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An anal fistula is an abnormal tunnel running from the outside skin in the anal area, through the anal muscles, and opening onto the inside lining of the anus. Although rare, anal fistulas are often encountered in a colorectal clinic. Overall, one person in 10,000 will develop an anal fistula. Those affected tend to be aged 20–40 years, with men developing the condition twice as often as women.

A third of people develop a fistula after having had an anorectal abscess. This may be immediately after the abscess has healed or been treated surgically, or it may appear many years after the abscess has healed. The cause of both these conditions is infection of an anal gland. The anal glands sit in between the two circular sets of anal sphincter muscles and their secretions are released into ducts that cross the internal anal muscle and open into the anus. When an anal gland becomes infected, an abscess can form in between these two sets of anal sphincter muscles. Eventually, the abscess discharges pus, and if it discharges in two directions (through the skin and through the anus), a fistula will form. The anal gland infection does not heal, so the abscess can recur.

Anal fistulas can also be caused by Crohn’s disease and more serious conditions such as cancer.

An anal fistula can cause recurring pain and is often associated with a discharge.

The discharge can lead to itching around the anal area, and some patients also develop recurring infections around the anus, as happens with an anorectal abscess.

Diagnosis

The diagnosis is usually made in the outpatient department when the surgeon sees an opening onto the skin around the anus. Often there is redness around the area, and sometimes if pressed, a discharge can be induced. It may also be possible for the surgeon to find the internal opening. This examination should not be painful, but may cause some minor discomfort. If it is painful, an examination under general anaesthesia can be performed.

A magnetic resonance imaging (MRI) scan of the area can be very useful, especially for a complex fistula, but sometimes the diagnosis can only be made by examination under anaesthesia in the operating theatre.

Surgical treatment

Sometimes the fistula is so minor that both the patient and surgeon are content to leave it alone. However, for patients who are having ongoing problems with their fistula, surgery is the only option. A fistula may be treated surgically in one of several ways according to its complexity.

• Fistulotomy, which opens the length of the fistula to the skin surface, allowing the open wound to heal slowly. Fortunately, 19 in 20 people have a so-called “low” fistula, ie, one located at the bottom of the anus and involving very little muscle, so when the fistula is laid open, the loss of muscle is so minor that there are no problems with continence. Fistulotomy is frequently performed for a low fistula and has a good long-term cure rate.
• One in 20 people have a so-called “high” fistula, where there is so much muscle involved in the fistula that there would be a high risk of incontinence if this was to be laid open. When this is found during surgery, the first choice is Seton placement. A Seton is a suture (stitch) that is introduced into the fistula and runs along its entire length, allowing it to drain from the inside out. Many patients are happy to live with the stitch permanently if their symptoms are minor. However, if the stitch causes significant issues or symptoms persist, further therapy can be considered. Merely leaving the stitch in place is beneficial for healing in some people. Some people’s bodies respond to placement of a Seton stitch by trying to push it out, and on follow-up we find that the fistula has moved from a high position to a low one that can be treated safely by fistulotomy.
• For people in whom a Seton is still troublesome or is not working its way out, we can proceed to a surgical fistula repair, the aim of which is to close the internal opening of the fistula and preserve the anal sphincter muscles. This is a more complex operation. There are several options available, but the best results are likely to be achieved by an advancement flap repair, which involves closing the internal opening of the fistula with a layer of either anal mucosa (a mucosal advancement flap) or with some anal skin (an anal advancement flap). Other options are fibrin glue injection, a fistula plug, or a LIFT procedure, which entails tying off the fistula between the sphincter muscles.

In patients who already have weak anal muscles, any treatment of an anal fistula is done very carefully and cautiously. None of the treatments available can guarantee success and all have a complication rate. Further, it is inevitable that any infection or condition affecting the anus has the potential to impact on bowel continence. Where there is a high fistula, ie, one that involves a significant amount of muscle, the surgeon and patient spend a considerable amount of time discussing the benefits of surgery versus the risk of incontinence.

Anismus, also known as pelvic floor hypertonicity, pelvic floor dyssynergia, dyssynergic defaecation, or paradoxical puborectalis contraction, is a condition in which the external anal sphincter and the puborectalis muscle, one of the core pelvic floor muscles, contract rather than relax during an attempted bowel movement. The puborectalis muscle forms a sling around the back of the lower part of the rectum and is normally tense (contracted). This muscle should be able to relax and allow the angle between the rectum and the anal canal to straighten so that stool can pass successfully. This relaxation does not happen in people with anismus.

Why some people develop anismus is not well understood. People with anismus often get a sensation of blockage or resistance to passing stool. This can be painful and lead to obstructive constipation. Other problems may include faecal impaction (hard dry stools that stay in the rectum) and megarectum (enlargement of the diameter of the rectum). People with anismus typically strain when attempting to have a bowel movement, which further irritates the pelvic floor muscles. Men and women with anismus may need to put a finger inside the anus and apply pressure to allow a bowel movement.

Anismus is diagnosed by clinical examination of the rectum and some additional tests, including anorectal physiology and proctography.

Treatment

Many patients report improvement in their symptoms with pelvic floor retraining, which helps the sphincter muscles to relax when going to the toilet. Alternatively, some patients benefit from Botulinum toxin injection into the puborectalis muscle. The first injection helps make the diagnosis. If anismus is the cause of the patient’s symptoms, a beneficial effect may be evident within the first week, but may take up to six weeks to appear. If there is no change in symptoms after six weeks, no further injection is given. If the injection helps, a repeat injection is given, and it is this second injection that gives long-term benefit, which may last for years or be permanent. If the initial Botulinum toxin injection is unsuccessful, there may be an underlying internal rectal prolapse, and an examination under anaesthesia in the operating theatre would be performed to confirm this.

An anorectal (perianal) abscess is a collection of pus near the anus, and a common reason for admission to hospital worldwide. Anorectal abscesses tend to be more common in people aged 20–30 years, but can occur at any age. They seem to affect men twice as often as women.

The anal canal is surrounded by the anal sphincter, which helps to keep people continent of faeces. The anal sphincter is made up of two sets of circular muscles and in between them are the anal glands, also known as the anal crypts. These glands produce secretions that enter the anus by crossing the inner ring of muscles.

Ninety percent of all infections in the anorectal area are due to an abscess forming in an anal gland. The remaining 10% of anorectal infections have rarer causes, such as Crohn’s disease or hidradenitis suppurativa (an inflammatory skin condition), trauma, or occasionally cancer.

Most people with an anorectal abscess complain of a pain around the anus, which can be dull or throbbing, and is particularly painful on sitting down. Other people notice a discharge or swelling in the painful area, and may develop a fever. The pain usually increases in intensity until the abscess spontaneously discharges or is treated surgically.

Diagnosis

Most abscesses can be seen directly, so are easily diagnosed by a specialist. Sometimes a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the pelvis is needed to diagnose deep-seated infections, which do not have the typical skin changes. These scans may also help in diagnosing the rarer causes of an anorectal abscess. Occasionally an examination under general anaesthesia in the operating theatre is needed to make the diagnosis, in which case the abscess is treated at the same time.

Treatment

If caught early by the GP, an anorectal abscess can be treated successfully with antibiotics alone. However, if pain and signs of infection increase, an urgent referral to a specialist is needed. Nearly all people in this situation need abscess incision and drainage. After surgery, the wound is left open to allow the pus to continue to drain. Over the next few weeks, the wound heals slowly from the inside out.

Antibiotics are rarely required for an anorectal abscess that has been drained surgically. The exceptions are when an abscess occurs in a diabetic patient or if the surrounding skin is very inflamed and infected. Antibiotics do not to help heal the wound, they merely help to tackle the infection associated with it.

Two thirds of people with an anorectal abscess will never have the problem again after surgery. However, the remaining third will go on to have further problems, which are likely to include developing a new abscess or forming a fistula, which is an abnormal connection between the inside of the anus and the outside of the skin, and also requires surgical treatment.

Cancer of the large intestine is known as colon cancer, and cancer in the rectum (the final part of the large intestine) is called rectal cancer. Cancer of the colon or rectum (together often referred to as bowel or colorectal cancer) usually starts from a small benign (non-cancerous) growth called a polyp. The cells in this polyp may then undergo changes in their genetic make-up, resulting in uncontrolled growth and spread. At this point, the growth is called cancer. In some people, bowel cancer can develop spontaneously, with no background of polyps.

Bowel cancer is the third most common cancer in the UK, with around 41,000 people diagnosed with the disease each year. The lifetime risk of developing bowel cancer is presently 1 in 16; for men the risk is 1 in 14 and for women 1 in 19.

We still do not know what causes bowel cancer, but certain factors are thought to increase the risk of developing the disease. These include alcohol, smoking, being overweight, high saturated fat intake, a history of colon cancer in close relatives, inflammatory bowel disease, presence of polyps, and age older than 60 years.

The bowel screening programme started here in 2006 and now covers the whole of mainland UK. Its purpose is to detect polyps and other changes in the colon and rectum that might develop into cancer in the future. This means that bowel cancers can be detected early on before people have any obvious symptoms. Colorectal cancer is usually very slow growing, and can be cured by surgery if detected before it has started to spread. Benign polyps can also be removed, which decreases the risk of developing bowel cancer later on.

In the early stages, people with bowel cancer may have no symptoms. However, the following may indicate colon cancer:

• Blood in the faeces
• Change in bowel habit, such as thinner stools, diarrhoea, and/or constipation
• Unintentional weight loss
• Tiredness
• Abdominal pain

These symptoms can also occur with a number of benign conditions as well, but it is always important to exclude bowel cancer as a cause. Anyone experiencing one or more of the above symptoms for more than three weeks should see their GP as soon as possible. The good news is that more than 90% of bowel cancers can now be treated successfully if diagnosed early.

Bowel cancer is diagnosed by symptoms, medical history, and certain diagnostic procedures, including colonoscopy or CT colonography. When the results of your tests are available, your diagnosis and treatment options will be explained to you. Usually it is a colorectal surgeon who makes the diagnosis, but if it is made by someone else, they will refer you to a colorectal surgeon immediately.

All patients with a diagnosis of colorectal cancer are discussed at a large multidisciplinary hospital team meeting. It may well be that the best initial treatment would be chemotherapy or radiotherapy to shrink the size of your growth before any potentially curative surgery. If this is the case, you may be referred to a medical oncologist. The type of surgery that is best for you will depend on the exact location of the cancer, its size and type, and whether it has spread. This will all be explained to you by a colorectal surgeon.

Luckily, we do not need to remove the whole large bowel if a cancer is found within it. The specific segment affected, including its blood supply, will need to be removed whether it is on the left or right side of the large bowel or in the middle (transverse colon). This procedure is known as a colectomy.

If the cancer is in the rectum (the lowest part of the large bowel), a more intensive procedure may be needed. There are two main types of surgery for rectal cancer, depending on how far the cancer is from the anus. With most rectal cancers, the anal sphincter muscles are not affected. In this case, an operation known as a low anterior resection is performed and may involve temporary diversion of the faeces (a colostomy) to enable recovery. If the patient has already weakened anal muscles, a low anterior resection would risk faecal incontinence after surgery and a colorectal surgeon may recommend a slightly different operation that leaves a patient with a permanent stoma. If the rectal cancer does involve the anal sphincter muscles, then an extra-levator abdominoperineal resection (eLAPE) of the rectum is necessary. Unfortunately, eLAPE involves removing the anus, so the patient requires a permanent colostomy.

Roughly half of all patients with a diagnosis of colon cancer can be cured by surgery alone and will never need to see an oncologist. However, if it is felt that you would benefit from a course of chemotherapy after your surgery to reduce the risk of the cancer returning, the colorectal surgeon will refer you to a medical oncologist. The networks and pathways for the treatment of all types of cancer are well developed in the UK, including in Essex, so you can be sure that you will be streamlined into the right pathway.

Anyone can become constipated at some point in their life, typically in association with a change in diet, a long period of travel, or pregnancy. In some people, constipation results from habitually ignoring the urge to have a bowel movement. In the vast majority of people, a healthy diet, plenty of fluids, and exercise is all that is needed to prevent constipation. Eating foods high in fibre, including breakfast cereals, wholegrain bread, and fresh fruit and vegetables should provide the 25–30 g of fibre needed for healthy bowel function, although population studies show that many people do not have this level of fibre intake. Drinking 6–8 glasses of water a day and getting regular exercise also help to maintain a healthy colon.

Daily bowel movements are generally considered to be ideal, but there is great variation around this. Passing stool anywhere between three times daily and three times weekly is still within normal limits.

Unfortunately, there is a significant number of people who suffer from chronic (ongoing) constipation. Medically this has a very complex definition, and in fact this definition is only useful for research. In everyday life, chronic constipation can mean different things to different people. Often it refers to infrequent bowel movements, but it can also refer to hard stool, straining to pass stool, and a sense of incomplete emptying, along with a need to take laxatives or suppositories to keep regular. That said, patients with chronic constipation visiting my colorectal clinic are more likely to complain of abdominal bloating, passing wind, and abdominal pain than infrequent bowel movements. Depending on who you ask, anywhere between 2% and 30% of people are thought to suffer from chronic constipation, but the overall accepted figure is around 10%–12%.

Chronic constipation can be classified as functional (primary, a condition in its own right) or secondary (resulting from an underlying condition). Functional constipation can be broadly divided into three classes, ie, normal-transit, slow-transit, and outlet constipation.

Functional chronic constipation

Normal-transit constipation

In people with normal-transit constipation, the way muscles contract and relax to move contents through the colon (colonic motility) is not altered, and stool passes through the colon at a normal rate. These people may complain of infrequent bowel movements, but have normal colonic transit tests. However, patients with this type of chronic constipation may have trouble emptying their bowels for another reason, eg, harder stools, which are more difficult to pass. As with other patients with chronic constipation, it is the bloating and abdominal pain that are the most troubling problems for the patient and where therapy is directed.

Patients with constipation-predominant irritable bowel syndrome (IBS-C) fall into this group. Some patients with IBS and diarrhoea alternating with constipation (IBS-A) are believed to have altered gut bacteria in the small bowel. When methane-producing bacteria are in predominance, the patient becomes constipated, and when there are changes to hydrogen-producing bacteria, the patient develops diarrhoea. In IBS-C, again there are many different ways of producing the constipation, but it may be that the makeup of the bacteria in the gut affects its motility.

Slow-transit constipation

In a person with a normally functioning bowel, the large intestine massages waste along its length to the rectum by rhythmic, muscular contractions of its walls (peristalsis). This activity is controlled by nerves of the enteric nervous system (ENS). In patients with slow-transit constipation, the time taken for stool to pass through the colon is decreased and bowel movements are less frequent, leading to symptoms like straining and harder stools. This disorder is thought to be caused by abnormal functioning of the ENS. Certain primary bowel motility problems may have constipation as their main symptom. Some patients are born with a peristalsis problem while others are born with a normal bowel, but events in their life change the way bowel works, so they develop a similar inability to move bowel contents along towards the rectum. The unusually slow passage of waste through the large intestine leads to chronic constipation. There are multiple forms of medical therapy available and most people with slow transit constipation will never need surgery. It is possible to perform surgery in some patients with slow-transit constipation, but this is only done after extensive investigation, which needs to examine the transit ability of the rest of the bowel. This surgery takes the form of a sub-colectomy, which is not straightforward or able to be reversed, and complications can occur.

Outlet constipation

Persons with outlet constipation often have pelvic floor dysfunction, ie, a defect in the coordination necessary for evacuation of stool. This usually occurs because of failure of the pelvic floor muscles (including the anal sphincter) to relax appropriately when going to the toilet. When this happens, stool passage is much more difficult, regardless of whether stool transit in the colon is normal or delayed. Obstruction to defaecation can also occur at the anorectum and this can be due to weakness of the pelvic floor and wall of the rectum, resulting in the rectum collapsing on itself (internal rectal prolapse) or ballooning out of the anus (rectocoele, external rectal prolapse).

Secondary chronic constipation

Medication

Many medications can slow the movement of food through the colon and worsen constipation. These agents include opioid-based pain killers, diuretics, antiepileptic drugs, antispasmodics, antidepressants, tranquilisers and certain other psychiatric medications, antihistamines, blood pressure medication, calcium channel blockers, iron or calcium supplements, and aluminium-containing antacids.

An underlying condition

Certain medical conditions can also lead to chronic constipation. These conditions include severe hyperthyroidism, hypercalcaemia, diabetes, coeliac disease, and certain neurological disorders such as Parkinson’s disease and myotonic dystrophy. Any problem at the end of the gastrointestinal tract that limits the ability to pass stool can also cause constipation. People may develop chronic constipation if they have an anorectal problem such as a painful anal fissure, where the patient may avoid going to the toilet, anismus, where the anal muscles contract instead of relaxing when the patient is trying to pass stool, and pelvic floor prolapse, where a prolapse of the rectum may cause the patient to have the sensation of blockage. Anal fissure and anismus can be treated by Botulinum toxin injection. Pelvic floor prolapse can be treated by pelvic floor physiotherapy, laxatives and occasionally surgery.

Seek a medical specialist’s opinion

People with a normal healthy colon can improve their bowel function by increasing their fibre intake, drinking plenty of water. However, these measures may not work people with IBS-C or IBS-A, and indeed may make their symptoms worse. The same is true for people with slow-transit constipation.

Chronic constipation is not thought to lead to anything serious, such as cancer. However, long-term dilatation of the bowel can lead to nerve damage and worsening of constipation because of reduced motility of the large bowel. In addition, chronic straining may lead to muscle and nerve problems in the pelvic floor.

Any change in bowel frequency or stool consistency should be reported to a doctor. More serious causes of constipation need to be excluded before a diagnosis of constipation is made. These include narrowings in the colon caused by repeated attacks of inflammation from diverticular disease or cancer of the colon. Any persistent change in bowel habit, increase or decrease in frequency or size of stool, or increased problems passing stool warrants an appointment with your family doctor. You should also be referred to a colorectal surgeon, who will organise a colonoscopy if this has not been already.

Crohn’s disease (CD) is a type of inflammatory bowel disease named after Burrill Crohn, a gastroenterologist in New York who described a number of patients with the condition in the 1930s. CD is a chronic disorder, meaning it continues for a lengthy period of time, maybe even lifelong. The disease often starts in adolescence or young adulthood. However, it can occur at any age, and there is a second spike in onset of the disease later on in life.

There are essentially three types of CD, one affecting the small (upper) bowel, one affecting the last part of the small bowel and first part of the colon, and one affecting the large bowel (colon).

Typical symptoms of CD are abdominal pain and diarrhoea. Some people also lose blood in their stools. Other symptoms can occur, depending on which part of the bowel is affected. CD can come and go, and there is generally a phase of healing in between. Unfortunately, because of this healing pattern, some people develop a narrowing of the bowel in the affected area, called a stenosis. When this narrowing becomes severe, patients can develop severe pain, nausea, and vomiting.

Around 50% of patients with CD develop problems around their back passage. These include infections and anal fissures (small tears in the lining of the anal canal) and anorectal fistulas (abnormal connections between the lining of the rectum and the outside skin around the anus). People with this disease can also develop fistulas, where abnormal connections develop between one piece of bowel and another, between the bowel and another organ, or between a piece of bowel and the skin surface. Many patients with the disease also have skin tags (harmless growths) around the anus and some develop bowel incontinence.

In younger people, CD may affect growth. Other organs can also be affected, include the eye, liver, joints, and skin. There is also an increased risk of developing a blood clot (thrombosis) in the legs and potential movement of the clot to the lungs (pulmonary embolism). There are a variety of conditions of the gum and mouth that can also cause problems in CD.

Some people with CD have a reduced ability to absorb nutrients and develop malabsorption syndrome, in which essential nutrients are not able to enter the bloodstream. Others actively avoid eating because there is a narrowing in their bowel or because they are trying to avoid pain and/or diarrhoea. Therefore, patients with CD are prone to losing weight very easily.

No one really knows what causes CD. The disease definitely has a genetic component. If you have a brother or sister with CD, you are 30 times more likely to develop the disease then someone who has not. To date, over 30 genes have been found to be linked to CD.

We also know that the environment plays a part as well. The disease is mostly found in industrialised countries, and is associated with having more animal and milk protein and less vegetable protein in the diet. Smoking increases the severity and risk of recurrence of CD, but is unlikely to cause the disease.

There is no evidence that CD is made worse by stress. However, many patients with CD also have irritable bowel syndrome, which is made worse by stress. There is no evidence that CD is made worse by activity or work. As always, exercise is recommended. The causes of CD are an intensive area of research, but as yet these remain elusive.

Diagnosis

CD can be difficult to diagnose. The average length of time between when symptoms of CD appear and when the disease is diagnosed is about seven years. This is because symptoms may be mild and overlap with those of other conditions.

Colonoscopy and upper GI endoscopy are excellent for visualising the upper and lower gastrointestinal tract. Colonoscopy can also check the last part of the small bowel for CD. If needed, the entire small bowel can be checked by capsule endoscopy. This is where a camera is swallowed and takes pictures along the entire gastrointestinal tract, from the mouth to the anus. Magnetic resonance enterography is also an excellent investigation for CD affecting the small bowel. This procedure involves the patient drinking a special fluid before they are scanned.

Blood tests are helpful for detecting complications of CD, including inflammation and malabsorption of nutrients from the diet. A faecal calprotectin test is useful for distinguishing between irritable bowel syndrome and CD.

Sometimes CD is diagnosed during surgery that is being done for something else. For example, during an operation for suspected appendicitis, it may become apparent to the surgeon that the problem is not the appendix itself but CD affecting the bowel near the appendix. The affected area can be removed surgically at that time.

Treatment

Unfortunately, there is no cure for CD. However, many people can be maintained with good quality of life and in some the disease seems to disappear. Hopefully a cure can be found when we understand why CD develops in the first place. The type of treatment offered depends on the severity of symptoms and the part of the gastrointestinal tract that is affected.

Diet

There are no specific food items proven to cause CD. However, certain foods or drinks can aggravate symptoms. Some people find limiting dairy useful, others prefer low-fat foods. Some people find it helpful to eat smaller meals more often during the day and to reduce their dietary fibre. For people with CD who also have irritable bowel syndrome, it may simply be that feeling better when they avoid certain foods is more to do with their irritable bowel syndrome than their CD.

Medication

Anti-inflammatory drugs, such as mesalazine, are useful for mild symptoms of CD. For more severe symptoms, drugs such as azathioprine that suppress the immune system may be needed. Steroids are usually needed for flare-ups of CD. Long-term treatment with antibiotics, commonly metronidazole or ciprofloxacin, are helpful for infections that develop around the anus. Medications used for CD affecting the last part of the colon are often given by suppository or enema. Steroids may be given intravenously in the event of a severe flare-up of the disease. Essentially, the amount of medication given depends on the severity of the disease.

Surgery

The aim of any surgery for CD is to preserve as much bowel as possible. The most common operation is removal of a segment of small bowel, but this is only done when absolutely necessary. If the colon (large bowel) is affected, some form of colectomy may be needed. Unfortunately, a total colectomy, ie, surgical removal of the entire large bowel, is sometimes the only way of treating CD.

CD can return in other areas of the bowel after surgery. One in two people who undergo surgery for CD will require further surgery in 10 years’ time, and in turn, one in two of those people will need further surgery in another 10 years, and so on. It is for this reason that we try very hard to treat CD medically and remove as little of the bowel as possible when surgery is needed.

Diverticular disease (also known as diverticulosis) is a condition in which small outpouchings (diverticula) develop in parts of the bowel wall. The normal colon is a smooth hollow tube, with a wall made up of three separate layers. However, there can be local areas of weakness in the bowel wall, and in some people the inner bowel lining protrudes through these weak areas, causing diverticular disease.

Diverticula can occur throughout the gastrointestinal tract, which extends from the mouth to the anus. They can occur anywhere in the large bowel, but the most common place they are found is in the left part of the colon known as the sigmoid colon.

Diverticular disease is very common and occurs increasingly with age. It is believed to be present in half of people in their fifties and in three quarters of those in their late seventies. It is also common in people who are prone to constipation. It is thought to be becoming more common in people with a low-fibre diet, especially if diverticular disease is present in other family members. People with connective tissue disorders (causing increased stretchiness of the soft tissues) are also at increased risk of developing diverticula.

Exactly why some people form diverticula and others do not is not known. Some vegetarians on an extremely high-fibre diet have many diverticula and others with an extremely poor diet never form a diverticula during their lifetime. However, with the increasing adoption of a lower-fibre and more processed diet, diverticular disease is becoming more common in younger people and is even seen now in some people in their twenties.

The vast majority of people with diverticular disease do not know they have the condition and have no symptoms whatsoever. However, some people do develop symptoms, which can be very similar to those of irritable bowel syndrome (IBS), to the point that it is often unclear whether it is the diverticular disease or IBS that is causing their symptoms. Typical symptoms include bloating, abdominal discomfort, and diarrhoea or constipation. Some people with the disease report bright red blood coming out when they go to the toilet. Thankfully, people with diverticular disease are at no extra risk of developing bowel cancer.

Some people with diverticular disease develop a condition called diverticulitis. This is when one or more specific diverticula become inflamed or infected. Diverticulitis is associated with a temperature, abnormal blood tests, and a computed tomography (CT) scan showing changes of infection around the affected diverticulum. No one is quite sure, but it seems that 10%–25% of people with diverticular disease will develop diverticulitis.

Diagnosis

Diverticular disease can be found by chance in people with no symptoms whatsoever during any type of large bowel investigation. Most commonly, these investigations will be colonoscopy or CT colonography. Without these tests, the diagnosis cannot be confirmed. Likewise with diverticulitis, a CT scan is needed to make the diagnosis.

The symptoms of diverticular disease and those of bowel cancer can be very similar and sometimes colonoscopy or CT colonography cannot look at the affected area accurately because of the large number of diverticula present. Therefore, surgery is sometimes recommended to make sure a bowel cancer is not missed.

Treatment

The treatment of diverticular disease depends mainly on its symptoms. If severe IBS-type symptoms are associated with diverticular disease, these will be managed just as they would be for IBS. Studies have shown that surgery does not improve the IBS-type symptoms associated with diverticular disease, so treatment is non-surgical in these cases.

Unfortunately, once diverticula have formed they will never go away, although we may slow their progression by improving the amount of fibre and fluid in the diet if this has been poor in the past.

Sometimes people with diverticular disease need to be admitted to hospital as an emergency, usually because they have developed diverticulitis and an abscess next to the bowel. This may need to be drained by X-ray techniques and treated with antibiotics. Occasionally the bowel wall can become perforated at the site of an inflamed diverticulum, and this also requires emergency surgery (usually in the form of a partial colectomy).

Some patients develop abnormal connections between their diverticula and the bladder (a colovesical fistula) or the vagina (a colovaginal fistula), allowing the bowel contents to spill into these organs. These patients need a surgical repair on a planned (elective) basis. Elective surgery is also needed for diverticular disease if there is a narrowing (stricture) in the bowel.

Modern medicine now sees continence as a highly complex interaction between the nervous system, the gastrointestinal tract, pelvic floor muscles, and emotion. The lower bowel must recognise when faeces is entering it and the pelvic floor must be able to keep the anus closed if defaecation is not convenient. When it is convenient to pass a bowel motion, the same muscles that are keeping the anus closed must be able to relax in a coordinated manner while the bowel above contracts to expel its contents.

In basic terms, faecal incontinence is the inability to control one’s bowel movements. Some patients have very minor soiling, usually presenting as a streak of faeces noted in their underwear after they are sure that they have cleaned themselves properly. At the other end of the spectrum, the problem may be so severe that the entire bowel contents can be evacuated involuntarily at once, causing great distress.

There are two main types of faecal incontinence. One is known as “urge” incontinence. Normally continent people get a feeling that they will need to defecate soon (known as a “call to stool”). In some people, rather than this just being a vague sensation, the feeling is of an extreme need to get to the toilet quickly. In a few of these people, their anal muscles are not strong enough to keep the anus squeezed tight, and if they do not get to the toilet in time, they will be incontinent of a variable amount of faeces. The other type is known as “passive” incontinence. This is where a patient will be incontinent of faeces without even realising they needed to go to the toilet, and faeces just presents itself in the underwear. Again, these are highly stressful experiences.

Faecal incontinence invariably ends up controlling the lives of those who suffer from it. Most people with faecal incontinence get to know where the toilets are on their daily route. They dare not catch a bus in case they are caught short, and frequently carry a change of clothes with them. Others avoid social activities so that they do not have to eat, because of the subsequent risk of needing to go to the toilet. People with severe bowel incontinence are likely to become completely housebound and have very poor quality of life.

This distressing condition is much more common than people might think. About six in every 100 women under the age of 40 years suffer from faecal incontinence. In older women, this figure rises to above 15%. Even more surprising is that 10% of men of any age suffer from some form of faecal incontinence. Certainly, the risk of faecal incontinence increases as people get older.

Faecal incontinence should be seen as a symptom rather than a condition in itself. There are many causes of faecal incontinence. Normally two or more causes are needed to overcome the normal continence mechanism. These causes can be divided into five main groups:

Group 1 – an abnormality of the anus or lower bowel arising from the trauma of child birth, surgical trauma, the presence of an anal fistula or abscess, or rectal prolapse

Group 2 – neurological conditions, including multiple sclerosis, spinal cord injury, stroke and spina bifida

Group 3 – constipation and overflow diarrhoea

Group 4 – memory and behavioural problems, such as dementia and learning difficulties

Group 5 – diarrhoea associated with inflammatory bowel disease and irritable bowel syndrome.

Some cases are classified as idiopathic, where no obvious cause can be found, but the person suffers considerably with the problem. There is hardly ever just one reason why someone suffers from faecal incontinence. It is the complex interplay between muscles, nerves, cognition, and the consistency of stools, so it is a case of “one size does not fit all”. Faecal incontinence is truly one symptom where the health professional has to be completely holistic and tailor treatment to the patient’s specific needs.

Diagnosis

If you are suffering from faecal incontinence, you should see a colorectal surgeon who specialises in both pelvic floor conditions and faecal incontinence. An extensive history will be taken and an examination performed. This will include examining the abdomen initially. Your surgeon will examine the perineum, anus, rectum, and perhaps also the vagina. You will be asked to squeeze and relax your pelvic floor muscles to help your surgeon make an initial assessment.

An experienced surgeon will have a very good idea about the possible causes of your faecal incontinence from the examination alone. However, other investigations may be required. The staff conducting these investigations are highly professional, and most patients report that their tests were not as bad as they thought they were going to be.

The first investigation is an anal ultrasound scan. This involves a small probe being placed in the anus and an ultrasound image being created of the anal muscles. This will look for any damage to these muscles.

The second investigation is anorectal physiology, which looks at your sensation in the lower bowel and ability to squeeze the anal muscles. This is performed by inserting a small balloon into the anus.

The third investigation is a defecating proctogram where an X-ray medium is instilled into the rectum and the patient is required to pass a bowel motion behind an X-ray screen. Another way to do this is in the MRI scanner, this is known as a magnetic resonance proctogram. This investigation shows the structure of the pelvis in great detail, and surgeons find this useful to help work out what is going on and what therapies may help. Understandably, patients can find the prospect of this investigation rather daunting, but for those with severe faecal incontinence, any reluctance tends to disappear when people realise that this test may well identify a treatment that will work for them.

Treatment

Conservative and medical

We have made great strides recently in the treatment of faecal incontinence, and most patients do not need surgery. For the vast majority, improving stool consistency with dietary or medical help is a good first step. Pelvic floor physiotherapy and biofeedback is very useful, but does not work overnight. It takes hard work and dedication on the part of both the patient and the physiotherapist to re-engage muscles that have been damaged and to encourage new neuromuscular pathways to develop and strengthen.

Some patients do extremely well with colonic and rectal irrigation. There are many good and convenient systems available, allowing patients to clear their lower bowels every day or every other day. Half of the patients prescribed this therapy do extremely well and say that it dramatically changes their lives for the better.

For those people who suffer from faecal incontinence associated with irritable bowel syndrome, extensive measures may need to be taken. These treatments include the FODMAP diet (www.ibsgroup.org/brochures/fodmap-intolerances.pdf), probiotics, or specific medications.

Percutaneous tibial nerve stimulation is an exciting new therapy that helps over half our patients with faecal incontinence. It is very simple and involves placing an acupuncture-type needle near the ankle for half an hour each week for 12 weeks. Top-up therapies can be offered thereafter.

Quality of life can be improved dramatically for most people using these non-surgical measures, and very few need to go on to have surgery.

Surgery

A colorectal surgeon with a specialist interest in faecal continence will think of surgery as the last line of treatment. However, this does not mean that surgery is not successful. Research has shown that the classic idea of repairing a damaged anal sphincter muscle in a person with bowel incontinence is not effective in the long run. However, it is still an option, although rarely done.

If a rectal prolapse is contributing to faecal incontinence, then this should be repaired. There are a variety of ways to do this, but the gold standard is a ventral mesh rectopexy or similar operation.

Sacral nerve stimulation, also known as sacral neuromodulation, is a good treatment for faecal incontinence in the right situation. Once a prolapse has been dealt with and there is still damage to the pelvic floor, sacral nerve stimulation becomes even more useful. Sacral nerve stimulation involves the implantation of wires through the lower back near to the pelvic nerves. These wires are then connected to a pacemaker battery that is implanted in the abdominal wall. The battery itself needs to be replaced every 5–8 years, but if successful, sacral nerve stimulation returns the patient’s quality of life to a near normal level.

Anal bulking is another option, and works best when there is a defect in the internal anal muscles and passive faecal incontinence. This technique involves injection of synthetic material into the anal muscles.

The anus contains a cushion-like ring of blood vessels that, together with the sphincter muscles, have an important role in maintaining continence. When these vascular cushions, also known as haemorrhoid tissue, become enlarged and swollen, they are known as haemorrhoids (or “piles”).

Haemorrhoids are sometimes described as “varicose veins of the anus”. Varicose veins originate as normal veins, but, for a variety of reasons, can become bigger and cause symptoms. In a similar way, the vascular cushions in the anus are a normal body structure that can also become enlarged and cause symptoms.

Symptomatic haemorrhoids can occur in both men and woman and at any age. Generally speaking, they are most common in people aged 40–60 years. If you look closely enough, nine in 10 people will have haemorrhoidal disease, but most do not have significant symptoms. Overall, half the people with haemorrhoids will have trouble with them in their lifetime.

Many people believe that a diet low in fibre and fluid causing constipation is the main cause of haemorrhoids. However, the exact cause of symptomatic haemorrhoids is unclear. Diet and fluid clearly have a role, as does constipation, although there are people with chronic diarrhoea who suffer from haemorrhoids. Being overweight, having a chronic cough, or suffering from pelvic floor problems can also cause haemorrhoids. Genetics may also be involved. In some people there is no obvious cause.

Pregnant women are particularly prone to haemorrhoids because the growing foetus increases the pressure in the abdomen and hormonal changes cause the blood vessels within the haemorrhoid tissues to increase in size. Labour itself further increases the pressure on the haemorrhoid tissues.

Many patients feel guilty about developing haemorrhoidal disease. However, although a number of people could improve their haemorrhoids by changing their lifestyle and diet, many have done absolutely nothing wrong, and simple measures will not improve their symptoms.

Colorectal surgeons define haemorrhoids as being internal or external. Internal haemorrhoids are those that form above a point 2–3 cm inside the anus in the upper part of the anal canal and receive a blood supply that comes downwards from the bowel. External hemorrhoids are usually found beneath the skin around the anal opening and receive a blood supply that comes upwards from the surrounding skin. The different blood supply for internal and external haemorrhoids explains why the treatment needed for the two types is different.

Both external and internal haemorrhoids can grow bigger, and internal haemorrhoids can become so large that they can fall out of place and protrude outside the anus. These are known as prolapsing internal hemorrhoids. External hemorrhoids are already outside the anus, so cannot prolapse. External hemorrhoids are easily confused with the more commonly found benign skin growths known as skin tags.

Most people with haemorrhoidal disease have no or very few symptoms. If symptoms do occur, they include bright red bleeding, mucus discharge, itching of the skin in and around the anal area, and prolapse of internal haemorrhoids. Often there is only mild discomfort, but pain can occur with haemorrhoids, particularly if a blood clot forms inside an external or prolapsed internal haemorrhoid. This is known as a thrombosed haemorrhoid, which can be extremely painful, especially for the first few days. Another condition known as a thrombosed perianal haematoma is easily confused with a thrombosed external haemorrhoid.

It is widely believed that any symptoms around the back passage must be from haemorrhoidal disease. This is far from the truth, and similar symptoms can arise from a wide range of conditions that involve the back passage, so should always be checked out.

Diagnosis

Haemorrhoids are diagnosed by physical examination. External haemorrhoids and skin tags can be diagnosed by simply looking at the skin surrounding the anus. A digital (finger) examination of the anal canal is then performed. A common misconception is that internal haemorrhoids can be felt by a finger – this is not the case because they only contain blood and the examining finger will compress them.

The only way to diagnose internal piles is by examining the anal canal with a narrow, hollow short tube known as a proctoscope. The proctoscope is inserted into the back passage and allows the colorectal specialist to see if haemorrhoids are present. When the proctoscope is being withdrawn, any internal haemorrhoids that are prolapsing out can be seen as well. This examination is not usually painful. It helps to exclude any other potentially serious causes for your symptoms, does not require anaesthesia, and can be done in the clinic.

The most common reason that people with symptoms affecting the back passage visit a colorectal specialist is to exclude bowel cancer. This is also in the back of the surgeon’s mind, so further tests may be ordered to look at the large bowel more closely. These tests may involve inserting a flexible telescope through the back passage to look at the large bowel or a computed tomography (CT) scan. These procedures are not done in the clinic, and will only be requested if necessary.

Treatment

Conservative

Thankfully, treatment is not usually required for haemorrhoidal disease. Many people, when reassured that nothing serious is going on, are happy to live with minor symptoms and bleeding. This is entirely safe. Most people with minor haemorrhoidal disease have intermittent symptoms that they learn to manage themselves. The mere presence of haemorrhoidal disease on examination does not mean treatment is needed. Leaving haemorrhoids untreated rarely causes any long-term problems. Haemorrhoids do not progress to cancer and hardly ever cause anaemia, despite significant blood loss. They can be safely left alone if the patient chooses.

Many patients benefit from increasing the fibre in their diet, decreasing their tea and coffee intake, and avoiding diarrhoea or constipation. However, there are others who have an excellent diet, exercise regularly, are not overweight, and never strain when they go to the toilet, yet suffer from significant haemorrhoidal disease. Very little can be done to prevent haemorrhoids forming and progressing in these people.

Non-surgical

A colorectal surgeon has a wide variety of treatments available to treat haemorrhoidal disease. Some can be performed in the clinic and others can only be done in the operating theatre under general anaesthesia.

Injection sclerotherapy or rubber band ligation of haemorrhoids can be done in the clinic without anaesthesia. These procedures are only useful for internal haemorrhoids, where the aim of treatment is to reduce the blood supply. They cannot be used for external haemorrhoids as this would entail treating skin on the outside of the body, which would be extremely painful. Normal skin sensation stops half way up the back passage and above this bowel sensation starts. The bowel has a much lower capacity to sense pain than normal skin does. Therefore, injections or bands are suitable for haemorrhoids present above this sensory level. Patients do experience some sensation when these procedures are being performed, but it is not painful. The surgeon will check that normal skin sensation has ceased before injection sclerotherapy or rubber band ligation is started.

Overall, injections and banding seem to help in 70% of patients. They do not cure haemorrhoids, but can certainly reduce symptoms to a manageable level. It must be remembered that haemorrhoid tissue does have a positive role in the body.

Surgery

Surgical treatments for haemorrhoids need to be performed in the operating theatre. They are all performed as open procedures and are reserved for external and internal haemorrhoids that cannot treated by injection sclerotherapy or rubber band ligation.

If the problem is external haemorrhoids, a traditional haemorrhoidectomy is needed, where the haemorrhoidal tissue is removed and the wounds may be closed with dissolvable stitches. If the problem is internal haemorrhoids, a traditional haemorrhoidectomy may also be performed, but may be combined with Doppler-guided haemorrhoidal artery ligation (HAL) and/or rectoanal repair (RAR, also known as haemorrhoidopexy). Another surgical option for internal haemorrhoids is a stapled haemorrhoidopexy. People who have stapled surgery may have less postoperative pain than people who have the more traditional haemorrhoid surgery, but are slightly more likely to have their haemorrhoids come back and need surgery again.

A hernia occurs when there is a weakness in the muscular abdominal wall that keeps the abdominal organs in place. This weak area allows organs and tissues to push through, or herniate, producing a bulge. The weakness may be present from birth or develop over a long period of time. Anything that increases the pressure in the abdomen can increase the risk of developing a hernia. Being overweight or obese, straining while moving or lifting heavy objects, having a persistent heavy cough, and having a history of multiple pregnancies are known risk factors for abdominal hernia. The risk of developing an abdominal hernia is increased in patients with certain medical conditions, such as emphysema, and those on dialysis for kidney disease.

The four types of abdominal hernia commonly seen in a colorectal clinic are:

• Inguinal hernia – a hernia occurring in the groin and found more often in men than in women. Inguinal hernia occurs in about 25% of men but in only 3% of women. They are more common in infants and in men aged older than 50 years.

• Umbilical hernia – this type of hernia occurs near the navel (belly button) and is common in infants and young children, especially in babies born prematurely. In many cases, the hernia disappears and the abdominal muscles reseal in the first few months of life, but a minority of children need surgery. An umbilical hernia can also develop in adults, who may have had a weak area around the navel since birth.

• Femoral hernia – a rarer type of hernia, occurring mainly in women and accounting for 2% of all hernias and 6% of all groin hernias. The risk of developing a femoral hernia increases with age, so most of these hernias are found in middle-aged or older women. They are thought to be more common in women because of their wider pelvis and a slightly larger femoral canal, into which intestinal tissue can herniate more easily than in men. Femoral hernias can be easily confused with inguinal hernias by both patients and doctors.

• Incisional hernia – a hernia that occurs through a previously made surgical incision in the abdomen. They are thought to be caused by failure of a surgical wound to heal, but are probably the result of multiple patient and technical factors. An incisional hernia is most likely to appear at around 6 weeks after surgery, when people become more physically active. Advances in surgical technique and materials have not removed this problem. Overall, the risk of developing an incisional hernia is about 1%, but may be up to 20% in patients with malnutrition, wound infection or diabetes, if the patient has been on corticosteroids, or if surgery is being performed as an emergency.

Symptoms

An abdominal hernia is felt as a lump in the groin (inguinal and femoral hernias), around the navel (umbilical hernia), or at the site of previous abdominal surgery (incisional hernia). People with an abdominal hernia may have no symptoms whatsoever and their hernia may only be found on examination by a doctor for something else. Some people do get pain from their hernia, especially when lifting. The hernia may appear to get bigger when laughing, coughing, or going to the toilet, and then shrink when the person is relaxing or lying down. Symptoms vary during the day. If the person has a strenuous job, any straining may increase the size of the hernia. The early small hernias seem to cause more symptoms. These symptoms may then diminish or go away altogether as the hernia gets slightly bigger, only to reappear when the hernia becomes even larger.

Diagnosis

An experienced colorectal surgeon can readily diagnose an abdominal hernia by taking a detailed history and performing a clinical examination. The hernia usually presents as a lump under the skin, which may only be present on standing up and disappear on lying down. Occasionally an abdominal hernia may be producing typical symptoms but be harder to find. In these cases, a CT scan or ultrasound may be useful.

Treatment

Conservative

If a hernia is small and causing no symptoms, it can be left safely alone initially. However, hernias don’t go away of their own accord. Over time, hernias tend to get bigger as the abdominal wall gets weaker and more tissue bulges through. Still, many people are able to delay surgery for months or even years.

Some people have additional medical problems that increase the risks associated with surgery to the point that these risks are greater than the risk of leaving the hernia alone. The treatment recommended for these patients is usually a custom-made corset (truss) to provide support for the hernia.

Surgery

Surgery is recommended for most adults with an abdominal hernia as the hernia is unlikely to get better by itself and will almost certainly get worse over time. Further, the risk of complications increases with age. Any patient with increasing symptoms from a hernia, a hernia that is increasing in size and/or not getting smaller when lying down, or that is interfering with work performance or activities of everyday living should consider a surgical hernia repair.

If a hernia is not surgically repaired, there is a small but ever-present risk of the portion of bowel in the hernia becoming stuck (obstructed), causing intense pain and needing emergency surgery. There is also a risk of the portion of bowel lodged in the hernia losing its blood supply (becoming strangulated). A strangulated hernia is potentially fatal and requires emergency surgery within hours to release the trapped tissue and restore its blood supply. Emergency surgery in these circumstances may also require the affected part of the bowel to be removed.

The risks of obstruction and strangulation are much higher for femoral hernias, even small ones, than for the more common inguinal and umbilical hernias. If a femoral hernia is suspected (or cannot be excluded), an appointment with a colorectal surgeon should be made as soon as possible. Unfortunately, over half of patients with a femoral hernia still arrive in hospital as an emergency, with all the increased risks that entails.

Inguinal hernia repair, umbilical hernia repair, and femoral hernia repair can be performed by an open approach or a laparoscopic approach. Small and medium-sized hernias, especially if they are on both sides of the body, are usually best suited for a laparoscopic approach. Laparoscopic surgery is said to have a shorter recovery period. Larger hernias and hernias that are not reducing are often repaired by an open approach. The general recommendation is to use mesh for hernia repair as it markedly reduces the chances of the hernia coming back.

Open surgery and laparoscopic surgery are excellent procedures, but both have a 1% chance of the hernia returning. If a hernia recurs after a previous repair, the new repair may be best done using a different approach to that done previously. For example, if the previous hernia surgery that failed was an open repair, then laparoscopic surgery should be considered and vice versa. Laparoscopic surgery should probably not be performed in patients who have had major abdominal surgery before.

Irritable bowel syndrome (IBS) is a collection of symptoms that together are labelled as a diagnosis. These symptoms include abdominal pain, bloating, diarrhoea and constipation. IBS is a very common condition, affecting up to one in four people, most of whom have mild symptoms. The main types of IBS are where constipation is predominant (IBS-C), where diarrhoea is predominant (IBS-D), and where diarrhoea and constipation alternate (IBS-A).

Although anyone can get IBS, some subgroups of people seem to be more prone to the disorder. Research is still a long way away from defining what IBS actually is, but there does seem to be an increased occurrence after a bout of gastroenteritis or a traumatic life event. There is also an association with chronic pain syndromes, chronic fatigue syndromes, and fibromyalgia.

Recent research suggests that there are multiple causes of IBS, with some causes probably yet to be identified. It appears that one in 10 cases of IBS are likely to have been triggered by gastroenteritis. In sensitive individuals, it seems that the damage caused by gastroenteritis allows bacteria that normally live in the gut to damage the bowel lining. This results in increased permeability (leakiness) of the gut membrane, which may cause mild inflammation of the bowel. This trigger of IBS can get better with time, but in a few it’s an ongoing problem.

Stress is often said to be a cause of IBS. However, this does not mean that reducing stress can improve IBS. It is probable that certain psychological traits are associated with conditions that can lead to IBS. Therefore, the widely held belief that reducing stress levels can improve IBS is probably incorrect.

Malabsorption of bile salts is the cause of IBS in one third of people with diarrhoea-predominant IBS. It is thought that bile salts are normally totally absorbed in the small bowel, but may cause irritation and diarrhoea if they enter the large bowel.

Bacterial overgrowth in the small bowel is another known cause of IBS. Bacteria are normally found in the large bowel and to a lesser degree in the small bowel. On a microscopic level, we know that the gut wall develops low-level inflammation to counter the bacterial load and toxins within the interior of the gut. There are 1000 –2000 different types of normal bacteria living in the gut and a decrease in numbers of these may allow levels of some bacteria that cause symptoms to increase. Unfortunately, some people seem to have more bacteria within the small bowel and this can result in inflammation and IBS-like symptoms.

Overall, it seems that is not just one cause of IBS, and IBS may in fact turn out to be an umbrella term for numerous different conditions. Some people are fortunate and only have IBS for a short time or their symptoms are very minor. However, others have a very difficult time with IBS throughout their lives. These people may have other severe conditions as well, and their quality of life can be very poor indeed.

The common triggers for IBS, including certain food items, antibiotics, acute gastrointestinal illness, and stressful life events, are not necessarily causal, and more likely to be the “final straw” in an individual with a predisposition to IBS and who was likely already on the verge of developing symptoms of IBS.

Management

There is no specific test that can diagnose IBS. The symptoms of IBS overlap with those of more serious conditions affecting the bowel, such as coeliac disease, inflammatory bowel disease, and colon cancer. Any change in bowel habit warrants a prompt visit to a colorectal specialist, whose job it is to exclude other potentially serious causes of your symptoms.

My interest in IBS started many years ago when I came to realise that treating pelvic pain in isolation would not help my patients and that an in-depth understanding of both pelvic pain and IBS was needed. I therefore made contact with some of the best minds in these fields in the country and have learned from them. I can now confidently manage both pelvic pain and IBS.

The pelvic floor consists of a group of muscles together with fascia, ligaments, and tendons that keep the pelvic organs and structures, i.e., the bladder, uterus (in women), and rectum in their correct place. These muscles also help to control the release of faeces from the rectum and urine from the urethra, so need to be strong to maintain continence as well as be flexible and able to relax when we go to the toilet.

When the muscles of the pelvic floor or their surrounding structures become weakened, damaged or uncoordinated, they may no longer be able to support the weight of one or more of the pelvic organs. When this happens, a pelvic floor organ may drop down from its normal position. This is known as pelvic organ prolapse. In some cases, the pelvic floor itself may prolapse as well.

Women are more prone to pelvic floor dysfunction than men, the most common cause being damage to the pelvic floor during childbirth, particularly if the second stage of labour is prolonged, the baby’s head is in an unusual position, or forceps are needed. Muscle mass tends to start decreasing at around 40 years of age, and if there is pre-existing damage to the pelvic floor, pelvic floor dysfunction may start to become apparent at this time. After the menopause, further muscle mass is lost, and some of the connective tissues may start to lose their strength, further weakening the pelvic floor. However, there are other causes of pelvic organ dysfunction and prolapse, and some women who have never had children (and men) suffer from pelvic floor dysfunction. Ongoing constipation and straining when going to the toilet also increase the risk of pelvic organ prolapse.

As with many other conditions, there is a genetic component to pelvic organ prolapse. Most people receive genes from their parents that provide a good balance between strength, flexibility and coordination in the pelvic floor. However, some people are born with more elastic connective tissues that stretch easily with age. A minority of people are born with a condition known as hypermobility syndrome, in which the connective tissues are markedly weak. These people tend to be double-jointed, very flexible, and athletic in younger adulthood, but the pelvic floor in these individuals may become weaker over time, leading to pelvic floor dysfunction.

When the pelvic floor starts to prolapse, stretching of the pelvic ligaments may result in a dragging pelvic sensation. This occurs only on standing up, and when the effect of gravity is removed by lying down, the dragging sensation ceases. Any trauma or tear in the muscle can lead to trigger points. These are similar to knots found in other muscles. These trigger points can cause muscles to act in an abnormal fashion and be painful to touch. Intercourse and the need to go to the toilet can trigger these pains, and treatment is generally needed to restore correct functioning of the pelvic floor.

The most common types of prolapse seen by a colorectal surgeon are those involving the rectum, vagina, and small intestine. Prolapse of the bladder can also occur, but is dealt with by a urologist or urogynaecologist. Prolapse of the uterus can be treated by a gynaecologist, but if it is associated with rectal prolapse is dealt with by a colorectal surgeon.

Rectal prolapse

The rectum is the final part of the large bowel, lying just above the anus. In women, the rectum and vagina are very close together but are normally kept separated by a strong wall of tissue known as the rectovaginal septum. If this tissue becomes weakened or damaged, the structures that keep the rectum in place begin to weaken such that the rectum can shift in position. In severe cases, the rectum can prolapse out of the vagina (a rectocoele), fall through the anus and be visible on the outside (external rectal prolapse), or telescope into the anus or another part of the rectum (internal rectal prolapse) without coming out of the anus.

Forty percent of women with a rectocoele have no symptoms. Those who do have symptoms may have difficulty controlling bowel movements, feel the need to have multiple bowel movements, and/or have a sensation of a bulge or fullness in the vagina. Occasionally, tissue may protrude out of the vagina.

An internal rectal prolapse often causes obstructive defaecation syndrome, ie, a sensation of a blockage in the bowel and difficulty passing a motion, with prolonged and often unsuccessful toilet visits. These patients frequently need to apply pressure with a finger or hand on the perineum, in the vagina, or on the anus to empty the bowel. Men with an internal rectal prolapse develop similar symptoms.

Investigations to exclude other causes will include a vaginal and rectal examination to assess the strength of the anterior (front facing) wall of the rectum. A special X-ray, called a defecogram, can also be used to evaluate the effect of the prolapse on bowel movements.

Rectal prolapse tends to occur gradually. Initially, the prolapse comes down with a bowel movement and then returns to its normal position. Rectal prolapse may be hard to distinguish from haemorrhoidal disease, and can be a confusing condition for specialists who are not evaluating and treating this problem on a regular basis.

Women over 50 years of age are six times more likely to develop rectal prolapse than men. It was thought historically that men do not suffer from pelvic organ prolapse because the male pelvis is much narrower than the female pelvis and does not need to deliver a baby. However, pelvic floor experts now recognise that men can also develop pelvic floor dysfunction. Most women with rectal prolapse are in their 60s, while the few men who develop prolapse are much younger, typically not more than 40 years of age.

Small bowel prolapse

In women, prolapse of the small (upper) bowel occurs when part of the small bowel prolapses into the upper part of the back wall of the vagina, creating a bulge (known as an enterocoele). Symptoms of an enterocoele may include a sensation of pelvic pressure and a feeling of blockage when going to the toilet. In women, an enterocoele is generally felt as a bulge into the vagina. The prolapse itself is not felt and may be difficult to diagnose. In men, the rectum is normally kept separate from the bladder in front of it by a strong wall of tissue known as the rectovesical septum. However, when the pouch between these structures is deep and there is pelvic floor dysfunction, a portion of small bowel may prolapse into this space, causing symptoms similar to those in women.

Surgical options

In women, rectocoeles and enterocoeles are usually defects of the tissue that supports the pelvis and not a problem with the bowel wall itself, so they are often treated by surgery that strengthens the back wall of the vagina.

There are a number of surgical procedures that can be performed for pelvic organ dysfunction. These include:

• Transanal rectocoele repair, an open procedure via the anus to repair a rectocoele. This is an option in patients who have symptoms from a rectocele and wish to avoid or cannot have abdominal surgery. It is lower risk, but there is a higher chance of the procedure not working.
• Rectoanal repair, an open procedure via the anus to repair a rectocoele or an internal rectal prolapse. This is useful in patients with some residual symptoms after a major robotic repair. It is also useful for those patients with less intrusive symptoms.
• Delorme’s procedure, an open procedure via the anus to repair an external rectal prolapse. This is generally reserved for less fit patients with short prolapses.
• Perineal rectosigmoidectomy (also known as Altemeier’s procedure), an open procedure via the perineum to repair an external rectal prolapse. This is generally reserved for less fit patients.
• Ventral mesh rectopexy and variations on this, ie, sacrocolporectopexyand modified Orr-Loygue rectopexy are laparoscopic or robotic procedures performed via the lower abdomen. Ventral mesh rectopexy and its variants are useful for repairing a rectocoele, enterocoele, internal rectal prolapse with obstructive defaecation syndrome or faecal incontinence, external rectal prolapse, or a vaginal prolapse. This is the treatment of choice for these problems.

Clearly, the choice of procedure depends on a number of factors, including the cause of your prolapse, your age, whether or not you have plans to start a family, and any other health problems you might have. All these issues will be discussed with you in detail when deciding on the type of repair that would be best for you.

Pelvic pain is pain that occurs in the lowest part of the abdomen and pelvis (the area below the navel and between the hips). When asked to indicate where the pain is, patients typically brush a hand over that whole area rather than point to a precise spot. Pelvic pain can occur suddenly, sharply and briefly (acute) or be constant or intermittent over a long period of time (chronic). Chronic pelvic pain (CPP) is generally accepted to be pain in the pelvic area that has been present for more than three months.

CPP can be a symptom of an underlying disease or be a disorder in itself. A number of conditions can cause CPP, so patients with this problem may need to see more than one specialist. If the source of the pain can be found, treatment focuses on that cause. If no cause can be found, treatment focuses on management of the pain.

CPP is found mostly in women, but can also occur in men.For some women, the cause of their CPP lies in the reproductive system. However, for other patients, male or female, CPP is related to a problem in the bowel, bladder, or the nerves supplying the pelvis.

There are four main causes of CPP:

• Neuropathic pain – typically burning tingling, shooting or stabbing pain that occurs when nerve fibres are damaged or become trapped. Nerve entrapment syndromes can also occur, as they do in other parts of the body.
• Endometriosis – this is a reasonably common condition in women, in which the tissue that normally lines the uterus also grows in other pelvic structures, including the ovaries, bowel, bladder or tissue lining the pelvis. The connection between endometriosis and CPP is well known. However, this only applies to moderate to severe endometriosis; mild endometriosis almost certainly does not cause the degree of pain seen in women with CPP.
• Levator ani syndrome – this pain comes from multiple trigger points and pressure areas in the musculoskeletal tissues of the pelvic floor, and is felt as an aching or pressure sensation high in the rectum, often worsened by sitting and relieved by walking. Any type of pressure on the pelvic floor can cause the pain to get worse. This pressure could come from intercourse, faeces within the rectum, or passage of faeces during a bowel movement.
• Proctalgia fugax – a rare condition where patients experience recurrent episodes of sudden, sharp shooting pain that starts around the anus and runs up into the pelvis and perhaps into the abdomen. These episodes last for seconds to minutes and may occur up to around 100 times a day. Attacks may come in rapid succession and then go away for long periods at a time.

Diagnosis

The symptoms described by patients with CPP are very helpful for pinpointing the cause of their pain. Therefore, if you have been referred to me for CPP, it would be helpful to write down a detailed list of your symptoms, including the following:

• How long has the pain been there?
• Is the pain continuous or does it come and go?
• Is the pain worse lying down or standing up?
• Is the pain related to your menstrual cycle and/or intercourse?
• Is the pain worse before or after going to the toilet?
• Does it hurt to touch the skin over the affected area?
• Is the pain shooting or dull in nature?
• Is there any shooting pain going up into the abdomen?
• Have you tried anything in the past that has helped to ease the pain?
• Are you being treated for a mental health problem?
• Have you had any injury, physical illness, or surgery in the recent past?

You will also need an examination of the pelvic floor so see how well the pelvic floor muscles are coordinated and if there are any trigger points for the pain, to exclude endometriosis as a cause, and if there are any sensory changes suggesting neuropathic pain. There are no laboratory investigations that would pinpoint the cause of CPP, apart from a laparoscopy for endometriosis. However, I do sometimes take patients to the operating theatre for a pelvic examination under anaesthesia via the rectum or vagina to exclude a range of underlying causes of CPP.

Treatment

My colorectal practice is unusual in that I see patients with CPP referred by my colorectal, gastroenterology and gynaecology colleagues whom most colorectal surgeons would not see. I believe that the most important part of my work as a colorectal surgeon is to know when and when not to operate. People with CPP often have a coexisting condition, like irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, a connective tissue disorder, or a mental health problem, and some may have more than one coexisting condition. My clinical experience over a number of years has taught me that the symptoms of these conditions also have considerable overlap, and need teasing out before I can recommend the best possible treatment plan, which does not necessarily involve surgery.

If neuropathic pain is the cause of CPP, we can start specific medication for this, and here I work very closely with chronic pain physicians. Pudendal nerve entrapment syndrome is a known cause of CPP. If nerve entrapment is the problem, this can sometimes be helped by a nerve release procedure.

If moderate to severe endometriosis is the cause of your CPP, you will need to see a gynaecologist. However, if you have seen a gynaecologist first and your endometriosis has been found to be mild, it is wise to ask for a referral to a colorectal specialist to check for other causes of your CPP before proceeding with a gynaecological procedure. In the same vein, if your CPP has been attributed to adhesions (bands of scar tissue that form between abdominal tissues and organs, causing them to stick together), it is worth a visit to a colorectal specialist to look for alternative causes for your pain. Adhesions do not contain nerves that transmit pain signals and there is no evidence that they cause CPP.

There are several treatments that can help patients with levator ani syndrome. These include pelvic floor physiotherapy, medications (commonly amitriptyline, pregabalin, or gabapentin), and/or Botulinum toxin injection into the pelvic floor muscles. These treatments are often trialled in consultation with a chronic pain physician.

Proctalgia fugax is difficult to treat. As the pain in intermittent and short-lived, painkillers are not particularly useful. For more debilitating cases, a few drugs can be trialled. Most people are happy to find out they have no underlying serious condition and manage the symptoms by themselves. Treatment is best given jointly by a colorectal surgeon and a chronic pain specialist.

CPP is notorious for being hard to treat and is often difficult to manage at the non-specialist level. It is rarely cured completely, but the pain can often be brought down to a manageable level where people can regain a good degree of control over their lives. I have a long-standing special interest in this condition and am receiving increasing numbers of CPP referrals from my fellow specialists. If you are suffering from CPP, it would be worthwhile discussing with your GP the possibility of a referral to me.

Pruritus ani is the medical term for any itch in or around the anal area (from the Latin words pruritus, meaning “itch” and ani, meaning “of the anus”). It can be minor and go away of its own accord or be so severe and long-lasting that it can have a severe impact on the life of its sufferers.

Pruritus ani can occur at any age, but seems to be more common in people aged 40–60 years. It occurs more often in men, with some research suggesting that men are up to four times more likely than women to develop the condition. There is no obvious reason why this should be the case, and more research is needed to look into this.

Pruritus ani can be classified as secondary or primary. If a condition is found in the lower bowel, anus, or on the skin surrounding the anus that is suspected to lead to anal itching, pruritus ani is classified as secondary to that condition. If no abnormality can be found in these areas, then the pruritus ani is considered to be primary (or idiopathic, meaning “no known cause”). Traditionally, pruritus ani has been thought of as a symptom rather than as a condition in itself. However, there is recent research suggesting pruritus ani that is initially secondary to another condition causes changes in the nervous system that lead to the itch becoming permanent, even though the original cause of the itch has disappeared.

Most studies suggest an underlying cause in half to three quarters of people with pruritus ani. Some surgeons believe that nearly all cases are secondary to another disorder and that the closer they look, the more likely an underlying cause will be found. Looking at the medical literature published over the past century, approximately 100 conditions have been reported to be associated with pruritus ani.

Any skin condition that causes itching, such as eczema or psoriasis, can affect the skin around the anus and cause pruritus ani just as easily as it can cause itching elsewhere on the body. However, the appearance of the affected skin around the anus may not necessarily look like the skin areas affected by the same condition on other parts of the body. Sometimes a skin biopsy is needed to make the diagnosis. People who are prone to atopic dermatitis may be at increased risk of pruritus ani.

In some people, a particular food item may be associated with pruritus ani, possibly because it makes their stools looser. Unfortunately, no specific dietary advice can be given to any individual patient, other than to see what happens when they avoid particular foods.

Any medical condition affecting the lower bowel, anus, and the surrounding skin can cause itchiness in the anal area. These range from serious conditions such as cancer of the bowel through to haemorrhoids, anal fissures, a weak anal sphincter, and internal rectal prolapse. All of these conditions are made worse if the person’s bowel motions are looser. With all these conditions, faeces may leak from the anus onto the skin outside, causing irritation. This leak may be so small that it goes unnoticed by the patient when cleaning the area or when it is on their underwear. However, the leak does occur and perpetuates the itch. Luckily, there is every chance that pruritus ani will improve if the patient sees a specialist who checks carefully for a secondary cause.

When no definite cause of pruritus ani can be found in a patient who has been fully investigated by colonoscopy, examination under anaesthesia of the anorectum, and biopsy of the skin, the condition is labelled as idiopathic. However, a good surgeon will always have a high level of suspicion that an underlying cause has been missed.

In a small minority of people, bad hygiene can undoubtedly lead to pruritus ani. However, as a general rule, people with pruritus ani are rigorous with their personal hygiene, which can actually make their anal itching worse.

Many people have itchiness around the anal region that resolves spontaneously or with simple measures. Unfortunately, many people who are profoundly troubled by pruritus ani consult health care professionals who do not take them seriously, so their symptoms do not improve. However, on seeking the advice of a specialist who is interested in this condition, most people report a significant improvement in their symptoms and quality of life.

Treatment

Eliminate irritants

The first step is to stop using any chemicals, including creams, soaps, bubble baths, and toilet paper, around the anal area and only use water for cleansing. Hypoallergenic laundry products are also recommended. Certain foods and drinks are believed to be associated with pruritus ani, and it is well worth eliminating these from the diet for a while to see if this helps. Possible culprits include coffee, tea, cola, energy drinks, chocolate, citrus fruit, tomatoes, spicy foods, beer, dairy products and nuts.

General control measures

The anal area should be cleansed with water alone in the squatting position, making sure to remove any faeces. The area should be patted dry with a soft flannel and dried using a hair dryer if necessary. Water-based creams and emollients can be used if more rigorous cleansing is required. Petroleum ointment, Sudocrem® or Cavilon® should be used as a barrier after cleansing. The anal itch can be hard to deal with when outside the home. Many patients carry a small tube of aqueous cream, which can be used with cotton wool balls to cleanse and coat the anal area after going to the toilet. Patients who sweat excessively can place cotton tissue (unscented products are best) around the anal area. The sedating effect of some antihistamine products may be useful in aiding sleep, but has no effect on the itch itself. Some self-help groups suggest wearing gloves at night to prevent scratching, although this is not always practical.

Drug therapy

Mild to moderate symptoms of pruritus ani without skin changes can respond well to hydrocortisone 1% ointment. How often the ointment is applied can be reduced as symptoms improve. This can be used at the same time as barrier creams. Severe symptoms and skin changes can be treated with stronger steroids for up to 8 weeks, and should be replaced with a weaker steroid ointment when symptoms have improved. Occasionally, creams to eradicate fungal infections such as thrush are useful. Antibiotic creams are no longer used.

Anal tattooing

I am one of the very few specialists in the UK able to perform anal tattooing for pruritus ani. This procedure is generally reserved for patients who cannot be help by other means and for those who have become steroid-dependent. Anal tattooing is performed under general anaesthesia and uses methylene blue to reduce sensation in the anal area, cutting off the sensation of itch. The tattoo itself lasts only a matter of weeks and the skin looks no different in the long term. The skin may have a reduced sensation for up to a year and the procedure can be repeated if necessary.

Ulcerative colitis (UC) is an inflammatory bowel disease affecting the colon and rectum. The colon and rectum are the final parts of the gastrointestinal system and together are known as the large bowel. They receive the end products of digestion from the small bowel and their role is to absorb water and salt. During this process, faeces are formed and stored by the colon and rectum until the person wishes or is able to go to the toilet.

Inflammation of the lining in the colon and/or rectum reduces the ability of the large bowel to absorb water and form faeces. Therefore, patients with UC typically develop diarrhoea that is sometimes bloody.

There are no obvious causes for UC, but undoubtedly it is a combination of genetic and environmental factors. Some families contain more members with UC than would be found in the general population, and there is an increased incidence in identical twins. However, it cannot be said that children will definitely develop UC if one of their parents has the disease.

Some researchers have suggested that certain types of food are associated with UC, but other studies have not confirmed this. Overall, the cause(s) of UC are still unknown. Stress and worry are not causes, but may trigger a relapse of UC or make its symptoms worse.

People with UC involving only the last part of the large bowel generally have milder symptoms. They may have only one flare-up in their lifetime and never have problems with UC afterwards. However, about 15% of people with initially mild UC may go on to develop more severe disease. Unfortunately, those patents with more extensive disease at the outset are less likely to achieve remission and are likely to have increasingly severe problems with UC.

We do know that there is an association between UC and an increased risk of bowel cancer. In people with UC affecting more than half of the large bowel (pancolitis) and the inflammation is particularly severe, there is an increased risk of colorectal cancer after 10 years. For this reason, patients with more extensive UC are offered annual screening colonoscopy for bowel cancer starting eight years after their diagnosis of active UC. There is no increased risk of bowel cancer in people with milder forms of the disease.

UC is diagnosed by colonoscopy. UC continues to be an area of extensive research, but as yet no major breakthroughs have been made.

Treatment

Medication

There are many medications that can help to reduce the symptoms of UC and induce remission, and others that can help to prevent flare-ups of the disease. These include the anti-inflammatories, steroids, immunosuppressants, and newer biological therapies. Each agent has specific uses and indications. Severe forms of UC can result in having many episodes of severe diarrhoea in a day, requiring intensive medical therapy that comes with side effects.

Women with UC are encouraged to time their pregnancies during periods of remission, so that their medications can be kept to a minimum. Some medications used in UC have no effect on the reliability of contraception, becoming pregnancy, or development of the unborn baby. Unfortunately others do, and women taking these are encouraged to use contraception. The chances of a woman with UC becoming pregnant are no different to the rest of the population, and the risks of pregnancy are the same.

Surgery

The milder versions of UC are not dangerous and only need treatment if symptoms warrant. However, the more severe forms of UC are associated with complications, some of which present needing emergency surgery. Other patients may opt for elective (planned) surgery for UC because medical therapy has not reduced the severity of the disease.

The most common procedure (emergency or elective) performed for UC is a total colectomy. This procedure is usually performed by laparoscopic surgery. When a total colectomy is performed as an emergency, the bowel ends are not joined together and the end of the small bowel is brought out through the right lower abdominal wall. This is known as an ileostomy. Effluent from the small bowel then collects into a bag that the patient empties as needed.

When the patient has recovered, there are several options available if the colon has been removed but the rectum is left inside. If the patient is still having trouble in terms of bloody or mucous discharge, the rectum will need to be removed at some stage. In this situation, the patient can decide whether they want to keep their ileostomy or wish to be considered for ileal pouch surgery. Pouch surgery is generally suitable for people younger than 45 years with good anal muscles and a clear understanding of the long-term nature of this procedure and its potential complications. In the small number of people in whom the rectum is not particularly inflamed, rejoining the small bowel to the top of the rectum is a possibility. All of these paths have advantages and disadvantages as well as complications, and these will be discussed in detail with you.