Anal itching (pruritis ani) is very common and can be very distressing and embarrassing. Although a long list of medical conditions can cause this symptom, the most common culprit is the use of dry toilet paper. A strategy of modified personal hygiene habit such as the use of wet wipes (or better still: water for ablution) and liberal use of barrier cream is successful in getting rid of this irksome symptom in a vast majority of patients. Itching that persists despite these measures warrants medical evaluation.
Protusions or lumps that can be felt around the back-passage, or from within it after a bowel action can be related to a number of conditions, most of them harmless.
Perianal skin tags are redundant folds of skin that are present around the back passage and are usually associated with long standing haemorrhoids or conditions such as an anal fissure in the past. These are harmless but may interfere with personal hygiene or be cosmetically undesirable.
Protusions from within the anal canal that can be felt after emptying bowels are usually haemorrhoids/piles. These retract spontaneously afterwards or sometimes have to be pushed back in.
Occasionally an anal canal polyp (fibro-epithileal polyp) can protrude out through the back passage.
True full thickness rectal prolapse is uncommon but when present is very different from haemorrhoidal prolapsed. It is circumferential and much larger/longer (5-10cm).
Self limiting/ transient episodes of either loose motions/ diarrhoea or constipation are very common. These are usually diet or life style related or viral in nature and resolve spontaneously after a few days with dietary manipulation and/or over the counter medications. However, a new change in bowel habit that is persistent and last more than a few weeks, should be investigated.
Persistent loose motions/ diarrhoea/ increased frequency can be caused by a number of colorectal conditions including infection (such as campylobacter or c-difficile), colitis (ulcerative colitis and Crohn’s disease), diverticulitis , severe constipation (overflow diarrhoea) and bowel cancer. Associated symptoms especially from rectal conditions such as ulcerative colitis and cancer include urgency (having to rush to the toilet with little warning), urge incontinence (not making it there on time), tenesmus (a feeling of incomplete emptying and a desire to go to the toilet very soon after and frequently) and wet wind (accidents/ leakages whilst passing wind).
Constipation is another common symptom and does not always herald an underlying bowel condition. People have varying bowel habits and frequencies and some only empty their bowels once or twice every week. Patients who have slow transit constipation can go even less frequently. Constipation that is a new change in bowel habit and does not resolve may signal an underlying bowel condition and merits investigations. Causes can range from harmless ones such as new medications (e.g. painkillers) or dietary changes (new weight loss diet) to the more sinister ones such as a blockage of the bowel. Associated symptoms of a blockage are abdominal distension, gripey abdominal pains, vomiting and inability to pass wind as well as the constipation. The presence of these symptoms together warrants urgent medical attention.
Irritable bowel disease often causes intermittent irregular bowel habits over a number of years. It is however important to exclude other causes of irregular bowel habits before attributing the changes to IBS. A small proportion of people with IBS type symptoms are found subsequently to have an underlying sinister bowel condition such as bowel cancer upon investigations.
Rectal bleeding is a common presentation of a range of bowel related conditions. The severity of the symptom ranges from minor traces of blood on the toilet paper to catastrophic bleeding.
The most common type of rectal bleeding is bright red blood that is seen on the toilet paper or minor amounts seen in the w.c. This blood is usually separate from the stools and is commonly caused by conditions of the anal canal such as haemorrhoids or anal fissures.
Haemorrhoidal bleeding can sometimes be alarming in quantity and a lot of blood can be seen splashed in the w.c. (“flash in the pan”).
Dark red rectal bleeding/ altered blood in the pan usually signals a cause that is higher up in the large bowel. A wide range of colonic conditions can cause this type of bleeding but the commoner causes include diverticular disease , colitis , blood vessel aberrations (angiodysplasia), colonic polyps and bowel cancer.
Catastrophic/ severe haemorrhage is usually caused by diverticular disease or angiodysplasia often excacerbated by blood thinning medications such as warfarin. This usually requires an emergency hospital admission. Sometimes even haemorrhoidal bleeding can be severe and frightening.
It is however important to understand that not all colonic conditions such as bowel cancer or diverticular disease will manifest with bleeding.
Abdominal (tummy) pain is a very common symptom. Causes can include a wide range of conditions. These may be related to the gastrointestinal tract (gut), urinary tract or female reproductive organs. Most episodes of tummy pain are self limiting and can be managed at home with simple remedies. Abdominal pain that lasts longer periods and do not resolve or sudden onset severe abdominal pain merit a consultation with a doctor.
Whilst most people think anal pain is caused by haemorrhoids, most haemorrhoids do not cause pain. The more common causes of anal pain are anal fissures, perianal haematoma (blood clot in a haemorrhoid), fistula and abscesses. Other less common causes include sexually transmitted diseases and tumour.
Severe pain at the time of defecation and stinging and burning afterwards usually imply an anal fissure. Pain may be accompanied by bleeding. Pain from an abscess is usually constant and throbbing in nature. Pain from a perianal haematoma can be severe and may last for a few weeks.
Anal pain that is severe or that lasts more than a few days should be reported to your doctor.