Right everyone, sit up straight and pay attention. This is an area that is poorly understood. I will now try to shed some light where the sun don’t shine
Your bum is designed to pass poo out. It does this best if it is in well formed turds. Liquid poo comes down the digestive tract (colon) round the S-bend (sigmoid colon) and into the rectum (the straight bit near your bumhole). Here the liquid poo has some of the water reabsorbed so that it becomes a nice putty consistency and can be poo’ed out (defaecation)
Haemorrhoids
The lining of the rectum is well supplied with blood vessels (so that water can be absorbed) and these are formed into small grape like clusters near the lower end. This is called the haemorrhoidal plexus (which is where the name haemorrhoids comes from). The haemorrhoidal plexus of veins can become distended and enlarged (a bit like varicose veins in the legs) and occasionally dangle out of ones tail end. If this occurs, they are usually easily pushed back in with a finger (they can have elastic bands placed around them to make them shrivel up (done in the surgical clinic up a device called a proctoscope). Some surgeon inject them with something to make them shrink (a sclerosant such as phenol)
If ones haemorrhoids are enlarged (something that can happen in pregnancy) then you are prone to having a hard bit of poo (like concrete) scrape them – this tends to cause painless bright red rectal bleeding and classically comes out of the bottom just after the poo, and can even leave bright red streaks of blood on the poo.
This is what one looks like up a proctoscope. For grading (I-IV by Banov) check the wikipedia link
Perianal haematoma
I will here mention another thing near the bottom called a peri-anal haematoma. This is important mainly because this is what most non-medical people (and a few medical ones) incorrectly call ‘piles’ or ‘haemorrhoids’. Ones anus (the crinkled skin which stretches to allow poo out and then shuts to keep ones pants clean) is a very well designed bit of kit. It needs a good blood supply and indeed gets one. The circular muscle just inside which has the same function is also well supplied with blood. This means that there are plenty of blood vessels around. The downside of this is that on ’straining at stool’ (trying to push a hard poo out) you can burst one of these blood vessels. This results in a blister under the skin right next to your anus. You can see these – they are bluish and around 1cm big. They are very tender to touch when they first form
Haemorrhoids are painless (because they come from inside you where there aren’t stretch fibres in the skin covering it) and perianal haematomas are painful (cos they arise from the outside skin – which really doesn’t like being stretched). Another word for haemorrhoids is ‘piles’ (or Chalfont-St-Giles in English cockney rhyming slang)
Piles are painless
When a perianal haematoma shrivels up (a few weeks later – though you can expect the pain to be gone after a few days) it is because the body has reabsorbed the blood. Sometimes the skin has become over-stretched and leave a small skin tag (these may be seen with the aid of a mirror and are of no consequence
Sometimes you get dark blood (or even black like coffee-grounds) out of your bumhole (this is potentially more serious and you should go and see a doctor – it can sometimes be a sign of cancer. Particularly if you have any unexplained weight loss or abnormal tiredness)
Cream for the itching?
Before I leave perianal haematomas alone I need to dispel a few more myths. Creams that you can buy from the chemist won’t help. They won’t go away any quicker (nor will proper haemorrhoids dangling out). These creams claim to stop itch.. well the itch is usually caused by poo. That’s right. Your ring piece has got beautiful crinkled skin and it is very easy to get a few specks of poo left after you wipe. This is much more likely to happen if you have a painful blue grape there as well (perianal haematoma). Poo is painless inside (again, the skin inside is specially designed for this) but very irritant if it is contact with the delicate outside skin
Quite a successful way of cleaning if one is in pain is to use wet-wipes (moist toilet tissues) and to gently wipe till you don’t get any marmite (brown slears). This is cheaper that those creams – and more likely to work now you have a good grasp of the underlying anatomy and medical condition which you may have
No more marmite
Anal fissures (not all they’re cracked up to be)
A quick word on fissures and then we’re done. A fissure is a crack or split in the skin of your anus (bumhole). These can be exquisitely tender and typically cause pain on pooing. Also some bright red blood may be seen on the toilet tissue. Most of these get better with good cleaning (see above) as this removes the irritant material with can perpetuate the fissure. Occasionally you may need to consult a doctor (who can prescribe medication – GTN or glyceryl trinitrate ointment, which can be very effective)
The last word is just to mention some detail about the above conditions for those who like to put things up in the other direction (fingers, willies, vibrators and so forth). Haemorrhoids won’t be worsened (though if bleeding occurs you may wish to be a trifle more gentle), perianal haematomas – i recommend waiting until they aren’t painful, these also won’t be worsened. Anal fissures may be worsened – so I would suggest waiting until the fissure is completely healed. Anal bruising is painful and looks like a generalised red/blue discolouration which tends to be painful – in which case I recommend lots more lubrication, more gentleness or avoid the bum
Keep well
dr B









