The commonest anal problems are usually related to haemorrhoids (piles).

However, there are several other anal problems that are not due to haemorrhoids. It is often that patients assume that any anal problem is due to haemorrhoids. A careful history and proper examination will usually determine the actual source of a patient’s anal symptoms, which may not be due to hemorrhoids.

Anal Fissure

An anal fissure is a ‘tear’ in the lining of the anal canal. This may occur usually after a bout of hard stools or diarrhea. The common symptom is pain which is worse during and after a bowel movement. The pain can sometimes be quite severe. There is sometimes associated bleeding.

Careful examination will show a tear in the anal canal, commonly at the 6 o’clock or 12 o’clock positions. Digital Rectal examination can be very painful and there is usually spasm of the anal canal.

Treatment is directed as reduction of inflammation, pain, and relieving the spasm of the anal canal muscles.

Medications like GTN ointment may help relieve spasm. However, the results are not consistent. In severe pain and spasm or if the fissure does not respond to medication, surgery may be required.

Surgery is usually by way of a ‘Lateral Internal Sphincterotomy’ where the internal sphincter, which is the smaller muscle in the anal canal, is divided surgically to reduce the anal spasm and hence the pain. The fissure is usually debrided at the same time. Results in terms of resolution of pain are good. However, there is a risk of some minor anal incontinence.

Anal Abscess

An anal abscess usually presents as a painful swelling in or around the anal region. The pain is usually gradually worsening and is constant and throbbing. The pain does not seem to be related to a bowel movement and a painful, sometimes warm swelling is felt.

Although antibiotic treatment may be attempted, usually surgery is required to incise and drain the abscess and pus. The wounds are usually left open to heal.

Anal abscesses usually originate from an infected anal gland. The anal glands are situated in the anal canal and when they get infected, the infection tracks towards the external anal area. Commonly, after the abscess is drained, the origin of the abscess is searched for and if found, a fistulotomy may be performed to address the origin.

Anal Fistula

An anal fistula is a narrow ‘tunnel-like tract’ that originates from an infected anal gland within the anal canal and usually ends somewhere in the skin around the anus. It may present with an anal abscess or as a small discharging ‘hole’ in the perianal skin.

Definitive treatment is usually by surgery. The tunnel and origin need to be disrupted. The problems with anal fistula and its treatment revolve around recurrence, complicated tracts and anal incontinence.

Simple, low anal fistulae usually respond well to opening-up of the tunnel (fistulotomy).

However, higher or complicated fistulae are sometimes very difficult to treat. Further assessment can be performed by an Endoanal Ultrasound to delineate the extent of the fistula and its relation to the anal sphincter muscles.

There exist various surgical options that, in principle, attempt to preserve anal continence with little or no sphincter division and address the origin of the fistula. Recurrence rates after surgery for difficult anal fistula are higher.

Less Common Anal Problems

Less common anal problems that may occur include diseases that manifest itself with symptoms in the anal region.

Diseases like Crohns’ disease may present with abscesses and fistulae. Less common infections like Tuberculosis, Sexually transmitted diseases like gonorrhoea, viral warts, herpes and HIV may also present themselves with anal symptoms.

Anal canal cancers are rare but may present themselves as anal pain, bleeding or ulcers.

A consultation and proper examination by a colorectal surgeon would be best to establish a correct diagnosis and discuss treatment options.