Understanding piles, fissures, and fistulae

A wide variety of medical conditions can result in discomfort and pain in the anus, and to a varying degree. But what's the difference between piles (haemorrhoids), fissures and fistulas? Revered consultant general surgeon, Mr Parv Sains, clarifies the differences in our latest article. The suregon, who practises in Worthing, Hove and London, explains what each of these conditions is an outlines how they are treated. 

What are piles, fissures and fistulae? 

Piles, also called haemorrhoids, are swellings containing blood vessels inside and around the anus. They are part of the normal anatomy of the anus and act as cushions so that the anus can close fully. It is common for the piles to swell and become larger than they need to be. Symptoms can include an itchy bottom, bleeding that is usually bright red in colour, or prolapse (something bulging out at the bottom end). It’s a benign condition that usually requires anything from no treatment, minor treatment such as ointments, to banding or surgery. 

Fissures are essentially a split in the anal canal skin. They can occur at any age but mostly affect the younger age groups, particularly those who have constipation or those who pass particularly large stools. They can be very painful and patients often describe the sensation of passing stool with a fissure like trying to pass a shard of glass. Pain can be present after going to the bathroom, lasting for hours as throbbing pain, or it may be more debilitating and constantly there. Like piles, fissures are a very common condition and completely benign, however, they can cause a lot of discomfort for the patient. 

A fistula is defined as a connection between two surfaces that shouldn’t be there. An anal fistula, or fistula around the bottom end, is a tunnel-like connection that joins the anus or anal canal to the skin of the buttocks. It normally results from an abscess, an infected pus-filled anal gland, that leaks out through the skin next to the bottom, but also into the anus or anal canal creating a channel. This can range from a simple issue that can be dealt with immediately, to something more complex that requires a lot more time and attention. 

Can one lead to another?

In the case of haemorrhoids, fissures or fistulas, thankfully having one doesn’t lead to having another.

Is it possible to have more than one condition at once? 

These conditions can coexist at the same time. If you are experiencing pain in that area, you can only determine what it is once you’ve been examined. 

What are the differences in treatment? 

The treatment for each condition is different. Many patients who visit their GP with symptoms are referred to a colorectal surgeon or a gastroenterologist. The primary aim of examinations when patients present symptoms is to ensure that there is nothing more worrying going on, like cancer. The procedure performed is based on a discussion, involving the patient, to see exactly what their symptoms are and what they want to achieve. 

Haemorrhoids can be treated with ointment and simple dietary changes to increase fibre intake and prevent constipation. Occasionally banding the haemorrhoids is required, which involves placing a tight band around the base of a haemorrhoid to cut off its blood supply. Stitching the blood vessels reaching the haemorrhoid is a similar method used. For the larger haemorrhoids sometimes more advanced treatments are required, and a haemorrhoidectomy, excising the haemorrhoid from the bottom end, may need to be performed. 

Fissures can be treated with ointments, and even Botox injections, but if they don’t heal there are operative procedures such as the lateral sphincterotomy procedure. This involves a little incision that’s made into the muscle of the anal canal, controlling the anus. Doing so relieves the pressure, allows a better blood supply to the fissure, and the anal fissure to heal.

While piles and fissures can be treated with creams, there are no ointments that can help fistulae. They require operative management, which can be a small operation that cuts the fistulae open, it is cleaned, and it is left to heal. Sometimes they can be more complex if they tunnel through the muscle around the area of the anus. In this case, a lot more investigation with MRI scans and a longer treatment period is required, often with something called a seton. A seton is a rubber sling that is inserted into the fistula through to the anus and kept there for several weeks to keep the fistula open, allowing drainage. It also helps the healing without causing injury to the sphincter muscles, which should be avoided to maintain continence. 

There are a variety of methods available to treat these conditions, my favourite being the approach that is most conservative, either in the way of an operation or seton. However, the method is ultimately decided with the individual patient, managing their expectations and keeping them informed on their options throughout to ensure they arrive at the solution they desire and to avoid further complications. It is vital to have an informed discussion with the patient and provide continued support and information until full resolution of the fistula has occurred.

Can the symptoms be a sign of something more serious, if so, what?

With some of the symptoms that are experienced, especially with piles, it is important to exclude anything else that is going on that is more worrying, like polyps or even bowel cancers. These are rarer than piles, but it is important to make sure that anything more serious is being excluded. A camera test (flexible sigmoidoscopy or colonoscopy)  is carried out, or a special type of CT scan, to make sure there is nothing within the bowel higher up that is causing the bleeding and a simple examination in a clinic is sometimes sufficient to make sure there is nothing else causing these symptoms. It can be it’s a very reassuring thing to do to make sure that the primary problem isn’t something like cancer, and the real cause can be treated accordingly. 

If you would like to book a consultation with Mr Parv Sains, you can do so by visiting his Top Doctors profile.