Resources

Common Procedural Questions

  • Prevention
  • Restoration
  • Rejuvenation

For answers to clerical questions, please go to our FAQ page

Prevention

  • Anal Care

    • Douching

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    • Lubricant

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    • Dilating

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    • Positions

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Restoration

  • Anal Fissure

    • What is an anal fissure?

      An anal fissure is a small tear in the lining of the anal canal.  This tear, which may develop from passing hard stools and/or anal intercourse, may be associated with pain, discharge, bleeding, or the development of a localized skin tag.  Acute fissures can heal without surgery and with an appropriate bowel regimen, as well as with the use of topical creams.  However, most anal fissures that become chronic will require surgical intervention.

    • What are the symptoms of an anal fissure?

      Symptoms vary from bleeding, discharge, pain, and/or the development of a localized skin tag.  Since the tear is overlying exposed muscle, you may also develop sphincter spasms.

    • How are anal fissures diagnosed?

      Most anal fissures can be diagnosed by visual inspection.  While anoscopy is the preferred method because it allows for a thorough evaluation of the diagnosis and its associated pathology, due to pain this exam may be deferred until it has had sufficient time to heal.

    • What is the treatment for an anal fissure?

      Non-Surgical Treatment

      The appropriate initial regimen to treat an anal fissure consists of:

      • Over-the-counter stool softeners, such as Colace, three times daily
      • Over-the-counter fiber supplements, such as Metamucil
      • Calmol 4 suppositories twice a day, found at small local pharmacies such as C.O. Bigelow or New London Pharmacy
      • Sitz baths, utilizing over-the-counter epsom salts
      • A small pea-size drop of Lidocaine 2%/Anusol 2.5%/Cardizem 2% topical anal ointment should be gently applied by fingertip to the anal opening before bed, in the morning, and after each bowel movement.  This compound can be obtained solely by prescription at CO Bigelow.
      • Boosting your fiber intake with choices such as grains and whole-grain products, fruits, vegetables, legumes, nuts, and seeds
      • Increasing your overall water intake to 8-12 ten ounce glasses per day
      • Refraining from caffeinated beverages, as they tend to cause dehydration
      • Keeping the anal area clean and dry.  Wash gently with warm soapy water, and pat dry.
      • Limiting the use of toilet paper, as wiping causes local inflammation.  Please refrain from using baby wipes or medicated pads for prolonged periods.

      Anal pathology takes time to heal.  You can imagine that every time it is attempting to improve, another local trauma/bowel movement occurs.  Do not try to avoid having bowel movements, and try not to get frustrated as you work on the above regimen.

      Surgical Treatment

      The most commonly used surgery is a fissurectomy, in which the chronic scar tissue and skin tag is completely excised.  This allows for new healthy tissue to form, while using the above medical management.  A lateral internal sphincterotomy is not advised in clients who engage in anal intercourse, as this procedure can cause future complications in anal intercourse, as well as incontinence.

  • Anal Fistula/Abscess

    • What is an anal fistula?

      An anal fistula is an infected tunnel that develops between the muscular gland opening at the end of the anal canal and the skin near the anus.  Most anal fistulas are the result of an infection in an anal gland that initially presented as an abscess and subsequently spread to the skin.

    • What are the symptoms of an anal fistula?

      Anal abscesses are generally associated with a throbbing pain that worsens when sitting.  Discharge of pus or blood, constipation or pain with defecation, or anal skin irritation may also be present.  An anal fistula is associated mostly with discharge and mild localized skin irritation.

    • How are anal fistulas diagnosed?

      Most anal abscesses/fistulas can be diagnosed by visual inspection.  An anoscopy is usually deferred during the abscess period due to significant pain in region and drainage being required.  Once a fistula develops, a full anoscopy may be performed in order to localize the internal connection and/or make sure no other pathology is associated.

    • What is the treatment for an anal fistula?

      Non-Surgical Treatment

      The appropriate initial regimen to treat an anal abscess/fistula consists of:

      • Over-the-counter stool softeners, such as Colace, three times daily
      • Over-the-counter fiber supplements, such as Metamucil
      • Sitz baths, utilizing over-the-counter epsom salts
      • Boosting your fiber intake with choices such as grains and whole-grain products, fruits, vegetables, legumes, nuts, and seeds
      • Increasing your overall water intake to 8-12 ten ounce glasses per day
      • Refraining from caffeinated beverages, as they tend to cause dehydration
      • Keeping the anal area clean and dry.  Wash gently with warm soapy water, and pat dry.
      • Limiting the use of toilet paper, as wiping causes local inflammation.  Please refrain from using baby wipes or medicated pads for prolonged periods.
      • Antibiotics for most anal abscesses, and sometimes for fistulas due to local inflammation

      Anal pathology takes time to heal.  You can imagine that every time it is attempting to improve, another local trauma/bowel movement occurs.  Do not try to avoid having bowel movements, and try not to get frustrated as you work on the above regimen.

      Surgical Treatment

      Most anal abscesses require in-office drainage.  Sometimes this may require monitored anesthesia care in an ambulatory setting.  Generally speaking anal fistulas must be treated surgically, and are characterized as either simple or complex.  The vast majority of simple fistulas are treated with a fistulotomy, which involves cutting open the fistula in order for the tract to close.  For complex fistulas, a technique commonly practiced involves ligation of the internal fistula tract (LIFT procedure) and removal of the remaining tract.  If an abscess and tract is still present during the initial operative evaluation, a seton drain may be placed to allow maturation of this tract, followed by the LIFT procedure mentioned above.

  • Hemorrhoids

    • What is a hemorrhoid?

      Hemorrhoids result from increased pressure in the veins of the anus causing them to bulge and expand, leading to significant pain, swelling, and bleeding. The most common cause is constipation and straining during bowel movements, sitting for prolonged periods of time, and/or anal intercourse.  Two different types of hemorrhoids can occur: external or internal.  More than 90% heal without surgery, and you will be given an appropriate bowel regimen and topical creams to provide relief as they heal.  However, hemorrhoids that become chronic may require surgical treatment.

    • What are the symptoms of hemorrhoids?

      While both external and internal hemorrhoids may cause bleeding, localized swelling, and thrombosis, the key difference between the two is that external hemorrhoids generally cause pain while internal do not.  Sometimes external thrombosed hemorrhoids develop skin tags in the region due to the overlying skin being stretched.

    • How are hemorrhoids diagnosed?

      Most external hemorrhoids can be diagnosed via clinical inspection, while internal hemorrhoids are examined by anoscopy.

    • What is the treatment for hemorrhoids?

      Non-Surgical Treatment

      The appropriate initial regimen to treat hemorrhoids consists of:

      • Over-the-counter stool softeners, such as Colace, three times daily
      • Over-the-counter fiber supplements, such as Metamucil
      • Sitz baths, utilizing over-the-counter epsom salts
      • Proctozone 2.5%, a prescription topical anal ointment, should be applied as directed by your physician.
      • Boosting your fiber intake with choices such as grains and whole-grain products, fruits, vegetables, legumes, nuts, and seeds
      • Increasing your overall water intake to 8-12 ten ounce glasses per day
      • Keeping the anal area clean and dry.  Wash gently with warm soapy water, and pat dry.
      • Limiting the use of toilet paper, as wiping causes local inflammation.  Please refrain from using baby wipes or medicated pads for prolonged periods, and do not spend more time sitting on the toilet than necessary.

      Anal pathology takes time to heal.  You can imagine that every time it is attempting to improve, another local trauma/bowel movement occurs.  Do not try to avoid having bowel movements, and try not to get frustrated as you work on the above regimen.  We will see you in 2-3 weeks from initial diagnosis to see what improvement has occurred.  Surgery is the last option in our management.

      Surgical Treatment

      Hemorrhoid treatments are very effective, but unless dietary and lifestyle changes are made, they may recur.  If symptoms persist or are severe, one of the following treatment options may be required:

      Cauterization. Using either an electric probe, a laser beam, or an infrared light, a burn seals the end of the hemorrhoid, causing it to close off and shrink.

      Banding. Prolapsed internal hemorrhoids are often removed using rubber-band ligation in the office.  A special instrument secures a tiny rubber band around the hemorrhoid shutting off its blood supply, causing it to fall off within a week.  Banding is not an option for large internal hemorrhoids.

      Surgery. For large internal hemorrhoids, uncomfortable external hemorrhoids, mild thrombosed hemorrhoids, or mild hemorrhoids with large remaining skin tags, a hemorroidectomy is warranted.

  • HPV/Genital Warts

    • What is HPV?

      Human papillomavirus (HPV) is the most common sexually transmitted infection.  The virus enters the body through a cut, abrasion, or small tear in the outer layer of your skin, and is transferred primarily by sexual intercourse and skin-to-skin contact.  It can easily be transferred to others even if you are asymptomatic, although treatment and monitoring may help.  It is the cause of nearly all anal cancers and their precursors HGSIL and LGSIL, however only a fraction of anal HPV infections develop into cancer.
       
    • What are the symptoms of HPV?

      Symptoms may include warts on the anus, genitals, surrounding skin, and/or face.  The warts may cause itching, bleeding, discharge, mucus production, lumps, pain, and/or constipation.  Although many people with HPV do not develop symptoms, one can still infect others through sexual contact and/or develop anal dysplasia.  For this reason, it is imperative to get tested annually and monitor accordingly.

    • How is HPV diagnosed?

      Human Papilloma Virus is diagnosed via cytological testing (HPV sub-typing and anal pap smear), along with an exam known as an HRA (High Resolution Anoscopy).  A plastic instrument called an anoscope is used to look at the anal canal with a special microscope called a colposcope.

      The anal pap smear examines cells that constitute the outer layer of anal tissue, known as squamous cells, and determines the level of infection that you may have.  Positive pap smears are classified into 3 diagnostic categories: ASCUS, LGSIL, and HGSIL.

      ASCUS. Atypical Squamous Cells of Unknown Significance is a diagnosis in which cells were found that were not normal, but also not identifiable.  This can be caused by dysplasia, but it can also be caused by inflammation or other factors like hemorrhoids and fissures.

      LGSIL. Low Grade Squamous Intraepithilial Lesion, also known as mild dysplasia, is a diagnosis that can present with warts or lesions.  It is not considered pre-cancerous, but can turn into HGSIL over time.

      HGSIL. High Grade Squamous Intraepithilial Lesion is a diagnosis in which there is precancerous change to the skin of the anal canal or perianal area.  This is not cancer, and only a small fraction of these diagnoses progress into cancer.

      The HRA is the best technique for detecting precancerous lesions, anal cancer, and dysplasia (a pre-cancerous condition which occurs when the lining of the anal canal undergoes abnormal changes).  If an abnormal area is seen, then a very small piece of anal tissue may be biopsied to check for signs of cancer or dysplasia.  Biopsies positive for dysplasia are classified into Anal Intraepithelial Neoplasia (AIN) levels 1-3, with AIN3 considered carcinoma in-situ.

      Utilizing a combination of cytological testing, HRA, and/or biopsy results allows for risk stratification and the development of a comprehensive treatment algorithm.

    • What is the treatment for HPV/genital warts?

      While there is no cure for HPV, the infection may clear on its own.  If it does not, and treatment is needed, there are many options.  Treatment focuses on wart removal and anal cancer prevention.  Warts can be approached with topical creams, acids, infrared coagulation, and/or electrocautery.  The best course of action is dependent on the extent and location of the disease.  Clients that present with only mild to moderate external disease may be given topical therapy such as Aldara for 8-16 weeks; if persisting or extensive disease is present, then an operation is warranted for eradication.  If internal disease is present, it is generally treated by cauterization in an operating room under anesthetic sedation for maximized comfort.  Recurrence rates can be as high as 30%, and since most recurrences are external we will prescribe topical treatment once surgery has healed.

      Clients that show a positive anal pap smear result of either ASCUS or LGSIL without wart disease are usually monitored with follow-up retesting within 3-6 months after the initial consultation.  If the result continues to remain abnormal, a complete HRA with mapping (a technique in which multiple pieces of tissue are biopsied in a clockwise fashion in order to pinpoint exactly where disease is present) is performed to look for any precancerous changes.  Clients that have an HGSIL diagnosis or lesions present must be mapped and treated surgically.

      Once mapping has been completed and the biopsies evaluated, treatment can be tailored to the region of disease.  AIN 1 can be seen in HPV/warts, fissures, hemorrhoids, and other localized inflammatory issues.  Most AIN 1 reverts to normal on its own, and should be continually monitored to check for signs of progression.  AIN 2-3 is considered dysplastic and requires the use of cautery for eradication.  Since this disease is contained to the superficial layer of the skin/mucosa, removal allows for new healthy cells to form.

      After your initial diagnosis and/or treatment, we will continue to monitor the anal canal to check for signs of disease regression or progression.  Our standard monitoring schedule begins with a follow-up visit after 1 month, followed by subsequent appointments 3, 6, & 12 months later.  From then on, you will continue to be seen annually.

      In terms of prevention, there is a vaccine called Gardasil that protects against the HPV strains that are most likely to cause genital warts and cancer, and is recommended for all patients under the age of 26.  If you are 26 or over and HPV-negative for one or more of the strains that Gardasil protects against, it may be useful to receive the vaccine.  For recurrent wart disease that has been difficult to control with treatment, obtaining the vaccine may prove beneficial due to it’s immune-boosting capabilities.

  • Skin Tags

    • What is an anal skin tag?

      Skin tags are extra-folds of anal tissue.  They may develop from the stretched overlying skin of a thrombosed external hemorrhoid or the way in which the tissue in an anal fissure fails to heal properly.

    • What are the symptoms of an anal skin tag?

      Anal skin tags can cause localized irritation, discomfort, itching, and can be considered aesthetically unpleasant.  They may cause hygiene problems, and also interfere with anal intercourse.

    • How are anal skin tags diagnosed?

      Anal skin tags are diagnosed through visual inspection.  An anosocopy is performed as well to ensure there are no other associated issues, specifically a connection to hemorrhoids that may change the surgical approach.

    • What is the treatment for anal skin tags?

      Non-Surgical Treatment

      Some skin tags may resolve on their own over time, while utilizing sitz baths and Proctozone 2.5%, a prescription topical ointment.  In most cases, however, a surgical approach is required.

      Surgical Treatment

      Skin tags are either removed via laser/electrocautery or surgical excision, with thought given to both functional and cosmetic goals.

Rejuvenation

  • Definition

    • What is Anal Rejuvenation?

      Anal rejuvenation focuses on bringing aesthetic pleasure and/or heightened functionality after the initial surgical concern has been treated and healed.