06. THE ANAL REGION

Examination of the Anus

Throughout history, the idea of good bowel function has been a mental image of good health, and practically every human malady has at some period been judged better or worse, depend­ing on the answer to the question, "How are the bowels?"

Bowel concern begins at birth, and grows to real awareness in mature years when activities begin to slow down, but it is in the senior years that good health is "proved" by statements claiming "wonderful bowels."

This picture in our minds that good health and good bowel function are closely associated is based largely on facts reflecting age, activities and physical abilities and probably not even the space age will greatly re-shape this idea.

Diseases of the rectum and anus have always been vexing prob­lems, often producing great pain and always demanding great sympathy. When Louis XIV had his rectal operation in 1686, his many attendants were ordered to wear bottom bandages out of sympathetic respect.

Happily, treatment of rectal diseases today is held in great esteem everywhere.

Finally, the social aspect of bowel function has a great impact on modern living. Universal demand has brought about the sci­entific advances of modern plumbing, privation and sanitation, as we now know them, and the lack of these advances more than anything else would make our urban world of today nearly impossible.

To view the anus directly, uncover the anal region and assume a squatting position eight to ten inches above a mirror lying on the floor. This will give a clear view of the anal region,

Fig. 120. The anal region normally reveals only the small, indented, puckered anus in its closed position. It is impossible to voluntarily open the rectum, but it can be stretched open by oncoming bowel matter or instruments introduced from outside.

The normal anus is a small, puckered and indented opening. It remains closed because the anus cannot open itself except by having something forced through it. Straining will make the anus stand out slightly and appear a little larger than usual. Its color and hair distribution follow individual body character­istics.

1. Examine  the  skin  surface  of the anal opening without straining.  Observe  any large  skin  folds,  any distended veins, or any sore irritated appearing spots. Observe also the existence of any generalized irritation of the entire anal region. These findings may be indications of disease as external hemorrhoids, mere skin flaps, or anal itching, tech nically known as pruritis.
2. Note the contour of the anus and surrounding skin when straining. Observe any mass protruding from the anus, any pus or blood from the anal opening, or from a pimple-like opening near the anal opening. These findings may indicate internal hemorrhoids of fistula formation.
3. Observe the skin forming the anus itself. Examine upon straining for any raw, split appearance in the folds of anal skin. Such a skin crack is possibly a fissure.
4. Note the texture of the skin of the anus and its surround­ings. Look closely for any whitened, thickened, water-soaked appearing skin of the anus and surrounding skin. Also look to see if there is any clear, water-like discharge

Fig. 121. The normal anus is a sphincter-type closure for the tube-shaped rectum. There are two sphincters for the anus: one is controlled automatically and the other is voluntary and controlled by the will.

about the anus and surrounding skin. These findings may accompany internal hemorrhoids, drug allergies or chronic irritation.

1. With one finger, gently press upon the skin surrounding the anus. Make note of any enlarged, reddened or boil-like sore surrounding the anus. Such a finding in this region is possibly an abscess or fistula.
2. Examine the skin in the fold between the buttocks. Look for any dimple-like indention of the skin two inches back of the anus, possibly discharging pus. This is probably a pilonidal cyst.

Diseases of the Anal Region

The anal region does not long suffer in silence, and its many difficulties are soon called to our attention by pain, often of severe degree. Most of us know very little about the anal region, and the idea of hemorrhoids, fistula or fissure, brings to mind only a vague picture.

Piles. This term signifies rectal disease to most people and usually means any kind of protrusion about the anus, the most

Fig. 122. Hemorrhoids are only enlarged blood vessels. Inside the rec­tum, they are called internal and are painless. On the outside, they are called external and may be very painful.

common of which is the skin tab. It is usually only an extra fold of skin about the anus which no longer contracts to a smooth skin surface after it is stretched. It means only that this individ­ual has seen younger years.

Hemorrhoids. Hemorrhoids, sometimes called piles, are only enlarged blood vessels about the anus. They are varicose veins of the rectum, exactly like varicose veins of the legs, but since they are usually painless, many people who have hemorrhoids do not know it. When the enlarged vein is on the outside of the anus, it

is an external hemorrhoid, and when it appears as a mass coming out through the anal opening, it is called an internal hemor­rhoid.

Through the years there have been many reasons stated as the cause of hemorrhoids. Some of these reasons have real merit and some do not. They are:

1. The erect position. Standing erect, unlike animals, probably helps hemorrhoids to occur, but then not all upright people have hemorrhoids.
2. Straining, as in constipation or pregnancy. This possibly enlarges hemorrhoids  already  present,  but hemorrhoids are not present in all constipated people, or in all women who have borne children.
3. Inheritance. A tendency toward hemorrhoid may be definitely inherited; however, not all cases of hemorrhoids can be blamed on our ancestors.

Also often heard are many completely unfounded ideas about the cause of hemorrhoids. They include sitting on cold ground, eating certain foods, and even bow-legs. These notions are not based on genuine fact, and cannot be given serious con­sideration.

The most reasonable cause of hemorrhoids is infection about the anus. Infection often weakens the wall of the vein and allows them to stretch and form the widely dilated veins which we call hemorrhoids.

Most people know when something is wrong about their anal region, but not what is wrong. A suspicion may exist for years that the protrusion from the anus during bowel movements is hemorrhoidal trouble but, frequently these protrusions are just pushed back into the rectum. This may go on until painful itching, bleeding or other symptoms become annoying enough to drive the person to his physician, where the difficulty becomes diagnosed exactly.

Rectal bleeding most often means hemorrhoids and is usually seen on the toilet paper or in the bowel waste. But, because it may have other meanings such as cancer, rectal bleeding makes necessary an examination by the physician to be sure it is not serious disease.

Pain in the anal region is caused by just about all rectal dis­eases but when due to hemorrhoids, is confined to an enlarged and painful lump at the anal outlet and the pain is usually in proportion to the amount of swelling about the involved hemorrhoid.

Fig. 123. Hemorrhoid protrusion is a mass of enlarged varicose veins internal to the anus, which is temporarily pushed through the anal sphincter when straining at bowel movement. Usually painless, internal hemorrhoids can be pushed back into the rectum.

Protrusions from the anus noted in straining during bowel movements are often long endured, because when no pain or bleeding is present, the protrusion is easily tolerated and de­mands no immediate treatment, even though it usually means that internal hemorrhoids of a fairly marked degree are present. When a protrusion appears, it is almost inevitable that the more troublesome difficulties of hemorrhoidal pain and bleeding will soon follow.

The care of hemorrhoids is quite variable. Mild hemorrhoids seen in the mirror may cause no trouble at all, but severe pain­ful hemorrhoids, possibly accompanied by itching and bleeding, may demand immediate care. Pain relief, from painful hemor­rhoids, may be obtained with ice packs for the first day, and warm water soak baths afterwards for a period of about ten days. These painful attacks might occur during pregnancy, or at other times but regardless of when this inhuman disease occurs, most of us are forced to seek relief and let the world go by until we succeed.

The treatment of hemorrhoidal disease has gone through long evolution. Injection treatment, now rarely used, is often tempo­rarily successful but is accompanied by many complications. However, it is still preferable in bedridden patients who cannot possibly stand even the mild rigors of the operating table, usu­ally because of debilitating disease.

Surgical treatment of hemorrhoids is very successful. In the past, surgery too, was often followed by complications and recur­rences but now it is a very effective operation, if done by a sur­geon of experience and training in this field. Unfortunately, the field of hemorrhoidal disease has for many years been filled to over-flowing with healers who have less than the best of training, and who give less than the best of treatment for rectal diseases.

Again, the qualified family physician has no equal in the ability to give his patients the best advice and treatment for hemorrhoidal as well as other types of diseases.

Anal Fissure. An anal fissure, or fissure-in-ano, is a crack in the skin of the anal wall similar to a crack in the corner of the mouth. The fissure is actually draining pus, like the top of a boil, from underlying infected tissues, in the wall of the rectum itself.

The difficulties from fissures include abscess formation, and continual drainage, but from the standpoint of the man who owns one, a fissure's most important feature is pain. Characteris­tic fissure pain accompanies and follows the bowel movement. While the smaller fissure might cause only a slight fleeting pain, a larger fissure often feels like a bowel movement of fire itself, which often continues after the bowel movement as an aching pain about the anus.

Bleeding often accompanies a fissure, but in small amounts and only on the toilet tissue. It may worry the fissure patient but more often it is the great pain which sends him to his doctor.

Constipation with a fissure is common. People soon discover that pain is brought on by bowel movement and to prevent pain they unconsciously delay the next movement. This, of course,

EXTERNAL OPENING

Fig. 124. External fistula, resulting from abscess formation, is actually another outlet of the rectum, in addition to the anus.

brings about a harder, larger stool which is even more painful as it passes through the painfully-fissured anal outlet.

The basic care for anal fissure, as well as all anal diseases, be­gins with proper cleansing about the anus. Soap and water cleansing are probably more indicated and less used in the anal region than anywhere else on the body. Severe fissures need definite medical care by a doctor qualified to treat anal diseases. The most accepted of these treatments is a surgical procedure which completely removes the fissure along with the infected tissue above it. These are very successful operations and very gratifying to the anal fissure sufferer.

Abscess and Fistula. Anal abscess and fistula can be described together because of their relationship. One creates the other. Abscess about the rectum is simply a boil-like process at the outlet of the anus, and its drainage tract from the inside of the rectum, out through the skin about the anal opening, is called a fistula.

An anal abscess produces an intense throbbing pain about the supersensitive anus region. This pain is not related to bowel movement, but becomes intense under any pressure, as in sit­ting. The abscess is caused by fecal material infecting the wall of the rectum and it looks much like a boil. It is reddened, swollen and hardened beside the anal opening, and may grow so large, the anus appears crowded off to one side.

Fig. 125. Fistula formation begins with infection perforating the rectal wall. This brings about abscess or boil formation, which in turn heads and ruptures through the outer skin at a distance from the anal opening. Instead of healing, the entire tract thus established continues to act like another anal outlet.

Relief from the intense pain of an anal abscess is eagerly sought because the sufferer is usually disabled for any other activity. There is temporary relief with sitting in warm water, but permanent relief is obtained only by drainage of the abscess. This is effected either by the abscess heading and draining it­self, or through an incision and drainage operation.

Anal fistula, we have seen, results from an abscess about the anus. After drainage, the abscess collapses into a string-like channel. If fecal material continues to reinfect this small chan­nel, there is continual formation of pus to drain out through the skin. Thus is a fistula born.

FISTULA

Fig. 126. An external fistula appears as a small pimple constantly draining in the anal region. It usually forms following an abscess which has drained. An anal fissure is an infected crack in the skin, similar to a crack in the mouth.

A fistula looks like a small red pimple in the skin close to the anus and usually does not produce much pain. Most of the sore­ness present is due to soreness from the continual irritating drainage on the surrounding skin. If the anal fistula heals over on the outside, the oncoming pus forms another abscess which soon penetrates the skin once more to restablish the fistula.

While localized heat applications are of temporary value in reducing irritations, they can do very little in the way of perma­nent results. This disease must be surgically treated in a special manner to prevent its recurrence.

Anal-Rectal Pain

Nearly all rectal difficulties are described by those who suffer from them in terms of pain, bleeding, or protrusion from the anal opening. Uppermost in mind, however, is the continual fear that such difficulty may be, or may become a cancer.

Each rectal disease has a characteristic pain pattern which helps to identify the disease present.

Anal pain of great intensity which starts suddenly and remains constant; which is painful to touch, but not made worse by bowel movement, is probably hemorrhoid pain. This sharp pain is caused by a blood clot forming within an external hemorrhoid. It remains intense from about a week or ten days, but happily goes away completely with little or no treatment.

Severe pain to one side of the anus, which is constant, intense, and attended by a throbbing, hardened enlargement under the skin, resembles pain of an anal abscess. It does not begin sud­denly, but arises over a day or two and grows to intense propor­tions. An anal abscess is very painful and disabling, and can be relieved only through drainage of the abscess, either spontaneous or induced by a small incision.

The pain of fistula, which frequently follows an abscess, is usually not severe. There is a more or less constant drainage of pus, and sometimes food from a small opening which was the drainage site of the original abscess. Fistula pain actually con­stitutes more of a soreness than a real pain. It can be very irrita­ting and annoying, but it is not disabling.

Pain about the anus, possibly severe, but present only during and following bowel movement, is the typical pain of an anal fissure. Looking like a crack in the side of the anal opening, a fissure becomes spread out as the anus expands for bowel pas­sage. The fecal material touches the open fistula and creates pain which may be slight or as intense as the cutting of a knife. It usually subsides after the bowel passage, but may linger as an aching pain for a short time afterwards.

Itching pain in a sore macerated skin area about the anus is probably caused by internal hemorrhoids which by themselves are painless. They hang like grapes on the inside of the rectum and their engorged condition causes them to secrete a sticky mucous material, which works out through the anal opening to continually bathe the anal skin. This secretion produces a macer­ated, itching and excessively sore anus. The hanging grape-like hemorrhoids inside the rectum, may also protrude from the anus on straining with the bowel movement.

The pains therefore, of anal diseases are recognizable. The sudden but temporary pain of external hemorrhoids; the in­tense boil-like pain of anal abscess; the continual skin irritation in the visible presence of a fistula; the severe pain at bowel movement time with a fissure; and the continually sticky macerated and irritated anus of internal hemorrhoids, sometimes with protrusion, do not speak for the pain of cancer in the anal-rectal region. Cancer is a disease which has no characteristic pain, but produces most often an uncomfortable ache, and possibly the sensation that the rectum is continually filled. Can­cer of the rectum is almost never accompanied by sharp or severe pain in the anal region.

It is well to know that the anal-rectal region may have two or more diseases. Even though the pain present might indicate a non-serious type of anal disease, a secondary disease such as cancer could be present only inches away. For this reason, when­ever anal or rectal diseases are present severe enough to cause bleeding, pain, protrusion, or continuous itching, it is well to have the entire rectum examined.

The Bowel Movement

Bowel waste matter, called the stool, tells an enlightening story of body function. It tells us through its color, form and other characteristics of possible serious disease, and often is the only abnormality present to herald approaching trouble.

We recognize various meanings of the bowel movement, based on simple body functions which influence the bowel waste. The average normal bowel movement, which may occur about once a day, is semi-soft, banana shaped and about walnut brown in color. It sinks in water, is usually slow to dissolve, and its odor which is always disagreeable, can during disease, be especially obnoxious.

What can be learned from the abnormal bowel movement? The frequency of the bowel movement varies from once or twice a day to a movement every two or three days. It is not necessary to have a movement every day to maintain good health, for as we grow older, lessened activities tend to slow down bowel action. Constipation however, of a stubborn nature, may mean an obstructing growth in the colon and it should be carefully observed until normalcy returns, or the physician has been visited.

The solidity of the bowel movement may be similar to thin mud in diarrhea, frequently seen with food poisoning, flu, or colitis in the bowels. A much hardened stool, approaching the intestinal consistency of wood, usually accompanies constipation so common with inactivity, and frequently seen in bedridden or debilitated people.

The shape of the bowel movement, normally approaching a banana form may become a thin pencil shaped stool, when any constriction of the colon outlet is present. This may mean a growth in the colon, or more probably an irritated anal sphinc­ter, possibly due to a fissure, abscess or other anal disease. With diarrhea of course, the bowel movement may become very slim, because only after a period of collecting and packing can the stool assume its usual thickened form.

The color of the bowel movement can assume many shades. A stool which has become nearly white or gray indicates a complete lack of bile coming from the liver—from which the normal stool color comes. In this event, jaundice, a yellow tint to the skin will probably soon be noticed to indicate serious disease in the liver region.

A black stool means that iron in the intestinal tract has been in contact with stomach acids and the most common reason for an inky black stool is the ingestion of iron in vitamins, tonics or other iron compounds. But if none of these medications have been taken, and the stool is still pitch black, its probable cause is bleeding in the stomach or intestinal tract. Blood hemoglobin also turns black after contact with stomach acids, and about three ounces of blood in the intestinal tract will supply enough iron to turn the entire stool black. With less than this amount, only a partly black stool is the result.

Red blood in the stool means bleeding from the lower intes­tine or colon. When the blood is mixed with the bowel matter, it is probably coming from a bleeding area within the upper colon, such as a growth or ulceration. When the blood appears only on the outside of the bowel movement as a thin covering, the most likely source of the bleeding is from the anal outlet, from such difficulties as hemorrhoids or fissure.

Occasionally, a stool will be found to float near the top of the water. This means that it contains more than the normal fat content in the stools, and is possibly due to an occasional meal containing too much fat which has rushed through the intestinal tract. Repeated stools that float, however, may mean a deficiency of digestive juices which should have digested the fat. This deficiency would point to the pancreas, whose faulty function is not supplying enough digestive juices.

Finally, the odor of the stools must be reckoned with. Odor of the stool is derived from the chemicals skatol and hydrogen sulfide. The psychology of the nose allows us a daily personal contact with our own bowel movement, without noticing its disagreeable odor. In disease however, when odors are arising from other than the usual bowel element, these intensified odors of the bowel movement may become immediately noted.

For each person, there develops over the years individual characteristics concerning the bowel movement and the stool itself. This is called the bowel habit, which, when noticeably and suddenly changed, especially in the over fifty age group, becomes medically significant. Daily observation of the bowel movement, can warn us very often when intestinal tract diseases are in their infancy, and will be of great value to the physician seeking information concerning the intestinal tract and the rest of the body as well.

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