Many gastrointestinal problems may involve the anus and rectum. The rectum is the end of the large intestine, between the sigmoid colon and the anus. The anus is located at the very end of the digestive tract, where stool exits the body. The anal sphincters are the rings of muscle that keep the anus closed between bowel movements. Changes in the frequency, consistency, composition or volume of bowel movements may signify a gastrointestinal problem.

Many anal and rectal problems involve abnormal structures and can be identified by a visual or manual examination. These include hemorrhoids, obstruction and congenital problems where there is no anal opening (imperforate anus) or the anal opening is abnormally small. Some problems occur due to malfunctioning muscles, nerves or other structures in the anus or rectum. Problems related to the function of the anus and rectum include fecal incontinence, proctalgia fugax or rectal pain, and painful bowel movements (dyschezia). Anal and rectal problems may also result from infectious or inflammatory causes such as anorectal abscesses and proctitis.

While the causes of anal and rectal problems are quite diverse, these problems may produce very similar symptoms. The most common of these are anal itching, constipation, pain and bleeding. The diagnosis of anal and rectal problems typically involves an evaluation of the patient's medical history, a physical examination and a series of diagnostic tests. While gathering the patient’s medical history, physicians and gastroenterologists generally ask about symptoms, bowel habits and changes in bowel patterns. The physical examination usually involves the examination of the anal area and a digital rectal exam. The most common diagnostic tests include anoscopy and sigmoidoscopy.

The anus and rectum are the final portions of the gastrointestinal tract in relation to digestion and excretion of food products, and are subject to numerous problems. However, many patients are reluctant to ask or speak about these problems with their physician or gastroenterologist. Some anal and rectum problems can become quite serious if they are not treated.

The rectum is at the end of the large intestine, between the sigmoid colon and the anus. It is lined with tissue that contains glands that secrete mucus to protect and lubricate the rectum.

The anus is located at the end of the rectum. It is the opening where stool exits the body. The anal tissue includes both surface skin layers and intestinal tissues. The nerves in this area are very sensitive to pain.

Rings of muscles called anal sphincters keep the anus closed between bowel movements. The interior sphincter is located closer to the rectum and is controlled subconsciously. The exterior sphincter is closer to the skin and can be controlled voluntarily.

Stool that passes through the digestive system is stored in the descending colon. When this becomes full, the stool moves through the sigmoid colon into the rectum, which stretches as it fills. As the rectum senses the presence of stool, it causes an urge to defecate. Older children and adults can hold stool in the rectum until an appropriate time and place for a bowel movement. However, infants and younger children do not have the necessary muscle control and cannot withstand the urge to defecate.

Bowel patterns vary greatly from person to person. Further, a person will generally have different bowel patterns at different times. Factors such as diet, stress, medications and disease can affect bowel patterns. Regular frequency of bowel movements in Western societies may range from two or three a week to two or three a day. In most cases, it is easiest to defecate in the morning, particularly 30 minutes to an hour after the first morning meal.

Chronic or sudden changes in the frequency, consistency or volume of bowel movements may signify a gastrointestinal problem. The presence of blood, mucus, pus or excessive oil or grease in the stool may be warning signs of a problem anywhere in the gastrointestinal tract. Problems that originate in the rectum or anus are usually related to abnormal structures, improper function or infections or inflammations. Some problems may fall into more than one category. For example, an anal fissure (tear) originates as a structural problem, but if left untreated may affect anal function.

Many anal and rectal problems involve abnormal structures and can be identified by a visual or manual examination. These include:

• Hemorrhoids and anorectal varices. Hemorrhoids are stretched, dilated veins in the walls of the anus and rectum. They may remain inside the anus or protrude. Hemorrhoids occur when pressure in the affected vein increases due to a variety of factors (e.g., straining during defecation, frequent heavy lifting, pregnancy). Anorectal varices are small, swollen veins located just under the inner mucosa layer in the anus and rectum. While they appear similar to hemorrhoids, anorectal varices are not directly related to them. They are the result of high blood pressure in the portal vein (portal hypertension).
  
  
• Obstruction and fecal impaction. Obstruction occurs when something blocks the stool and impedes defecation. Fecal impaction occurs when obstruction is caused by hardened stool in the colon or rectum. This occurs more frequently in older adults and pregnant women. Possible causes of other forms of obstruction include anal stenosis, dysfunction of the pelvic muscles, Crohn's disease, injury or inflammation following radiation therapy, infection and cancer.
  
  
• Anal fissure and ulcer. An anal fissure is a tear in the lining of the anus. If the fissure does not heal, it becomes an ulcer. Anal fissures cause spasms in the anal sphincter, which make healing difficult. They may be caused by a hard or large bowel movement or by sexual penetration of the anus.
  
  
• Anorectal fistula. An abnormal passageway between the anus or rectum and the skin around the anus or another organ, especially the vagina (rectovaginal fistula). While these may be birth defects, they are usually caused by an abscess. Congenital (birth defect) fistulas are more common in boys. Anorectal fistulas may develop after injury during childbirth, after radiation therapy or as a result of certain diseases (e.g., diverticulitis, Crohn's disease, tuberculosis, cancer).
  
  
• Rectal prolapse and rectocele. Rectal prolapse occurs when the rectum turns inside out and protrudes through the anus. In children, it may occur while they are straining to defecate, which is usually temporary and not serious. However, in adults, prolapse typically persists and worsens. In some cases, the entire rectum may prolapse (procidentia). In women, rectocele occurs when the rectum protrudes into the vagina. Rectal prolapse and rectocele in adults are generally believed to be caused by a loss of strength in the tissues that hold the rectum in place. This is more common with advancing age. Rectocele occurs as a result of damage after vaginal childbirth, the strains to the tissue caused by constipation, obesity or heavy lifting.
  
  
• Anal stenosis. The narrowing of the anal canal. This may occur as a birth defect in infants or from scarring after anal surgeries among adults. Current treatments can either dilate the anus or surgically remove scar tissue.
  
  
• Imperforate anus. A birth defect where the anal and rectal region is not properly developed. This occurs in around 1 in 5,000 infants, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). In some cases, the rectum does not connect to the anus (anorectal atresia). It may simply end or connect elsewhere, such as the urethra, bladder or vagina. In other cases, the anus may be very narrow or missing (anal atresia). In girls, a single opening may incorporate the rectum, vagina and bladder (congenital cloaca). These conditions require surgical correction.
  
  
• Hirschsprung’s disease. A rare congenital abnormality where the nerves to anal sphincters are not normally developed and infants are severely constipated because the sphincters do not relax.  Occasionally, a milder form is found in adults.  Surgery is usually required.
  
  
• Foreign bodies. Sometimes, objects may become stuck in the rectum or anus. These may be objects that have been swallowed (e.g., toothpicks) or objects inserted through the anus (e.g., enema tips, thermometers, objects used for sexual stimulation).

Many anal and rectal problems are the result of improper function of the muscles, nerves or other structures in the area. These functional problems of the anus and rectum include:

• Fecal incontinence. The inability to control bowel movements. According to the American College of Gastroenterology, more than 5.5 million Americans experience fecal incontinence. This condition generally occurs when the anal sphincter muscles weaken or are damaged, the nerves supplying the sphincter muscles are damaged, or the rectum thickens so that it cannot stretch properly. Diarrhea and fecal impaction may cause brief episodes of fecal incontinence. Persistent fecal incontinence may occur as a symptom of many problems, such as  spinal or anal injuries, anorectal abscess or fistula, rectal prolapse, dementia, radiation therapy or certain  illnesses (e.g. Crohn's disease, multiple sclerosis, diabetes). The sphincter muscles become weaker with age, making this more common in older adults. The external sphincter is also thinner and more susceptible to injury in women.
  
  
• Proctalgia fugax. Severe, episodic pain around the rectum and anus. This pain usually occurs at night and lasts from a few seconds up to 30 minutes. While the cause is not known, spasms in the muscles around the rectum are generally believed to be involved.
  
  
• Levator ani syndrome. Persistent, aching, pressure-oriented pain around the rectum and anus. The pain may be initiated by bowel movements or sitting for long periods of time. It is believed to be caused by spasms in the muscles around the anus.
  
  
• Dyschezia. The inability to properly control the muscles in the pelvis and anus, leading to difficulty in defecating. This may be caused by rectal prolapse, rectocele, failure of the sphincters to relax during defecation (anismus) or a disturbance in pelvic muscle coordination (pelvic floor dyssynergia).

Anal and rectal problems may also result from infectious or inflammatory causes. These include:

• Anorectal abscess. An abscess is an enclosed, infected cavity filled with pus. Anorectal abscesses typically develop in the deep mucus glands located in the wall of the anus or rectum. They may occur deep in the rectum or close to the skin around the anus. Abscesses near the skin may be visible as red, tender lumps. Most anorectal abscesses are caused by bacterial infections. Abscesses may eventually form an anorectal fistula, an abnormal channel in the anus or rectum.
  
  
• Proctitis. Inflammation of the lining of the rectum (rectal mucosa).  This may be chronic or acute. There may be a number of causes, including Crohn's disease and ulcerative colitis. Other causes include rectal injury, allergies, nerve malfunction, sexually transmitted diseases (e.g., gonorrhea, syphilis, chlamydia, herpes) and bacterial infection (e.g., salmonella). Radiation therapy and antibiotics may cause proctitis by changing the balance of naturally occurring bacteria in the rectum, called the intestinal flora, allowing other bacteria to grow in their place. Patients with weakened immune systems have an increased risk for proctitis.
  
  
• Inflammatory bowel disease (IBD). Chronic inflammation of the intestine. These conditions may affect the anus and rectum as well as other parts of the bowel. The primary types of IBD are ulcerative colitis and Crohn’s disease. Ulcerative colitis usually begins in the rectum or sigmoid colon and spreads to other areas of the colon. However, it may affect the rectum alone (ulcerative proctitis). Crohn’s disease and other forms of colitis may also inflame the rectum and colon.
  
  
• Anal warts. Cauliflower-like warts may develop on the skin around the anus. These are typically caused by an infection of condylomata acuminata, which is usually transmitted sexually.
  
  
• Anal and rectal cancer. Colorectal cancer may affect the anus and rectum. Anal cancers are very rare.

While the causes of anal and rectal problems are quite diverse, they may produce very similar symptoms. For instance, anal itching (pruritus ani) is extremely common and affects nearly everyone at some time.

Anal itching has numerous causes. Certain foods, such as spices, citrus fruits, coffee or beer, can cause itching. Poor or excessive hygiene can irritate the anus, causing itching. More serious causes include draining fistulas, infections and cancers. In some cases, the cause is not directly related to the anus or rectum. For instance, diabetes and liver disease have been associated with anal itching.

Significant changes in bowel consistency or frequency are also common symptoms of anal or rectal problems. For instance, constipation is a common symptom of obstruction and dyschezia. Because the stool cannot pass from the body, it remains in the intestine and becomes hard and dry. This form of constipation is often accompanied by a frequent or constant urge to defecate. Pseudodiarrhea may occur when watery mucus or liquid stool oozes around an obstruction. Anal stenosis may cause bowel movements to be very thin and difficult and may lead to bloating. Loss of appetite, nausea, vomiting and abdominal bloating may also occur when constipation results from an inability to pass stool from the body. However, diarrhea is usually caused by medical issues occurring higher in the intestines rather than the anus or rectum.

Mild to severe pain is a common symptom of several anal and rectal problems. Anal fissures often result in severe, tearing or burning pain that begins during a bowel movement and lasts for minutes or hours. Sudden, severe pain during bowel movements may also be a symptom of a foreign object in the rectum or anus. An anorectal abscess may produce severe, continuous, throbbing pain that gets worse when walking or straining during a bowel movement. Other potential causes of anal or rectal pain include hemorrhoids, anorectal fistula, proctitis and fecal impaction.

Many anal and rectal problems may cause streaks of blood in the stool or on toilet paper. Bleeding may be painless. Blood in the stool is usually associated with other gastrointestinal problems, such as polyps or peptic ulcers. Anorectal problems that may cause bleeding include hemorrhoids, fissures, proctitis or anorectal varices. These generally result in only small amounts of blood, but anorectal varices may cause massive, life-threatening bleeding. When bleeding is extensive, anemia may result. Any rectal bleeding could also signify more serious problems (e.g., cancer) and require a thorough evaluation by a physician or gastroenterologist.

Mucus discharge may occur in some anal and rectal problems such as hemorrhoids or proctitis. Pus discharge may result from other problems (e.g., anorectal fistulas). This discharge may seep through the anus or appear on the side of the stool.

Although most anal and rectal problems can be diagnosed by a physician, many patients are referred to a gastroenterologist, colorectal surgeon or proctologist. The diagnosis of anal and rectal problems typically involves an evaluation of the patient’s medical history, a physical examination and a series of diagnostic tests. While gathering the patient’s medical history, physicians and gastroenterologists generally ask about symptoms, bowel habits and changes in bowel patterns. They may ask if the patient has had similar symptoms in the past or if he or she has a family member with similar symptoms. Patients may be reluctant to discuss these factors, but need to be open and honest to obtain an accurate diagnosis.

The physical examination usually begins with an examination of the anal area. The skin around the anus is examined for any abnormalities. The physician or gastroenterologist will generally test (palpate) for anal reflexes by using light pressure or even tiny pinpricks around the anus. A digital rectal exam is generally performed. A gloved finger is inserted into the rectum to feel for any abnormalities. This may be accompanied by a visual and manual examination of the vagina in women.

Imaging tests help diagnose many anal and rectal problems. The most common of these involve a tiny, lighted camera on a thin tube connected to a monitor. An anoscope or proctoscope uses a short, rigid tube to examine just the anus and rectum. A sigmoidoscope uses a longer, flexible tube capable of extending deeper into the colon. These tools are inserted through the anus. While these procedures may be uncomfortable, they are typically not painful. If the anal and rectal area is sensitive due to a condition, anesthesia may be used. Tissue and stool samples may be obtained during these procedures for biopsy.

Other diagnostic tests for anal and rectal problems include:

• Barium enema. A solution containing barium is inserted into the rectum and colon. Barium acts as a contrast medium to allow the internal structures to show up more clearly on an x-ray.
  
  
• Endoscopic ultrasonography. An ultrasound probe is inserted into the rectum to generate images of the rectal and anal structures including the sphincter muscles.
  
  
• Defecography (proctography). A barium solution is used, followed by an x-ray of the anal and rectal region that is taken while the patient sits on a specially designed toilet. The patient is generally asked to cough, press the buttocks together, defecate and bear down as if trying to defecate. Images can show the muscle movements in the anus and rectum.
  
  
• Anal electromyography. The electrical nerve function of the anus is assessed using tiny needle electrodes inserted into the muscles around the anus.
  
  
• Anorectal manometry. A test that measures the strength of the anal sphincter muscles and rectal sensation. A short, flexible tube is inserted into the anus and rectum to assess the pressure generated by the muscles at rest and when squeezing.
  
  
• Blood and fecal tests. Can be used to identify the presence of infection and rule out other possible causes of symptoms.

Most anal and rectal problems can be treated successfully when diagnosed early. Many simple alterations in diet and daily habits can help to both treat and prevent many problems of the anus and rectum. A diet with plenty of fiber and water is important. Fiber and fluids help maintain proper bulk and consistency of stool, reducing the chance of constipation and problems linked to constipation. Soft, consistent stool is also much less likely to irritate the lining of the rectum and anus. Loose, lightweight cotton underwear is better for hygiene purposes.  Tight underwear can cause anal itching and irritation.

Regular bowel habits may help alleviate or avoid many problems. When feeling a need to have a bowel movement, patients should not wait any longer than is necessary to find a toilet. A bowel movement should not be forced. It is best to allow plenty of time rather than straining. When cleaning the anal area after bowel movements, absorbent cotton or soft, plain toilet or facial tissue may be used to gently dab and wipe. Women should wipe front to back to avoid transmitting bacteria from the anus to the vagina. The cotton or tissue may be moistened with warm water. Aggressive rubbing or the use of harsh, scented tissue can cause irritation. The anal area should be washed with plain water without soaps. It is best to keep it dry. A small amount of cornstarch or talc may be used to absorb moisture.

Many medications may be used to treat anal and rectal problems. Stool softeners or bulking agents are frequently used to combat constipation, although some causes of constipation (e.g., fecal impaction) do not respond well to these. Medicated suppositories and creams may be used to speed healing and ease discomfort, pain and itching. Anal and rectal problems caused by infections (e.g., certain forms of proctitis, anorectal abscess) may be treated with antibiotics. Anti-inflammatory drugs may be used to treat pain and inflammation.

A sitz bath is commonly used to treat many anal and rectal problems associated with pain, including hemorrhoids and anal fissure. The patient sits in a bath or special container filled with warm water that covers the hips and abdomen. It eases discomfort and increases blood flow.

Anal and rectal problems caused by weakness of the sphincter muscles (e.g., fecal incontinence) may be treated with bowel training and exercise therapies. These help to establish regular bowel movements and improve the strength and tone of the muscles around the anus. The anal muscles are exercised by squeezing and releasing them. Biofeedback may also be used to retrain the anal sphincters and increase rectal sensation.

Fecal impaction may be treated with digital fecal removal. This involves using a gloved finger in the anus to remove hardened stool. This and other causes of constipation may also be treated with enemas to clean the stool from the rectum and colon.

Many anal and rectal problems can be treated with minor procedures in the office of a physician or gastroenterologist. An injection with Clostridium botulinum toxin may be used to reduce sphincter spasms so that anal fissures may heal.  Hemorrhoids may be shrunken using rubber band ligation, in which a tiny rubber band is wrapped around the base of the hemorrhoid to make it shrink. Bleeding caused by hemorrhoids or proctitis, may be stopped using electrocoagulation or laser coagulation. Foreign objects may be grasped and pulled removed. In some cases, a rectal retractor may be used to spread the anal canal wider in order to make it easier to remove a foreign object. If an object cannot be removed by these means, surgery may be necessary.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following anal and rectal problem-related questions:

1. What kind of anal or rectal problem do I have?
   
   
2. Is this problem likely to lead to more serious complications?
   
   
3. What may be the best treatment for my problem?
   
   
4. How long will it take to treat my problem?
   
   
5. What activities should I avoid during treatment?
   
   
6. When will I be able to resume my normal daily activities?
   
   
7. Is my particular medical issue hereditary? Should members of my family be screened?
   
   
8. Are my child’s (or infant’s) bowel habits in the normal range or is there the possibility of a problem?
   
   
9. How may I prevent this and other anal and rectal problems in the future?
   
   
10. Which signs or symptoms should I report to you immediately?
    
    
11. Is this problem related to other gastrointestinal problems?