nhsManagers.net | Briefing | 13 May 2017

Medicine for Managers

Dr Paul Lambden BSc MB BS BDS FDSRCSEng MRCS LRCP DRCOG MHSM FRSM

The ‘embarrassment factor’ is important because a more serious problem may be ignored and late diagnosis may make treatment more difficult.

The area circled in red is the part of the gut which I shall address today.

Proctalgia, derived from the Greek word proctos (to describe the anus and rectum) and the Greek word algos (meaning pain) is the medical term for pain in the lowest part of the bowel and we derive words like

proctologist who is a doctor who is a specialist in the lower bowel.

Perhaps the most common pain is caused by symptoms associated with the anus itself, notably haemorrhoids, anal fissures, anal fistulas and abscesses.

Haemorrhoids are formed as a result of swelling of the veins at the anus. In some cases the cause is unknown whilst in others straining at stool and repeated heavy lifting have been implicated.

They may be isolated or they may form a rosette around the opening of the anus.

They often cause no symptoms or may simply feel like a lump. However, for many they cause discomfort and become inflamed. For others they may bleed, commonly after having the bowel open and

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.

A Pain in the Bottom This popular descriptive term for a difficult individual actually gives a clue about this common symptom and how troublesome it can be. There are a variety of causes, often leading to significant distress. Most are treatable and resolvable without difficulty. They concern the bottom four to six inches or so of the digestive tract and are commonly too embarrassing even to discuss with the GP.

others suffer from anal pain. This is particularly the case in circumstances where one or more of the veins entering the haemorrhoids develop a clot (thrombosis) and the resulting blood-starved pile becomes very painful.

Haemorrhoids can be treated either by injecting them with phenol to shrivel them up, or placing an elastic band round the top of them to achieve the same effect. Thrombosed piles can be injected with local anaesthetic and the clot then removed with often dramatic relief.

An anal fissure is a split in the skin of the anus which usually follows the passage of a particularly large and hard stool. The result is pain during defaecation (when having the bowels open), some bleeding which appears as flecks of blood on the toilet paper and pain which may persist for a significant time after defaecation has occurred.

Although uncomfortable or painful, they generally heal on their own over a few weeks. Using a laxative may help by softening the stools as may increasing dietary fibre. In resistant cases, there are various ointments, both available at the chemist and prescribable, which may ease the symptoms.

Anal Fistulas and abscesses cause inflammation and soresness round the anus, constant throbbing pain, general symptoms of infection with a temperature and feeling unwell and passing blood or pus with defaecation. A fistula is a lined tube connecting the skin of the outside with the lower part of the bowel

An abscess may need to be drained surgically and fistulas almost invariably need to be excised surgically because they virtually never heal on their own.

There are some less common causes of anal pain.

Proctalgia fugax (fugax derives from the Greek word meaning fleeting or temporary) is a condition causing sudden and unexpected episodes of severe and sharp pain in the anus that may last only a few seconds and generally do not last more than a few minutes at the most. It is caused by intense muscle spasm round the anal canal, does not occur prior to puberty and affects more women than men. Menstruation is believed to be a trigger. It may be treated by counselling if stress is believed to be the cause. Hot baths may help and, if recurrent, the use of glyceryl trinitrate ointment may help with the symptoms.

The inflammatory bowel diseases, Crohn’s disease and ulcerative colitis, may affect the lowest part of the bowel and cause pain, bloody diarrhoea, and weight loss. Management of the conditions is along the same lines as the diseases presenting anywhere else in the bowel.

Other occasional causes are associated with;

nerve irritation and damage as a result of bony damage through osteoarthritis or trauma, bone pain from coccydynia (sacral pain), or through bone damage or tumour infiltration, cancer in and around the anus and the floor of the pelvis or urinary infections and prostatic inflammation or infection

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.

Seeing the GP

Discussing the anus, bowel activity and other intensely personal matters is incredibly difficult especially if, over the years, your GP has become your friend.

The thought of showing him or her your bottom is unthinkable. However, people die every year because they prefer not to admit to symptoms associated with the back passage until it is too late. It is important to go to see your GP if:

• You develop bleeding from the back passage. It shouldn’t happen. Find out why and do not just assume it is a ‘touch of piles’.

• You develop pain around or inside the anus which persists for more than three to five days

• You get episodes of severe pain, whether or not it is short-lived.

Let me finish by returning to haemorrhoids. Piles are fleshy projections of dilated veins outside the anal ring (the ring of muscle which keeps the anus closed when not in use). 50% of people have had haemorrhoids.

They are a problem but remember there is always someone worse off than you!

Have a good week.

paullambden@compuserve.com

Medicine for Managers articles are not intended to be a source of medical advice. Their purpose is to familiarise the non-medical reader about current key medical disorders. Any medical or medicinal products mentioned by name are examples only and should not be regarded as an endorsement of their use.