Initial consultation

This is recommended for all new patients and will take place in a comfortable consultation room at Litfield House. We recommend at least 30 minutes to fully explore all aspects of your symptoms. This will include a dietary assessment, toileting habits, previous surgery and, for women, a thorough childbirth history.

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Treatment

Most treatments will involve the use of local anaesthetic. We will apply topical anaesthetic cream when you arrive at Litfield house and ask you to wait in the waiting area for 20 minutes. Occasionally we may also use a local anaesthetic injection in addition to the topical cream. This is to ensure you are as comfortable as possible during your treatment. The treatment itself may take 10-15 minutes depending on which one you are having. Afterwards, we ask that you relax in the waiting area for 45 minutes before leaving to go home. This is because treatments on the anal sphincter can be uncomfortable. It is a very sensitive area of the body. Usually we will recommend that you have simple painkillers such as paracetamol or ibuprofen available to take for 24 hours after the procedure.

Follow up consultation

This is recommended for all anal treatments. We can offer this either face to face or over the phone depending on your circumstances and preference. Some anal conditions can recur and others may be longer term conditions such as incontinence. We are happy to provide longer term care for those who need this.

Individual treatments

Haemorrhoids or ‘piles’ are extremely common and can affect both men and women. They can cause fleshy lumps around the anus and symptoms usually include; rectal bleeding*, itchiness, mucus/slime leakage from the back passage and pain/discomfort. They can be small or extremely large needing to be encouraged back into the anal canal. We know that usually piles are related to the consistency of your stool and the way in which you evacuate. Mostly toilet advice and dietary changes are enough to treat piles. Sometimes other treatments are needed. In The McCarthy Clinic we offer treatment of haemmorrhoids that do not require a general anaesthetic (banding or injection sclerotherapy).

Banding of haemmorhoids is a straight forward procedure that takes less than 10 minutes. It is indicated for haemorrhoids that are not fully prolapsed, all of the time. Rubber bands are applied to the fleshy piles, inside the anal canal. Up to 3 rubber bands can be applied at one treatment setting. The strangulated piles will then slough off, with the rubber band, into the toilet in 3 days. It may be that you do not notice this at all. This treatment is the most effective out patient treatment of haemmorhoids with 2 in 10 patients requiring a second banding within 6 months. Complications associated with this treatment include ; pain, infection and bleeding. Usually it is a well tolerated procedure.

Injection sclerotherapy of haemorrhoids is a traditional outpatient treatment of haemorrhoids. Phenol in oil is injected into the base of up to 3 haemorrhoids. This stops the blood supply to the haemorrhoid and causes the haemorrhoid to shrink away over 3-4 days. It takes 5-8 minutes and is usually well tolerated and effective in most patients. Complications include infection and there have been rare cases of erectile dysfunction in men when the oil is not correctly sited. For those with nut allergies an alternative solution is advisable.

Haemorrhoidectomy is an operation to remove haemorrhoidal tissue that is permanently on the outside of the tail end. This may be required if you have tried all conservative measures and some of the treatments above. At our clinic it is offered under local anaesthetic. It might be that your haemorrhoids are on the large side in which case we may recommend that you attend a hospital facility and consider having this operation under general anaesthetic. Sometimes it is only safe to remove half of the haemorrhoidal tissue in one operation. A second operation may therefore be required and it is a good idea to leave 12 weeks between operations in order to allow the skin to heal. The open wounds after this time of surgery can take 6-8 weeks to heal and are sore!. Ensure you have down time after this operation and don’t plan to go abroad or do strenuous work.

* it is vital that any patient with new onset rectal bleeding sees their GP urgently. The current recommendations are that patients must be investigated for other causes or rectal bleeding such as bowel cancer. Usually an endoscopy procedure such as a flexible sigmoidoscopy or colonoscopy would be recommended depending on fitness. These tests are not available at Litfield House and would need a referral either through the NHS or through a private hospital with an endoscopy unit.

Anal fissures are very painful and can feel like you are passing glass when you open your bowels. They are tears that occur right along the opening of the anal canal. It used to be called ‘executive bottom’ – busy people, drinking lots of coffee, lots of work commitments, no time to toilet. Now it can affect anyone at any time.

Fissures usually occur as a result of hard stool and evacuatory disorders. Their symptoms usually include extreme pain on opening bowels and for 1-2 hours afterwards. For most people, when the symptoms start, creams and laxatives can improve the symptoms. Unfortunately the pain can return and plaque you for longer in the day. You begin to feel unwell for longer and lumps/growths can appear around the rim of the tail end.

With time, severe anal spasm can develop as the condition becomes chronic. The fissure develops into an ulcer with raised edges in a wound deep in the crevice of the anal canal. A vicious cycle develops whereby to may need to strain even with soft stool – this is all due to the increased pressure in the anal canal as a result of the chronic fissure/ulcer.

Treatment usually involves softening the stool and specific topical cream. After 6-8 weeks if the fissure is still problematic, it is then referred to as a chronic fissure. The investigation of this condition may require anorectal physiology testing of the pressures in the muscles of the pelvic floor. It is important to know if there is a high pressure within the anal sphincter before any surgical treatment is offered. These surgical treatments will be discussed with you after an examination to assess has taken place. There are more than 1 surgical option and the risks and benefits will be discussed fully. Unfortunately an anal fissure that has become chronic may not heal with conservative therapies – surgery is usually the best option.

Surgical options include a fissurectomy (electric removal of old tissue within fissure), injection to relax tight sphincter muscles or a division of small amount of muscle tissue (sphincterotomy). Most patients respond well to the muscle relaxing injections (low, medium and high doses available)+/- fissurectomy without the need to progress to a sphincterotomy. The results are reassuringly good (70-90% success rates). The good news is that the injection of muscles can be repeated and does not stick around long term in the muscle fibres. There is an associated risk of anal incontinence to wind, however, it is very rare for most patients to experience this side effect.

All of these treatment options will be discussed with you. They are all offered under local anaesthetic @ The McCarthy Clinic. For those who would prefer a general anaesthetic we would recommend contacting a hospital setting instead.

Removal of anal skin tags or lumps

Anal skin tags can be very bothersome. They are usually the leftover feature of large fleshy haemorrhoids or a chronically healed anal fissure. They can interfere with effective wiping after passing a motion, particularly looser motions. Small amount of faecal leakage can lead to itchiness and a permanent sense of not being clean. Surgery to remove this skin can be straightforward and easily performed under local anaesthetic. The skin in this area is extremely sensitive as it is partly responsible for continence. It also has a rich blood supply and as such can bleed after this type of minor surgery. If the anal tags are fully covering the anal canal, it may sometimes recommended to have the removal procedure in two attempts. This preserves the skin on the anus as much as possible and is a safer approach. The procedure takes approximately 10-15 minutes and may be sore afterwards. There may be a small dissolvable stitch and some glue as a waterproof dressing. Occasionally there may be a need to send the anal lumps to the local hospital for pathology analysis. This will be discussed at the time.

Surgery is generally effective and hopefully should not need to be repeated unless further haemorrhoids occur. Complication include pain, bleeding, infection, and temporary flatus incontinence.

Anal fistula treatments

Anal fistula is a small tunnel that develops near the anal canal after an anal gland infection (peri-anal abscess). It is relatively common, however embarrassing, and little talked about. Symptoms include pain and swelling around the anus, fatigue, fevers and chills. In addition there may be a persistent foul smelling discharge needing pads/tissues in the underwear. There may be one tunnel, however sometimes there are more suggesting a complex anal fistula. Some people have medical conditions that make this condition more likely – Crohns disease, HIV, patients taking immunosuppressant drugs and occasionally sexually transmitted diseases.

Anal fistula treatments can be extremely frustrating. Usually treatment is prolonged over 18 months requiring multiple operations under general anaesthetic. The main issue is that it is not advisable to simply lay the tunnel open for healing as this would have a high risk of faecal incontinence and anal sphincter damage(40%).

After the initial consultation it may be that an MRI scan is recommended to assess the extent of the fistula. This was be undertaken at a neighbouring hospital.

‘Plug’ treatment is the only non-surgical treatment of anal fistula. Unlike surgical treatments, this treatment is associated with minimal risk to the anal sphincter. It involves careful cleaning or ‘curettage’ of the fistula tract. This is performed under local anaesthetic in clinic. Once the fistula tract is thoroughly cleaned, a plug is inserted to try and seal the tunnel. It is a well tolerated procedure and successful in 50% of cases. For those that aren’t successful, a repeat procedure is sometimes advisable. It is considered a good first choice of treatment.

A face to face follow up consultation with examination is recommended for this treatment. If the anal fistula is not effectively healed with glue, more complex surgery may be recommended at a nearby hospital.

Pilonidal disease

Pilonidal disease usually presents as a small, red infected lump just above the anal canal between the buttocks. It occurs most commonly in younger people and is thought to be related to hair and obesity. Sadly unwanted hairiness in this area or nearby can lead to pilonidal disease as the hair is ‘massaged into the sinuses’ by the movement in the buttocks.

Occasionally it can become infected needing treatment with antibiotics. Symptoms can range from a mild dimple to a large boggy area with fevers and feeling generally unwell. It can significantly impact on quality of life as there can be a persistent foul smelling discharge need tissues/pads in the underwear. This can be a very embarrassing situation and interfere with intimate relations.

There are many different surgical treatment options for this condition. Generally it is a difficult condition to treat as the affected areas doesn’t generally see the light of day and takes the full weight of the body when the patient is sitting down. Most cases are straightforward and can be dealt with in an out patients clinic. Treatment involves removing the top of the dimple under local anaesthetic and thoroughly cleaning out the hair. At The McCarthy Clinic we offer phenol/glue treatment as a non surgical treatment to try and heal the sinus or tunnel. After treatment, it is advisable to not sit directly on the area for 1 week. In addition it is advisable to use hair removal techniques to the nearby hair every 2-3 weeks to thin out the hair in this area.

This is a long term condition and there is a risk this condition may recur. For recurrent pilonidal disease, complex surgery may be recommended which would require a referral to a neighbouring hospital.

Constipation – difficulties evacuating

Anal irrigation therapy can be an effective treatment for some patients with stubborn constipation that affects their left colon and rectum. There are multiple functional bowel disorders that reduce the rectums ability to effectively evacuate a bowel motion. Usually this situation has developed over many years with patients trying many different laxatives.

Anal irrigation therapy offers the opportunity for some patients to take control of their bowel motions rather than the other way around. During consultation for functional/evacuatory disorders, it is likely that specialist tests may be recommended. these include anorectal physiology which can be provided on site and others such as a proctogram and colonic transit x-ray which would require a trip to a neighbouring hospital.

Once fully investigated, it may be that anal irrigation therapy is an option. There are several different types of equipment which will be offered depending on requirements. A trial is recommended for 4-6 weeks to see if this therapy is for you. It can been continued in the longer term for patients who derive benefit. Occasionally this treatment can aid with regaining some normal sensations to evacuate.

Continence treatments

Anal incontinence is a difficult symptom to talk about. It generally means the inability to control flatus or stool from the back passage. It can be a very embarrassing symptom and may result in a change of behaviour in affected patients. This may include the need to wear pads, the need to be near a toilet and avoidance of long journeys and social gatherings. Symptoms vary from mild leakage to a full, unnoticed bowel motion in the underwear.

Incontinence can be due to a variety of reasons. Most commonly childbirth is the culprit. Damage sustained during childbirth can increase the risk of a weakened anal sphincter later in life, commonly at the menopause. Other risk factors include previous anal surgery, commonly haemorrhoidectomy, increasing age, medical illnesses and diarrhoea. The anal sphincter is not designed to control liquid and so conditions associated with liquid motions commonly result in incontinence. These include gut infections, inflammatory bowel disease, irritable bowel syndrome (diarrhoea type) and occasionally diverticular disease.

At The McCarthy Clinic we will fully assess and grade your incontinence symptoms. It is likely that anorectal physiology and pelvic floor exercises will be recommended. In addition we may suggest lifestyle changes and recommend different ways of approaching toiletting habits. Treatment options may include medications, dietary changes, targeted physiotherapy, irrigation therapies and nerve modulation ( posterior tibial and/or sacral nerve stimulation).