UNDERSTANDING PILES, FISSURES AND FISTULAS

Dr Antonio De Bossuet Afonso: Piles (haemorrhoids) are enlarged blood
vessels that one can get inside or around your anus. They’re usually small,
round, discoloured lumps. One might be able to feel them on ones anus or
hanging down from the anal canal.

An anal fissure is a small tear in the thin, moist tissue
(mucosa) that lines the anus. An anal fissure may occur when you pass hard or
large stools during a bowel movement.

An anal fistula (fistula-in-ano) refers to an abnormal
connection between the anal canal and the perianal skin.

HC: Why do we get them?

Dr ABA: Piles result when there is an increase in the pressure in the
small vessels that make up the haemorrhoid, causing them to swell and engorge
with blood. Increased pressure may be caused by a variety of factors such as
strain when having a bowel movement, increasing the pressure within the blood
vessels. This happens in case of low fibre diet and small calibre stools;
increased pressure of the enlarged uterus on the rectum and anus especially
during pregnancy. In addition, hormonal changes with pregnancy may weaken the muscles
too; prolonged sitting on the toilet may increase pressure within the
haemorrhoid blood vessels; obesity; acute and chronic diarrhoea; colon cancer;
previous rectal surgery and spinal cord injury and lack of erect posture.

Anal fissure is caused by hard stools and constipation, chronic
diarrhoea, anal intercourse and childbirth.

Anal fistula can be caused by clogged anal glands and anal
abscesses. Other causes include diseases like Crohn’s, Tuberculosis,
Diverticulitis, STDs, cancer etc; radiation therapy; and trauma.

HC: Are there any herbal or local remedies that work?

Dr ABA: There is no scientific evidence to show the effectiveness of any
herbal medications.

HC: Is it safe to be treated by piles and fistula specialists from
alternative medicine?

Dr ABA: As it is not my area of expertise, I wouldn’t want to comment
about the allied systems of medicine.

HC: What are the preventive measures we can adopt?

Dr ABA: The best way to prevent haemorrhoids, anal fissures and fistulas
is to keep your stools soft, so that they pass easily. This can be achieved by:

Eating high-fibre foods. Eat more fruits, vegetables and whole
grains.

Drink plenty of fluids. Drink six to eight glasses of water and
other liquids (not alcohol) each day to help keep stools soft.

Consider fibre supplements. Most people don’t get enough of the
recommended amount of fibre — 25 grams a day for women and 38 grams a day for
men — in their diet. If you use fibre supplements, be sure to drink at least
eight glasses of water or other fluids every day. Otherwise the supplements can
cause or worsen constipation.

Don’t strain. Straining and holding your breath when trying to
pass a stool creates greater pressure in the veins in the lower rectum.

Go as soon as you feel the urge. If you wait to pass a bowel
movement and the urge goes away, your stool could become dry and be harder to
pass.

Exercise. Stay active to help prevent constipation and to reduce
pressure on veins, which can occur with long periods of standing or sitting.

Avoid long periods of sitting. Sitting too long, particularly on
the toilet, can increase the pressure on the veins in the anus.

HC: Once we get them, what are the different options for treatment?

Dr ABA: Treatment of piles: Depending on the severity of the
haemorrhoids, they are graded by the degree of prolapse into the anal canal and
managed based on their grades as follows:

Grade 1 Internal haemorrhoids that bulge into the canal but do
not prolapse are treated symptomatically. Warm sitz baths, sitting in a warm
tub for 20 minutes, two or three times a day may be helpful. Avoiding spicy
food may also prevent anal itching.

Grade 2 and 3 haemorrhoids may protrude past the anal verge with
and without any straining respectively. Initial treatment is to destroy the
haemorrhoid by making it sclerosed or hardening it using rubber bands, etc

People who have failed conservative therapy or who have Grade 4
haemorrhoids are candidates for surgery, where removal of the swollen
haemorrhoids with laser surgery or haemorrhoidectomy, using a scalpel or
stapler is performed.

Treatment of anal fissures: In most cases of anal fissures, the
issue will resolve by itself within a few weeks. Medications to relieve
symptoms of pain, burning or discomfort may be used. If the patient is
suffering from constipation, a laxative may be prescribed.

The doctor may recommend a topical anaesthetic for relief.

In chronic cases (long-term) which do not heal, surgical
removal, sphincterectomy or fissuretomy is done.

Treatment of fistulas: For fistulas, surgery is usually
necessary to treat an anal fistula as very few heal by themselves. There are
several different procedures. The best option will depend on the position of
your fistula and whether it’s a single channel or whether it branches off in
different directions.

Fistulotomy involves cutting along the whole length of the
fistula to open it up so it heals as a flat scar. The aim of surgery is to heal
the fistula while avoiding damage to the sphincter muscles. Different
techniques are used based on the extent of the fistula into the anal sphincter,
like Seton technique, Advancement flap procedure, LIFT procedure etc.

HC: Is it true that surgery can cause recurrence?

Dr ABA: Although there is a risk of recurrence with all methods of
treatment, surgery is the most effective method and one with least recurrence.

HC: How about ispaghula or milk of magnesia?

Dr ABA: Milk of Magnesia or ispaghula can be used for constipation as it
acts as a laxative.

HC: When should a patient seek immediate medical assistance in
relation to these conditions?

Dr
ABA: Doctors may be
consulted if there is severe perianal pain or bleeding from the rectum. If the
patient notices any swelling or discharge from anus or perianal region,
doctor’s opinion should be taken at the earliest.