, are similar to those of colorectal cancer and other diseases of the digestive system. Therefore, it is important that all symptoms are investigated by a physician specially trained in treating diseases of the colon and rectum and that everyone 50 years or older undergo screening tests for colorectal cancer. Do not rely on over-the-counter medications or other self-treatments. See a colorectal surgeon first so your symptoms can be properly evaluated and effective treatment prescribed. Back To Top Pelvic Floor Dysfunction What is pelvic floor dysfunction? For most people, having a bowel movement is a seemingly automatic function. For some individuals, the process of evacuating stool may be difficult. Symptoms of pelvic floor dysfunction include constipation and the sensation of incomplete emptying of the rectum when having a bowel movement. Incomplete emptying may result in the individual feeling the need to attempt a bowel movement several times within a short period of time. Residual stool left in the rectum may slowly seep out of the rectum leading to reports of bowel incontinence. The process of defecation (having a bowel movement) requires the coordinated effort of different muscles. The pelvic floor is made up of several muscles that support the rectum like a hammock. When an individual wants to have a bowel movement the pelvic floor muscles are supposed to relax allowing the rectum to empty. While the pelvic floor muscles are relaxing, muscles of the abdomen contract to help push the stool out of the rectum. Individuals with pelvic floor dysfunction have a tendency to contract instead of relax the pelvic floor muscles. When this happens during an attempted bowel movement, these individuals are effectively pushing against an unyielding muscular wall. How is pelvic floor dysfunction diagnosed? The diagnosis of pelvic floor disorder starts with a careful history regarding an individual�s symptoms, medical problems and a history of physical or emotional trauma that may be contributing to their problem. Next the physician examines the patient to identify any physical abnormality. A defecating proctogram is a study commonly used to demonstrate the functional problem in a person with pelvic floor dysfunction. During this study, the patient is given an enema of a thick liquid that can be detected with x-ray. A special x-ray video records the movement of the pelvic floor muscles and the rectum while the individual attempts to empty the liquid from the rectum. Normally the pelvic floor relaxes allowing the rectum to straighten and the liquid to pass out of the rectum. This study will demonstrate if the pelvic floor muscles are not relaxing appropriately and preventing passage of the liquid. The defecating proctogram is also useful to show if the rectum is folding in on itself (rectal prolapse). Many women have outpouching of the rectum known as a rectocele. Usually a rectocele does not affect the passage of stool. In some instances, however, stool may become trapped in a rectocele causing symptoms of incomplete evacuation. The defecating proctogram helps to identify if liquid is getting trapped in a rectocele when the individual is trying to empty the rectum. How is pelvic floor dysfunction treated? Pelvic floor dysfunction due to non-relaxation of the pelvic floor muscles may be treated with specialized physical therapy known as biofeedback. With biofeedback, a therapist helps to improve a person�s rectal sensation and pelvic floor muscle coordination. There are various effective techniques used in biofeedback. Some therapists train patients by teaching them to expel a small balloon placed in the rectum. Another technique uses a small probe placed in the rectum or vagina or electrodes placed on the surface of the skin around the opening to the rectum (anus) and on the abdominal wall. These instruments detect when a muscle is contracting or relaxing and provide visual feedback of the muscle action. This visual feedback helps the individual to understand the muscle movement and aids in improving muscle coordination. Approximately 75% of individuals with pelvic floor dysfunction experience significant improvement with biofeedback. Abnormalities identified with a defecating proctogram such as rectal prolapse and rectocele may be treated with a surgical procedure. Back To Top Pilonidal Disease What is pilonidal disease and what causes it? Pilonidal disease is a chronic infection of the skin in the region of the buttock crease. The condition results from a reaction to hairs embedded in the skin, commonly occurring in the cleft between the buttocks. The disease is more common in men than women and frequently occurs between puberty and age 40. It is also common in obese people and those with thick, stiff body hair. What are the symptoms? Symptoms vary from a small dimple to a large painful mass. Often the area will drain fluid that may be clear, cloudy or bloody. With infection, the area becomes red, tender, and the drainage (pus) will have a foul odor. The infection may also cause fever, malaise, or nausea. There are several common patterns of this disease. Nearly all patients have an episode of an acute abscess (the area is swollen, tender, and may drain pus). After the abscess resolves, either by itself or with medical assistance, many patients develop a pilonidal sinus. The sinus is a cavity below the skin surface that connects to the surface with one or more small openings or tracts. Although a few of these sinus tracts may resolve without therapy, most patients need a small operation to eliminate them. A small number of patients develop recurrent infections and inflammation of these sinus tracts. The chronic disease causes episodes of swelling, pain, and drainage. Surgery is almost always required to resolve this condition. How is pilonidal disease treated? The treatment depends on the disease pattern. An acute abscess is managed with an incision and drained to release the pus, and reduce the inflammation and pain. This procedure usually can be performed in the office with local anesthesia. A chronic sinus usually will need to be excised or surgically opened. Complex or recurrent disease must be treated surgically. Procedures vary from unroofing the sinuses to excision and possible closure with flaps. Larger operations require longer healing times. If the wound is left open, it will require dressing or packing to keep it clean. Although it may take several weeks to heal, the success rate with open wounds is higher. Closure with flaps is a bigger operation that has a higher chance of infection; however, it may be required in some patients. Your surgeon will discuss these options with you and help you select the appropriate operation. What care is required after surgery? If the wound must be left open, dressings or packing will be needed to help remove secretions and to allow the wound to heal from the bottom up. After healing, the skin in the buttocks crease must be kept clean and free of hair. This is accomplished by shaving or using a hair removal agent every two or three weeks until age 30. After age 30, the hair shaft thins, becomes softer and the buttock cleft becomes less deep. Back To Top Polyps of the Colon and Rectum Polyps are abnormal growths rising from the lining of the large intestine (colon or rectum) and protruding into the intestinal canal (lumen). Some polyps are flat; others have a stalk. Polyps are one of the most common conditions affecting the colon and rectum, occurring in 15 to 20 percent of the adult population. Although most polyps are benign, the relationship of certain polyps to cancer is well established. Polyps can occur throughout the large intestine or rectum, but are more commonly found in the left colon, sigmoid colon, or rectum. What are the symptoms of polyps? Most polyps produce no symptoms and often are found incidentally during endoscopy or x-ray of the bowel. Some polyps, however, can produce bleeding, mucous discharge, alteration in bowel function, or in rare cases, abdominal pain. How are polyps diagnosed? Polyps are best diagnosed by looking at the colon lining directly with a colonoscopy. Colonoscopy uses a flexible instrument to inspect of the entire colon. Bowel preparation is required, and sedation is used. Although checking the stool for microscopic blood is an important test for colon and rectal disorders, a negative test does NOT rule out the presence of polyps. The discovery of one polyp necessitates a complete colon inspection, since at least 30 percent of these patients will have additional polyps. Do polyps need to be treated? Since there is no fool-proof way of predicting whether or not a polyp is or will become malignant, total removal of all polyps is advised. The vast majority of polyps can be removed by snaring them with a wire loop passed through the instrument. Small polyps can be destroyed simply by touching them with a coagulating electrical current. Most colon examinations using the flexible colonoscope, including polyp removal, can be performed on an outpatient basis with minimal discomfort. Large polyps may require more than one treatment for complete removal. Some polyps cannot be removed by instruments because of their size or position; surgery is then required. Can polyps recur? Once a polyp is completely removed, its recurrence is very unusual. However, the same factors that caused the polyp to form are still present. New polyps will develop in at least 30 percent of people who have previously had polyps. Patients should have regular exams by a physician specially trained to treat diseases of the colon and rectum. Back To Top Pruritis Ani What is Pruritus Ani (proo-r�-tus a-n�)? Itching around the anal area is called pruritus ani. This condition results in a compelling urge to scratch. What causes this to happen? Several factors may be at fault. A common cause is excessive moisture in the anal area. Moisture may be due to perspiration or a small amount of residual stool around the anal area. Pruritis ani may be a symptom of other common anal conditions such as hemorrhoids and anal fissures. The initial condition can be made worse by scratching, vigorous cleansing of the area or overuse of topical treatments. In some individuals pruritus ani may be caused by eating certain foods, smoking and drinking alcoholic beverages, especially beer and wine. Food items that have been associated with pruritus ani include: Coffee, Tea Carbonated beverages Milk products Tomatoes and tomato products such as Ketchup Cheese Chocolate Nuts Does Pruritus Ani result from lack of cleanliness? Cleanliness is almost never a factor. However, the natural tendency once a person develops this itching is to wash the area vigorously and frequently with soap and a washcloth. This almost always makes the problem worse by damaging the skin and washing away protective natural oils. What can be done to make this itching go away? A careful examination by a colon and rectal surgeon or other physician may identify a definite cause for the itching. Your physician can recommend treatment to eliminate the specific problem. Treatment of pruritus ani may include these three points. 1. Avoid moisture in the anal area: Apply either a few wisps of cotton dusted with cornstarch powder to keep the area dry. Avoid all medicated, perfumed and deodorant powders. 2. Avoid further trauma to the affected area: Do not use soap of any kind on the anal area. Do not scrub the anal area with anything � even toilet paper. For hygiene, it is best to rinse with warm water and pat the area dry. Use wet toilet paper, baby wipes or a wet washcloth to blot the area clean. Never rub. try not to scratch the itchy area. Scratching produces more damage, which in turn makes the itching worse. For individuals that experience irresistible itching at night, wearing socks on the hands may be helpful. 3. Use only medications directed by your physician. Apply prescription medications sparingly to the skin around the anal area and avoid rubbing. Prolonged use of prescribed or over the counter topical medications may result in irritation or skin dryness that can make the condition worse. How long does this treatment usually take? Most people experience some relief from itching within a week. If symptoms do not resolve after 6 weeks, a follow-up appointment with your colon and rectal surgeon may be needed. Back To Top Rectal Prolapse What is rectal prolapse? Rectal prolapse is a condition in which the rectum (the lower end of the colon, located just above the anus) becomes stretched out and protrudes out of the anus. Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage, resulting in leakage of stool or mucus. While the condition occurs in both sexes, it is much more common in women than men. Why does it occur? Several factors may contribute to the development of rectal prolapse. It may come from a lifelong habit of straining to have bowel movements or as a late consequence of the childbirth process. Rarely, there may be a genetic predisposition. It seems to be a part of the aging process in many patients who experience stretching of the ligaments that support the rectum inside the pelvis as well as weakening of the anal sphincter muscle. Sometimes rectal prolapse results from generalized pelvic floor dysfunction, in association with urinary incontinence and pelvic organ prolapse as well. Neurological problems, such as spinal cord transection or spinal cord disease, can also lead to prolapse. In most cases, however, no single cause is identified. Is rectal prolapse the same as hemorrhoids? Some of the symptoms may be the same: bleeding and/or tissue that protrudes from the rectum. Rectal prolapse, however, involves a segment of the bowel located higher up within the body, while hemorrhoids develop near the anal opening. How is rectal prolapse diagnosed? A physician can often diagnose this condition with a careful history and a complete anorectal examination. To demonstrate the prolapse, patients may be asked to sit on a commode and "strain" as if having a bowel movement. Occasionally, a rectal prolapse may be "hidden" or internal, making the diagnosis more difficult. In this situation, an x-ray examination called a videodefecogram may be helpful. This examination, which takes x-ray pictures while the patient is having a bowel movement, can also assist the physician in determining whether surgery may be beneficial and which operation may be appropriate. Anorectal manometry may also be used to evaluate the function of the muscles around the rectum as they relate to having a bowel movement. How is rectal prolapse treated? Although constipation and straining may contribute to the development of rectal prolapse, simply correcting these problems may not improve the prolapse once it has developed. There are many different ways to surgically correct rectal prolapse. Abdominal or rectal surgery may be suggested. An abdominal repair may be approached laparoscopically in selected patients. The decision to recommend an abdominal or rectal surgery takes into account many factors, including age, physical condition, extent of prolapse and the results of various tests. How successful is treatment? A great majority of patients are completely relieved of symptoms, or are significantly helped, by the appropriate procedure. Success depends on many factors, including the status of a patient's anal sphincter muscle before surgery, whether the prolapse is internal or external, the overall condition of the patient. If the anal sphincter muscles have been weakened, either because of the rectal prolapse or for some other reason, they have the potential to regain strength after the rectal prolapse has been corrected. It may take up to a year to determine the ultimate impact of the surgery on bowel function. Chronic constipation and straining after surgical correction should be avoided. Back To Top Rectocele What is a rectocele? A rectocele is a bulge of the front wall of the rectum into the vagina. The rectal wall may become thinned and weak, and it may balloon out into the vagina when you push down to have a bowel movement. Most rectoceles occur in women where the front wall of the rectum is up against the back wall of the vagina. This area is called the rectovaginal septum and may be a weak area in the female anatomy. Other structures may also push into the vagina. The bladder bulging into the vagina is called a cystocele. The rectum bulging into the vagina is termed a rectocele. And the small intestines pushing down on the vagina from above may form an enterocele. Although uncommon, men may also develop a rectocele. A rectocele may be present without any other abnormalities. In some cases, a rectocele maybe part of a more generalized weakness of pelvic support and may exist along with a cystocele,urethrocele, and enterocele, or with uterine or vaginal prolapse, rectal prolapse, and fecal orurinary incontinence. What can cause a rectocele? The underlying cause of a rectocele is a weakening of the pelvic support structures and thinning of the rectovaginal septum. Certain factors may increase the risk of a woman developing a rectocele. These include birth trauma such as multiple, difficult or prolonged deliveries, the use of forceps or other assisted methods of delivery, perineal tears, or an episiotomy into the rectum or anal sphincter muscles. In addition, a history of constipation and straining with bowel movements, or hysterectomy may contribute to the development of a rectocele. Commonly, these problems develop with age but they may occasionally occur in younger women or in those that have not delivered children. What are the symptoms of a rectocele? Many women have rectoceles but only a small percentage of women have symptoms related to the rectocele. Symptoms may be primarily vaginal or rectal. Vaginal symptoms include vaginal bulging, the sensation of a mass in the vagina, pain with intercourse or even something hanging out of the vagina that may become irritated. Vaginal bleeding is occasionally seen if the vaginal lining of the rectocele is irritated, but other sources of the bleeding should be checked by your doctor. Rectal symptoms include constipation, particularly difficult evacuation with straining. Often this is associated with bulging in the vagina when straining to have a bowel movement. Some women find that pressing against the lower back wall of the vagina or along the rim of the vagina helps to empty the rectum. At times, there will be a rapid return of the urge to have a bowel movement after leaving the bathroom because stool that was trapped in the rectocele may return to the low rectum after standing up. A general feeling of pelvic pressure or discomfort is often present but this may be due to a variety of problems. How is a rectocele diagnosed? Most rectoceles may be identified on a routine office examination of the vagina and rectum. However, it may be difficult to assess the size and significance of the rectocele. A more accurate method of assessing the rectocele is an x-ray study called a defecagram. This study shows how large the rectocele is and if it empties with evacuation. When should a rectocele be treated? You should consider having your rectocele treated when it causes significant symptoms. It takes an experienced doctor to help you decide whether your symptoms are caused by a rectocele. If there are multiple abnormalities present, it may be best to address them all at once as this will result in the best chance for improvement. What treatment is available for a rectocele? Rectoceles that are not causing symptoms do not need to be treated. In general, you should avoid constipation by eating a high fiber diet and drinking plenty of fluids. Medical treatment A bowel management program is the best first step. This includes a diet high in fiber and 6 to 8 glasses of fluids each day. Fiber acts like a sponge. It soaks up fluid so that less is removed as the stool travels around the colon. The stools will be larger, softer and easier to pass. You may wish to add a fiber supplement and/or a stool softener to this regimen to improve stool consistency. Most fiber supplements are made of psyllium, a seed product, or of a hydrophilic colloid (gel) that absorbs water. Most stool softeners are composed of docusate. This helps to smooth and lubricate the stool. Active laxatives are best avoided in most cases. Avoid prolonged straining. If you cannot completely empty, get up and return later. Holding pressure with a finger to support the rectocele and encourage the stool to go in the correct direction is often helpful. This may be accomplished by pressing against the lower back wall of the vagina or along the posterior rim of the vagina. Avoid placing a finger inside the anus to pull the stool out as this may cause harm. A pessary may be used to support the pelvic organs. It is a ring that is inserted into the vagina and must be individually fit to each woman. Surgical treatment If symptoms persist even with medical therapy, then surgical repair may be indicated. There are several surgical techniques used to repair a rectocele. A rectocele repair may be performed through the anus, through the vagina, through the perineum between the anus and vagina, or from above through the abdomen. When there is extensive pelvic relaxation and prolapse, the best approach may be a combined repair. Who should treat me for this problem? Both colorectal surgeons and gynecologists are trained to deal with these problems. If the symptoms are entirely vaginal, then it is appropriate for your gynecologist to address the problem. If your symptoms are rectal, then a colorectal surgeon should be involved. If there is any question, seek opinions from physicians of both specialties. Back To Top Ulcerative Colitis What is ulcerative colitis? Ulcerative colitis is an inflammation of the lining of the large bowel (colon and rectum). Symptoms include rectal bleeding, diarrhea, abdominal cramps, weight loss, and fevers. In addition, patients who have had extensive ulcerative colitis for many years are at an increased risk to develop large bowel cancer. The cause of ulcerative colitis remains unknown. How is ulcerative colitis treated? Initial treatment of ulcerative colitis is medical, using antibiotics and anti-inflammatory medications such as aminosalicylates. If these fail, prednisone can be used for a short period of time but long-term use can be associated with significant side effects. If prednisone is ineffective or cannot be discontinued, immunomodulators such as 6-mercaptopurine or azathioprine can be used to control active disease that does not merit hospitalization. In order to maintain control of the disease, aminosalicylates or immunomodulators are used on a long-term basis. "Flare-ups" of the disease can often be treated by increasing the dosage of medications or adding new medications. Hospitalization may be necessary to put the bowel to rest and deliver steriods directly into the blood stream. When is surgery necessary? Surgery is indicated for patients who have life-threatening complications of inflammatory bowel diseases, such as massive bleeding, perforation, or infection. It may also be necessary for those who have the chronic form of the disease, which fails to improve with medical therapy. It is important the patient be comfortable that all reasonable medical therapy has been attempted prior to considering surgical therapy. In addition, patients who have long-standing ulcerative colitis may be candidates for removal of the large bowel, because of the increased risk of developing cancer. More often, these patients are followed carefully with repeated colonoscopy and biopsy, and surgery is recommended only if precancerous signs are identified. What operations are available? Historically, the standard operation for ulcerative colitis has been removal of the entire colon, rectum, and anus. This operation is called a proctocolectomy and may be performed in one or more stages. It eliminates the disease and removes all risk of developing cancer in the colon or rectum. However, this operation requires creation of a Brooke ileostomy (bringing the end of the remaining bowel through the abdomen wall) and long-term use of an appliance on the abdominal wall to collect waste from the bowel. This option eliminates the risks of cancer and risks of recurrent persistent colitis, but the internal reservoir may begin to leak and require another surgical procedure to revise the reservoir. Some patients may be treated by removal of the colon, with preservation of the rectum and anus. The small bowel can then be reconnected to the rectum and continence preserved. This avoids an ileostomy, but the risks of ongoing active colitis, increased stool frequency, urgency, and cancer in the retained rectum remain. Are there other surgical alternatives? The ileoanal procedure is the most common surgical treatment for the management of ulcerative colitis. This procedure removes all of the colon and rectum, but preserves the anal canal. The rectum is replaced with small bowel, which is refashioned to form a small pouch. Usually, a temporary ileostomy is created, but this is closed several months later. The pouch acts as a reservoir to help decrease the stool frequency. This maintains a normal route of defecation, but most patients experience five to ten bowel movements per day. This operation all but eliminates the risk of recurrent ulcerative colitis and allows the patient to have a normal route of evacuation. Patients can develop inflammation of the pouch (pouchitis), which usually responds to antibiotic treatment. In a small percentage of patients, the pouch fails to function properly and may have to be removed. If the pouch is removed, a permanent ileostomy will likely be necessary. Back To Top