Rectal Surgery: What is a rectal abscess? How is a fistula treated? Is it easy to fix?

Anorectal Infections

INFECTIONS do not occur because the rectum is dirty and has "bad" bacteria. The bacteria in the mouth, especially in the presence of bad teeth and gums, are capable of producing even more virulent infections. The majority of the infections in this area originate in the little slitlike pockets in the anus. A bit of stool gets caught in this pocket; this hard particle abrades the lining, rendering it a portal for bacteria to enter the deeper tissues and to infect them. These infections may also start in anal cracks (fissures) .that can come about from direct injury or from excessive straining at stool. The large amount of fat around the rectum, in the innermost area of the buttocks, is a poorly resistant area and, therefore, especially prone to these infections and abscesses.

What is a rectal abscess? 

This is a collection of pus in the fatty tissues alongside the rectum. It is different from the more usual type of skin boil which just happens to be near the anus.

How does it differ from a boil? 

The difference is important not only in the way it originates but in the treatment and in what may occur. A rectal abscess has its start within the rectum, and its external manifestation is in the skin and fat. Therefore, in order to achieve a cure, it is necessary to open up the rectal part of the abscess to remove the feeding area. It is not enough to drain off the collection of pus (abscess); the source of the leak (the internal opening in the rectum) must also be opened. A skin boil starts in the base of a hair follicle and is cured by opening it.

Can this rectal infection come from something I do? 

It is possible. A fissure, or crack in the rectum, can result from a scratch due to squeezing through the passage of hard stool. Some people on occasion become so constipated that they extract the hard stool with their fingers; this can likewise bruise the area. The rectum can be bruised by an indelicate insertion of an enema tip, thermometer or other instrument.

Can my fistula or an abscess become a cancer? Is it a venereal disease? 

No.

What is a fistula? 

This is a tunnel that runs beneath the skin from an infected area in the rectum to the skin about the rectum. It discharges pus either continuously or intermittently. The external opening, a small dimple, can remain closed and apparently healed for a long time only to reopen because the infected feeding focus is still present.

How is a fistula treated? Is it easy to fix?

It can be permanently cured only by surgery. The entire tunnel, including the internal opening in the rectum, must be either totally removed or drained; otherwise, it will recur. This is sometimes easily accomplished. In other instances, especially with recurrent operations or where there are many external openings, it can be a complicated procedure. The operation may have to be done in several stages.

Should all fistulas be operated on? 

There are rare exceptions to doing it, and they usually relate to the patient's general condition. These fistulas do not remain stationary. They periodically become reactivated and burrow through the area about the anus, making all sorts of complicated intercommunicating tunnels. If an operation is not done, the patient will also continue to have a moist discharge, which may cause a skin reaction and itching. I've heard of one man who lost control of his bowels after this kind of operation.

This complication can occur if the muscle that controls the opening (sphincter muscle) is cut. The surgeon is aware of this possibility with some abscesses and fistulas and tries to avoid this complication. To do this and at the same time effect a cure by draining the internal opening, he may have to do the operation in two stages. In the first stage the muscle is preserved but lassoed with a string. After the first cut the tissues are firmly scarred; it is safe to deal with the muscle directly without the danger of fecal incontinence, i.e., an uncontrollable loss of some of the anorectal contents.

I've known of a man whose anus became so tight after one of these operations that he had to have a second plastic operation to make it adequate. This is often a preventable problem, which results from too much internal scarring. It can be avoided by careful attention to the amount of tissue removal in the area and by making all possible efforts to avoid complicating secondary infections with resulting scar contraction. Careful postoperative care and stretching of the area is especially important.

What can cause the severe itching in my rectal area? 

I'm embarrassed because I can't help scratching. It is terrible and I've gotten no relief. It is often difficult to find a specific treatable cause for this common complaint. We look for rectal infections of the usual type. These are the commonest causal factors. Then a search should be made for a specific irritation produced by worms or certain varieties of yeast or fungi. In still other instances it is a complication of antibiotics. All this searching may reveal nothing. There can be no satisfactory surgical treatment unless a specific cause is apparent.

Is there anything you can do to help me? 

It's obviously impossible to treat a condition if we don't know what causes it. Since there is no obvious surgically treatable condition, surgery is not advised. Former operations involving nerve cutting and tattooing the area have little relevance today. The most effective treatment now is to correct the rectal hygiene. Many individuals tend to be careless about their toilet habits they don't clean themselves adequately and often bruise the area. You should be particularly careful to clean yourself thoroughly, using soapy cotton balls instead of toilet paper. Because you perspire excessively, you should bathe frequently. A bland anesthetic ointment can be locally applied. It is best to avoid alcohol and very highly seasoned food while you have symptoms. Frequent changes of underclothes are obviously required. This is a problem of anal hygiene, not for surgery.

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