Common Anorectal Disease

Most anorectal conditions are quite common and frequently caused by benign disorders. Although they can often be treated in the outpatient setting, they sometimes require surgical intervention. Common anorectal conditions include fissures, fistulas, hemorrhoids, pruritis ani (anal itching), pilonidal disease, rectal pain, and condyloma/AIN (Anal Intraepithelial Neoplasm).


An anal fissure is a cut or split in the lining of the anal canal and is one of the most common causes of severe anorectal pain. Among the more common causes are hard or large stools passing through the anal canal, straining during bowel movements when you are constipated, chronic diarrhea, and inflammation in the area of the anus as a result of Crohn’s disease or other inflammatory process. Symptoms include pain during bowel movements accompanied by blood on the toilet paper. You may also experience intense pain or spasms for several hours after a bowel movement. Anal fissures can be diagnosed through history and physical examination.

Sometimes fissures are found in uncommon places in the anus. Causes of fissures located in these places include Crohn’s disease, which is the most common, but can also be caused by other inflammatory bowel diseases, syphilis, tuberculosis, leukemia, cancer, and human immunodeficiency virus (HIV).

Most anal fissures can be treated medically and over 80% don’t require surgery. If the cause is constipation or diarrhea, treating those conditions frequently cures the fissure within about 4 to 6 weeks. These home treatments include a high fiber diet, stool softeners, laxatives, taking in plenty of fluids, and sitting in a warm bath two to three times a day. After a couple of day’s treatment, the pain you experience during bowel movements usually goes away.

If a fissure doesn’t heal after six weeks, it may need additional treatment with special medications. Anal surgery is very effective, but usually only recommended when more conservative treatments have not been effective. This surgery is frequently done as “same day” surgery meaning after the surgery you can go home.


Fistula (Anal Abscess):

An anal abscess is a pus-filled cavity found near the rectum or anus. Anal glands that are located just inside the anus can become clogged. When they do, they may become infected and an abscess can develop. If you experience constant pain that gets worse when you sit or have a bowel movement or pus or blood in your stool, you could be suffering from an anal abscess or fistula. In order to relieve the pressure caused by the abscess, the pus is drained by making an incision (cut) in the skin. Frequently this can be done in the physician’s office.

After an abscess is drained, a tunnel may remain that connects the abscess to the skin. This tunnel is called a fistula. The word fistula means pipe or tube. Continuous drainage from the anus to the outside skin indicates the presence of a fistula. About 50% of the time abscesses will result in fistulas. However, they can be related to other conditions like Crohn’s disease, proctitis (inflammation of the lining of the rectum), or anorectal cancer. Although fistulas often develop four to six weeks after draining an abscess, they can occur months or even years later.

Physical examination by a physician may identify the external opening of the fistula as a protrusion or induration (hardening) and may help the physician identify the tract of the fistula. For proper treatment it is critical for the physician to identify the anatomy related to the fistula. Several research studies have determined that an MRI and anorectal endosonography (EUS) are accurate methods to determine the anatomy related to the fistula. Other methods include a probe with a dye, fistulography (use of x-ray and contrast liquid to determine, the length, shape, and direction of the fistula), and anal ultrasound.

Since the principal method of managing a fistula is surgery, it is important to obtain an early referral to a surgeon. The goal of surgery is to remove the fistula tract and preserve fecal continence (the ability to control the passage of waste). If the fistula heals properly, usually the problem will not return. That’s why it is important to follow the instructions of your colon and rectal surgeon to help prevent any recurrence.



Hemorrhoids are cushions of tissue and veins located in the anus or lower rectum. (The rectum is the last part of the large intestine (colon) and leads down to the anus. The anus is the opening through which solid waste (feces) is eliminated). Each year more than one million people in the U.S. are affected by hemorrhoidal conditions. When hemorrhoids become inflamed, they can itch, bleed, and cause pain. Since they tend to get worse over the years, it is recommended that treatment be sought early. This common problem can be painful, but it’s usually not serious. Hemorrhoids are not dangerous or life threatening. There are several conservative medical treatments that can often be used to treat hemorrhoids including analgesics (medications that reduce or eliminate pain), anti-inflammatory drugs, topical creams, increasing fiber in your diet, and taking Sitz baths (sitting in warm water for 10 minutes several times a day). However, if they don’t respond to medical therapy, there are procedures that can be done in the surgeon’s office.

Treatments and Procedures

Pruritis Ani (Anal Itching):

Pruritis ani is an irritation around the anus which causes itching and the need to scratch. There are a number of reasons why this may be occurring. Typically it is due to moisture around the anus either from perspiration or residual stool. However, it may be a symptom for other conditions including hemorrhoids or anal fissures. You can make the problem even worse by intense scratching, strongly cleansing the area, or excessively using topical creams and ointments.

In some people pruritis ani has been associated with eating certain foods, smoking, and drinking alcoholic beverages, especially beer and wine. Because there are so many possible causes of prutitis ani, you should see a physician for accurate diagnosis and treatment. Examination by a colon and rectal surgeon may identify the definite cause of the problem. Your physician may order tests to determine if the causes are from systemic disease or a local source. Your surgeon may use a proctocolonoscope or an anoscope to view the anal canal and lower rectum.

Treatment for pruritis ani may include:

  • Keeping the area free of moisture
  • Avoiding further irritation of the area
  • Using medications as recommended by your physician

You should begin to experience relief within about a week. If symptoms persist, you should contact your physician.


Pilonidal Disease:

Pilonidal disease is a cyst (capsule-like sac) located in the natal cleft (crease) at the top of the buttocks (sometimes called “butt crack”) that can become infected (called an abscess) and cause pain and drainage. Although it is often thought that hair in the cleft is the cause, this is not always true. Hair follicles can be the cause. The follicle is the sac the hair grows from. Essentially, the cyst is located beneath the skin and can become terribly painful if infected. You may experience redness or swelling in the area, blood or pus draining from the abscess, and pain when walking or sitting. Physicians can usually diagnose this disease by a physical exam of the buttocks. More men than women suffer from this disease, which frequently occurs between puberty and age 40.

Pilonidal cysts rarely go away on their own. Sometimes they respond to being lanced (opened) and drained or to treatment with antibiotics. If your surgeon has to lance and drain the cyst, this can be done in the office with local anesthesia. With local anesthesia, only the specific area that is affected is numbed so you can’t feel any pain. You are awake during the procedure. It often takes a month or so to heal. Oftentimes, however, surgical intervention is required to remove the cyst. Removing the cyst is more complex than just draining it. This procedure is usually done in the hospital using general anesthesia. This means you will be asleep and not feel any pain during the procedure. Time to heal can range anywhere from ten days to six weeks.

As part of your treatment, there are some things you can do at home. You should keep the affected area dry and clean. Your surgeon may advise that you use antibacterial soap or an alcohol swab to clean the area. You may also be advised to shave the area and soak in a warm tub of water.

Cysts can come back after treatment and a few patients develop recurrent infections, which almost always require surgery to treat. There are different surgical options that are available; your surgeon will discuss the different types of procedures with you.


Rectal Pain:

Rectal pain is common and usually not due to any serious medical condition. Common causes include:

  • Hemorrhoids: Hemorrhoids are cushions of tissue and veins located in the anus or lower rectum. When hemorrhoids become inflamed, they can itch, bleed, and cause pain. This is a common problem and affects almost one million people in the U.S. each year.
  • Anal Fissure: This is a small tear in the skin at the opening of the rectum. Common causes include hard or large stools, straining during bowel movements when you are constipated, and inflammation in the area of the anus as a result of other inflammatory diseases.
  • Levator ani Syndrome: This is similar to Proctalgia fugax. The term levator ani refers to muscles that surround the anus. It is thought that spasms of these muscles cause the pain. The pain is often described as a dull ache high in the rectum. Your surgeon may perform a rectal examination to determine if the levator muscle is tender when digitally pressed. Initial treatment usually consists of hot baths, non-steroidal anti-inflammatory drugs, muscle relaxants, and periodic massage of the spastic muscles.
  • Other Causes: Less common causes of rectal pain include: cancer, infection (including abscesses), diseases such as Crohn’s disease, ulcerative colitis, and inflammatory bowel disease, or rectal prolapse (rectum slips outside of the anus).
  • Proctalgia fugax: This is a benign condition associated with intermittent rectal pain that can be severe and occurs in 8% of Americans. This severe pain generally occurs at night and will awaken you form a sound sleep. It occurs more commonly in women and in people younger than 45 years of age. Although the exact cause of the pain is not known, many doctors believe spasm of the anal sphincter muscle is the responsible factor. Diagnosis is made based on your symptoms and the lack of any other cause. As a result, your surgeon may perform a sigmoidoscopy or colonoscopy to make sure there is no other serious problem causing the pain.



Condyloma or genital warts (also called venereal warts) are transmitted by the Human Papilloma Virus (HPV) usually by direct sexual contact. HPV is the most common sexually transmitted disease (STD). Condyloma are contagious and can spread during oral, vaginal, or anal sexual contact with a partner who is infected. They can be spread by skin contact with an infected partner and two thirds of those people who have sexual contact with an infected partner will develop warts, usually within a period of three months after contact. Using condoms may help, but does not guarantee protection against genital warts.

These warts are found on the genitalia (penis, scrotum, vagina), in the anal area, mucous membranes of the mouth, or they can be found internally in the upper vagina or cervix in females and in the male urethra (canal through which fluid is discharged from the bladder to the outside). These warts sometimes take on a cauliflower-like appearance in the genital area. They are usually flesh-colored and raised. If you observe these warts, you should see a physician to determine if they are genital warts or a different type of growth. You may have no symptoms associated with these warts or they may produce burning, tenderness, itching, pain during intercourse, or frequent urination. Outbreaks of these warts seem to get worse during pregnancy or if your immune system is compromised (impaired by disease or medical treatment). If you have a history of genital warts, you may be at higher risk for certain types of cancers.

Your physician can diagnose genital warts frequently through direct visualization. This involves examining the genital areas, thighs, pelvic region, mouth and tongue for signs of the warts. For women your physician may perform a pap smear to check for internal genital warts. This involves scraping cells from the cervix and examining them under a microscope for abnormalities. Your physician may also use a colposcope, which is a lighted magnifying device to better view the cervix to check for signs and symptoms of genital warts.

There are three categories of treatment for genital warts:

  1. Topical medications that destroy the warts. This is often the first treatment used. Your physician may apply any medicines that could damage the skin surrounding the warts. S/he may prescribe other medications that you can apply at home. It is important that you follow the treatment regimen and you have to be capable of identifying and reaching all the areas where the genital warts are located.
  2. Surgical methods to remove the warts. This involves physically removing the warts by excising (cutting) them using a scalpel or laser. This is often done for extensive warts or when other treatments haven't worked. Another method used on less extensive warts is cryotherapy. This method uses a chemical to freeze the warts, which then just fall off. If the warts are located in the cervix a method called loop-electrosurgical excision procedure (LEEP) may be used. This method uses electrical current to cut and cauterize (burn) the warts. This can be done in the surgeon's office usually under local anesthetic.
  3. Biologic-based treatments which target the HPV virus at the root of the problem. These are anti-viral drugs that are injected directly into the warts. This is often used to treat warts that have returned persistently. This attacks the virus itself, but may not lessen the rate at which they return.

It is important to realize that there is no cure for condyloma or genital warts. Treatments may remove your symptoms, but the warts can recur at any time. This is because the virus that causes the warts - human papilloma virus (HPV) - has no cure.


AIN (Anal Intraepithelial Neoplasm):

AIN is the abnormal growth of cells in anal tissue that may progress to cancer. These microscopic abnormal cells represent different grades of dysplasia. Dysplasia refers to changes in the structure, size, and organization of cells. This dysplasia is thought to result from local infection of the human papilloma virus (HPV).

Several risk factors have been identified for AIN. These include anal HPV infection, HIV infection, receptive anal intercourse, and having a depressed immune system. AIN is primarily asymptomatic, which means you may not demonstrate any symptoms. However, AIN can cause symptoms locally such as pruritis (itching), pain, bleeding, irritation, discharge, and tenesmus (the feeling that you constantly need to move your bowels).

AIN has been categorized into three stages - AIN I, AIN II, and AIN III, representing low, moderate, and high grade dysplasia.

AIN I: Stage I represents mild dysplasia. This means there are mild changes to the abnormal cells.
AIN II: Stage II represents moderate dysplasia. This means there are moderate changes in the abnormal cells.
AIN III: Stage III represents severe dysplasia. This means there are severe changes in the abnormal cells. This is a progressive, potentially pre-cancerous condition that should be treated. Severe dysplasia is essentially the same as carcinoma in situ, which means cancer that is confined to a specific area and not invading other areas. However, even with treatment invasive cancer can develop, especially in individuals who are immunosuppressed.

Different methods are used to diagnose AIN and they can be done in the physician’s office. Initially, your physician may visually examine the area around your anus (perianal area) for abnormal cytology (cells). The next step may be collecting cells from the anal canal for examination under a microscope. This involves inserting a swab into the anal canal and swabbing the tissues so that cells can be collected. The cells are then smeared onto a microscope slide for subsequent examination. If abnormal cells are found on the microscope slide, a visual examination of the anal canal may likely be necessary. An anoscope is used to examine the anal canal. This is a small tubular device with a light source and magnifying lens that enables the surgeon to view the anal canal and identify abnormalities.

Treatment for AIN usually falls into three categories:

  • Local treatment by physician or patient. For small lesions (abnormal cells) topical creams and liquids may be effective.
  • Physician administered ablation treatments. Ablation means to remove something or stop it from functioning. These include:
    • Electrocautery: This uses a device that generates heat to remove the abnormal tissue.
    • Laser: Lesions are destroyed using highly focused narrow beams of light that deliver intense heat.
    • Infrared coagulation: A pulse of irradiation is applied directly to the area of abnormal tissue and destroys the cells.
  • Surgery may be required to remove the diseased tissue. This is often done for larger lesions.

Your surgeon will discuss these options with you including any side effects of the treatment and a plan for follow-up.