Rectal Bleeding
Rectal bleeding is a very common symptom. It can be divided into overt (visible) bleeding and occult (invisible) bleeding. Mostly overt rectal bleeding is due to benign causes (non-cancerous), but it should always be discussed with your doctor and in most cases it should be investigated. The minimum examination would include a rectal exam (finger in the bottom) and a sigmoidoscopy, both of which can be done in a clinic setting. Painless bright red bleeding on the toilet paper or dripping into the pan is usually due to haemorrhoidal bleeding. If the bleeding is associated with painful passage of stools, then it is possibly due to a fissure (crack) in the anal canal. Both conditions are easy to treat and mostly don’t require surgery.
Passage of altered blood especially if mixed with stool, mucus or associated with a change in bowel habit is more concerning and must be investigated. In this case the lining of the rectum and colon should be directly viewed with a colonoscopy. Increased frequency of bowel motions and a sensation of incomplete evacuation are concerning symptoms especially when accompanied by bleeding. Occult (invisible) bleeding is only picked up when a patient becomes anaemic or iron deficient due to chronic blood loss. Alternatively it can be found by measuring blood in the stool, faecal occult blood test or FOBs. It should always be investigated, usually by colonoscopy and gastroscopy.
If in doubt always discuss your bleeding with your doctor.
Common Bottom Problems
Haemorrhoids (piles)
The haemorrhoid tissue is a specialised ring of tissue in the top of the anal canal rich in blood vessels. In some people the connective tissue holding it in place can become weakened and the haemorrhoid tissue can then become a problem. The commonest symptom is painless bleeding of bright red blood onto the paper or into the pan with defecation. As they progress the haemorrhoidal tissue can prolapse leading to lumps that need to be reduced after defecation. Haemorrhoids are only painful when the blood vessels inside clot causing thrombosed haemorrhoids that look like purple grapes around the anal opening. Many times the history of haemorrhoids will run down the male side of the family or be associated with pregnancy.
Most haemorrhoidal bleeding can be treated with rubber band ligation plus injection of a sclerotherapy agent called phenol in almond oil. This is often done after or during colonoscopy or in the clinic. Surgery is only needed for large prolapsing haemorrhoids.
Fissure in ano or anal fissure
This is a common condition that causes extreme pain, plus or minus bleeding with defecation. It is caused by a small longitudinal crack running down some of the length of the anal canal usually at the back or front. It comes on for no obvious reason in most patients but can be associated with pregnancy and bouts of diarrhoea. Treatment is with topical medication, laxatives and good diet and exercise. In some people the condition becomes chronic and surgery is needed to fix it.
Skin tags
These are extremely common tags of skin that hang around the anal canal. They become more common as you get older and may follow on from pregnancy, previous haemorrhoids or fissures. In themselves they are not a problem apart from their cosmetic appearance. Occasionally they can make cleaning after defecation a problem in which case they can be surgically removed.
Pruritis ani (itchy bum)
This is an extremely common problem especially in men and especially in summer. It is caused by a multitude of problems including haemorrhoids and anal fissure. It can be very resistant to treatment and may need specialist input.
