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Problems of the perineum i.e. the anal canal and the area surrounding it are very common. Especially so in women following childbearing. However patients often fail to seek medical help feeling shy and embarrassed to discuss the topic. Perianal conditions are universally clumped as piles or haemorrhoids by the general population and relief is sought through hearsay and not to forget the internet in today’s net savvy culture.
In this post, instead of talking about different diseases affecting the perianal region, I’m addressing one of the common symptoms patients suffer from - Pain, what this symptom may imply and when to seek medical attention.
Painful defecation: pain may occur during passage of stools, lasting for a few minutes to hours. Sharp knife like pain occurring with defecation indicates some injury at the anal outlet. This condition is known asanal fissure. It’s a skin cut at the anal opening which extends inside the anal canal. The skin cut (anal fissure) at the anal opening is excruciatingly painful and causes the muscle to go into a spasm. Straining against this spasm to pass stools causes repeated injury at the skin cut and a vicious cycle ensues.
Treatment: The only way to ensure healing of the cut is to relieve the pain and thus break the vicious cycle of pain - trauma - pain. This can be done by warm water soaks in a tub called Sitz baths and local ointments which your doctor will prescribe. In addition taking laxatives ensures smooth evacuation of stools without straining, thus minimising injury to the cut while defecating. You may be prescribed painkillers for a few days to tide over the acute phase. The most important advice however is to follow vital lifestyle modifications to ensure healthy bowel habits and prevent another episode of trauma from happening in the future. These are adequate hydration, avoiding spicy foods (red and green chillies), a high fibre diet and moderate physical activity. The treatment needs to be followed for the duration advised by your doctor. Stopping it early may result in a relapse which may then not respond to medication. If there is no improvement despite adequate advice being followed, the alternative is a surgical procedure known as lateral sphincterotomy. It’s a short procedure to relieve the muscle spasm but cutting the muscle, allowing the fissure to heal.
Perianal pain with local swelling: This occurs due to bleeding under the perianal skin or an infection of a perianal gland. The bleeding is actually inside a pile mass under the skin and leads to swelling and clotting of the blood forming a markedly painful lump at the site. The condition is medically called athrombosed pile. Pain of a thrombosed pile starts suddenly, is severe and continues throughout the day. It is usually self-resolving, but rarely may require surgical intervention.
The second common condition associated with this type of pain is an infection. The pain increases in intensity over a few days as the infection worsens. This infection maybe of a gland in the perianal skin or more commonly a gland inside the anal canal. The infection rapidly progresses to formation of pus which is medically termed perianal abscess. The severity of a perianal abscess ranges from a small painful lump which bursts and discharges pus, to a condition where the pus may spread to the entire perineum and may become a life threatening infection. This condition requires surgical drainage for relief.
Treatment: Thrombosed piles - Supportive care for pain relief in the form cold compresses and local gels along with oral painkillers is all that is needed. Laxatives to avoid straining during defecation also help. In case the pain is unbearable, a short surgical procedure to evacuate the clotted blood helps in providing immediate relief. It may be possible to take care of the underlying haemorrhoid problem at the same time if conditions permit. It is advisable to get the surgery for haemorrhoids done once the thrombosed pile resolves.
Perianal abscess - Treatment is primarily surgical and immediate medical help should be sought. The pus needs drainage and is followed by a period of wound healing where daily dressings are needed. The condition is often followed by formation of an anal fistula (Will discuss this in another blog).
Perianal pain - Other causes: These are not as common as the causes discussed above and include painful arthritis of the tail bone medical term - coccidodynia. The condition is diagnosed on medical examination by a doctor. The pain is worsened on sitting and relieved on standing and lying down. Spasm of a major muscle of the perianal region known as the levator ani also causes a similar pain. The pain can be so severe that it wakes you from sleep at night. Levator ani syndrome (LAS) is diagnosed after excluding other causes of perianal pain. Gynecological conditions like endometriosis, tumors of the rectum, spine and pelvis are some of the other conditions where rectal pain maybe one of the complaints. The pain in such conditions is chronic and increases over several weeks to months. If you are having similar pain then you must seek medical advice.
Treatment: for coccidodynia and LAS comprises primarily hot fomentation, painkillers, Sitz bath and physiotherapy. The conditions are chronic and may wax and wane over time and will require supportive treatment whenever there is worsening of symptoms.
Note: Common conditions causing pain in the perianal period can be relieved quickly and effectively if diagnosed and treated on time. Pain increasing gradually over a prolonged period of time should not be ignored. So do not self-medicate and delay treatment. Specialists for treating these conditions are available in all hospitals.