In 2017, nearly 136,000 new cases of colorectal cancer were expected to be diagnosed in the U.S. About 1 in 20 (5%) Americans will develop colorectal cancer during their lifetime. 
Colorectal polyps (benign abnormal growths) affect about 20% to 30% of American adults.

Colorectal cancer is preventable. Nearly all cases of colorectal cancer develop from polyps. They start in the inner lining of the colon and most often affect the left side of the colon. Detection and removal of polyps through colonoscopy reduces the risk of colorectal cancer. Colorectal cancer screening recommendations are based on medical and family history. Screening typically starts at age 45* in patients with average risk. Those at higher risk are usually advised to receive their first screening at a younger age.

While it is not definitive, there is some evidence that diet may play a significant role in preventing colorectal cancer. A diet high in fiber (whole grains, fruits, vegetables and nuts) and low in fat is the only dietary measure that may help prevent colorectal cancer.

*In 2018, secondary to new data on the increased risks of colon cancer in those under 50, the American Society of Colon and Rectal Surgery changed recommendations to consider starting screening at age 45. 

• Physical exam and medical history.
• Blood tests.
• Colonoscopy: Examination of the entire colon with a long, thin flexible tube with a camera and a light on the end (colonoscope).
• Biopsy: Removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer.

The following tests may be used for staging:

• Computed Tomography (CT) scan: A highly sensitive x-ray test that allows physicians to see “inside” the body to identify new or recurrent tumors. This test can accurately detect the presence of most cancer cells that have spread outside of the colon.
   
• Positron emission tomography (PET) scan: An imaging test that uses a special dye that has radioactive tracers. This allows physicians to detect the presence of most cancer cells that have spread outside of the colon.
   
• CEA assay: Carcinoembryonic antigen is a substance in the blood that may be elevated if cancer is present. Although not completely conclusive on its own, this test is often done with other diagnostic tests.
   
• Magnetic Resonance imagin (MRI): An imaging test that uses a magnetic field and pulses of radio wave energy to create pictures of organs and structures inside the body. This helps determine if the tumor has spread through the wall of the rectum and invaded nearby structures.
   
• Abdominal ultrasound: A procedure in which a transducer is moved along the skin over the abdomen. This test looks for tumors that may have spread to the liver, gallbladder, pancreas or elsewhere in the abdomen.

The extent of cancer (clinical stage) is linked to treatment decision making and post-treatment patient outcome. Staging is based on whether the tumor has invaded nearby tissues or lymph nodes, and/or cancer has spread to other parts of the body. The exact stage is often not determined until after surgery. 

Chemotherapy may be offered either before or after surgery, depending on the stage of the cancer. Unlike rectal cancer, radiation therapy is rarely used for colorectal cancer. 

The exact cause of colorectal cancer is unknown. Physicians often cannot explain why one person develops this disease and another does not. However, the understanding of certain genetic causes continues to increase. The following factors can increase one’s risk of colorectal cancer.

• Age: More than 90% of people are diagnosed with colorectal cancer after age 50.
• Family history of colorectal cancer (especially parents or siblings).
• Personal history of Crohn’s disease or ulcerative colitis for eight years or longer.
• Colorectal polyps.
• Personal history of breast, uterine or ovarian cancer.

Colorectal cancer often causes no symptoms and is detected during routine screenings. It is important to note that other common health problems can cause some of the same symptoms. For example, hemorrhoids are a common cause of rectal bleeding, but do not cause colorectal cancer. Colorectal cancer symptoms include:

• A change in bowel habits (e.g. constipation or diarrhea).
• Narrow shaped stools.
• Bright red or very dark blood in the stool.
• Ongoing pelvic or lower abdominal pain (e.g., gas, bloating or pain).
• Unexplained weight loss.
• Nausea or vomiting.
• Feeling tired all the time.

Abdominal pain and weight loss are typically late symptoms, indicating possible extensive disease. Anyone who experiences any of the above symptoms should see a physician as soon as possible.

Surgery to remove the colorectal cancer is almost always required for a complete cure. The tumor and lymph nodes are removed, along with a small portion of normal colon on either side of the tumor. A colostomy is a surgically created opening that connects a part of the colon to the skin of the abdominal wall. This procedure is typically only done in a very small number of colorectal cancer patients.

Minimally invasive surgical techniques may be used by trained surgeons based on the individual case. Your surgeon will discuss this with you prior to surgery and decide on the most optimal approach. 

Patient outcome is strongly associated with colorectal cancer stage at the time of diagnosis. Cancer confined to the lining of the colon is associated with the highest likelihood of success. This is one reason why early detection through screening methods like colonoscopy is crucial.

Follow-up care after treatment for colorectal cancer is important. Even when the cancer appears to have been completely removed or destroyed, the disease may recur. Undetected cancer cells can remain in the body after treatment. Your colon and rectal surgeon will monitor your recovery and check for cancer recurrence at specific intervals. Blood tests, clinical examinations and imaging tests may be performed based on the stage of the cancer.

No one knows the exact causes of rectal cancer. Rectal cancer is more likely to occur as people get older, and more than 90% of people with this disease are diagnosed after age 50. Other risk factors include a family history of colorectal cancer (especially in close relatives), and a personal history of inflammatory bowel disease such as ulcerative colitis, colorectal polyps or cancers of other organs.

Many rectal cancers cause no symptoms at all and are detected during routine screening examinations. The most common symptoms of rectal cancer are a change in bowel habits, such as constipation or diarrhea, narrow shaped stools, or blood in your stool. You may also have pelvic or lower abdominal pain, unexplained weight loss, or feel tired all the time.  Other common health problems can cause the same symptoms. Hemorrhoids do not cause rectal cancer but can produce similar symptoms. Anyone with these symptoms should see a doctor to be diagnosed and treated as early as possible. Abdominal pain and weight loss are typically late symptoms, indicating possible extensive disease.

• The stage of the cancer (how far advanced the cancer is).
• Where the cancer is found in the rectum.
• Whether the bowel is blocked or has a hole in it.
• Whether all of the tumor can be removed by surgery.
• The patient’s general health and ability to tolerate different treatment regimens.
• Whether the cancer has just been diagnosed or has recurred (come back).

For a complete cure, surgery to remove the rectal cancer is almost always required.  Depending on the location and stage, this may be performed through the anus (opening of the rectum) or through the abdomen. Rectal cancer surgery removes the cancer and lymph nodes, along with a small portion of the normal rectum on either side of the tumor. The creation of a colostomy (opening the intestine to a bag on the skin) is typically needed only in a very small number of patients. Trained surgeons may use minimally invasive surgical techniques depending on certain features of your cancer. Your surgeon will discuss these features with you prior to the operation. Additional treatment with chemotherapy or radiation therapy may be offered either before or after the surgery, depending on the stage of the cancer.

After treatment for rectal cancer, a blood test to measure amounts of CEA (a substance in the blood that may be increased when cancer is present) may be done to see if the cancer has come back. Routine CT scans, clinical examinations, and colonoscopy are also performed at intervals determined by the stage.

Rectal cancer is preventable. Nearly all rectal cancer develops from rectal polyps, which are benign growths on the rectal wall. Detection and removal of these polyps by colonoscopy reduces the risk of getting rectal cancer. Your doctor can provide exact recommendations for rectal cancer screening based on your medical and family history. Screening typically starts at age 45* in patients with average risk, or at younger ages in patients at higher risk for rectal cancer.

Though not definitely proven, there is some evidence that diet may play a significant role in preventing colorectal cancer. As far as we know, a diet high in fiber (whole grains, fruits, vegetables, nuts) and low in fat is the only dietary measure that might help prevent colorectal cancer.

*In 2018, secondary to new data on the increased risks of colon cancer in those under 50, the American Society of Colon and Rectal Surgery changed recommendations to consider starting screening at age 45.

• Physical exam and medical history
• Digital rectal exam (DRE)
• Proctoscopy: An office based exam of the rectum using a proctoscope, inserted into the rectum.
• Colonoscopy: A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer.

Distant Staging:

• CT scan can accurately detect the presence of most cancer cells that have spread outside of the rectum.
• PET scan
• CEA assay

Local Staging:

• MRI is one of the tests used for local staging. This will help determine if the tumor has spread through the wall of the rectum and if it has invaded nearby structures.
• Endoscopic ultrasound (EUS): A procedure in which an endoscope or rigid probe is inserted into the body through the rectum.

The outcome of patients with rectal cancer is most clearly related to the stage at the time of diagnosis, with cancer that is confined to the lining of colon having the best chance of success. This is one reason why early detection through screening methods like colonoscopy is crucial.

Surgery is the most effective treatment for colorectal cancer. Even when all visible cancer has been removed, it is possible for cancer cells to be present in other areas of the body. These cancer deposits, when very small, are undetectable at the time of surgery, but they can begin to grow at a later time. The chance of recurrence depends on the characteristics of the original cancer and the effectiveness of chemotherapy, if needed, or other follow up treatment. Patients with recurrent cancers – if diagnosed early – may benefit, or be cured, by further surgery or other treatment.

Another good reason for postoperative follow up is to look for new colon or rectal polyps. Approximately one in five patients who has had colon cancer will develop a new polyp at a later time in life. It is important to detect and remove these polyps before they become cancerous.

Your doctor will examine you approximately every two or three months for the first two years, and discuss your progress. A CEA blood test can be done, as a method of trying to detect recurrence of cancer. Because this test is not totally reliable, other follow up examinations may be advised. These examinations may include flexible sigmoidoscopy (an examination of the rectum and lower colon with a flexible, lighted instrument), colonoscopy (examination of the entire colon with a long flexible instrument), chest x-rays, and sometimes CT scans or ultrasound tests.

Most recurrent cancers are detected within the first two years after surgery. Therefore, follow up is most frequent during this period of time. After five years, nearly all cancers that are going to recur will have done so. Follow up after five years is primarily to detect new polyps, and can, therefore, be less frequent but advisable for life.

Close relatives of patients with colon and rectal cancer (parents, brothers, sisters, children) are at increased risk for the disease. Because of this risk, periodic colonoscopy is advised to detect small polyps. Prompt detection and removal of polyps reduces the risk of developing cancer. Your colon and rectal surgeon can further advise you and your family members on colonoscopy. Other factors which increase the risk of developing polyps or cancer include cancer occurring at an early age, and a personal history of breast or female genital cancer. 

Colorectal cancer is the fourth most common non-skin cancer, affecting all ethnic groups. 140,000 people will be diagnosed with colorectal cancer each year and more than 50,000 will die; the lifetime risk is 1 in 20 (5%).  An increased risk of developing colorectal cancer is present if there is a personal or family history of colorectal cancer.  A personal history of breast, uterine, or ovarian cancer also increases one’s risk of developing colorectal cancer.  A personal or family history of colonic polyps also increases that risk. Both Crohn’s Disease and ulcerative colitis may also make colorectal cancer more likely after having the disease for a number of years.

Fecal occult blood testing checks several stool samples for invisible amounts of blood from a colorectal polyp or cancer. If it is positive, a colonoscopy (see below) is needed.

Colonoscopy uses a long, flexible instrument to evaluate the lining of the colon and rectum; abnormal areas may be sampled or removed and sent to the lab for testing. Safe and effective, colonoscopy is the most commonly recommended screening test, as the whole colon is seen and pre-cancerous polyps can be removed, preventing colon cancer.  Colonoscopy is the “gold standard” for colorectal cancer screening.

Flexible sigmoidoscopy allows a physician to look at the lower third of the colon, where about half of all polyps and cancers are found. If an abnormality is found, a colonoscopy is then needed. Fecal occult blood testing and flexible sigmoidoscopy are often combined for colorectal cancer screening.  However, colonoscopy, is considered the optimal method of screening when the test is available and there is no medical contraindication.

An air-contrast barium enema is an x-ray test in which the colon is filled with air and dye to make the lining visible. It is mostly used only if a complete colonoscopy cannot be done.

Virtual colonoscopy combines CT scan images of the air-filled colon into pictures that look like a colonoscopy.  If abnormalities are found, colonoscopy is then necessary. It is also useful in patients who have an incomplete colonoscopy.  However, most insurance plans as well as Medicare may not cover this procedure.

People who have precancerous polyps completely removed should have a colonoscopy every 3 to 5 years, depending on the size, type and number of polyps found. The exam interval will usually depend upon the pathology of the growth removed.  If a polyp is not completely removed by colonoscopy or surgery, another colonoscopy should be done in 3 to 6 months.

Most colorectal cancer patients should have a colonoscopy within 1 year of its initial removal. If the whole colon could not be examined prior to surgery, then colonoscopy should be done within 3 to 6 months. If this first surveillance is normal, then colonoscopy should be done every 3 to 5 years.

Patients with ulcerative colitis or Crohn’s Disease for 8 or more years should have a colonoscopy with multiple biopsies every 1 to 2 years.

Colorectal cancer rarely causes symptoms in its early stages. Colon cancer usually starts out as a benign polyp. Colon polyps can be both pre-cancerous and non-pre-cancerous.  Polyps can be detected by screening tests and can be removed, thus preventing colorectal cancer. Early cancers can be cured in up to 90% of cases. Once colorectal cancer causes bleeding, change in bowel habits, or abdominal pain, it has usually progressed to a more advanced stage where less than 50% of patients are cured.

For people with no risk factors, screening starts at age 45.* Having a colonoscopy every 10 years is considered the gold standard. Flexible sigmoidoscopy every 5 years with yearly stool occult blood testing is an acceptable alternative when a colonoscopy is not feasible.

People with a close relative (parent or sibling) with colorectal cancer or polyps will start screening at age 40, or 10 years before the youngest age at which a relative was diagnosed. These patients will often undergo screening every 5 years, even if their test is normal.

Less common types of inherited colon cancer (hereditary non-polyposis colon cancer and familial adenomatous polyposis) may require much more frequent screening, beginning at a much earlier age. 

*In 2018, secondary to new data on the increased risks of colon cancer in those under 50, the American Society of Colon and Rectal Surgery changed recommendations to consider starting screening at age 45. 

Genes are inherited from each parent. They determine various physical features and may predispose people to certain diseases. All cancers, but especially colon and rectal cancers, commonly referred to as colorectal cancer (CRC), have hereditary factors that potentially increase one’s risk. Genes are the underlying reason why many diseases such as CRC affect some families more often. For this reason, it is important to provide physicians with a detailed family history of cancer.

Sporadic colorectal cancer is the most common type, with 90% of people diagnosed at age 50 or older. It is not directly related to genetics or a family history. About 1 in 20 Americans develop this type of CRC. When a person is the first family member to be diagnosed with CRC, they should inform close relatives. People with a family history are advised to receive screenings at a younger age.

Hereditary colorectal cancers are associated with a specific inherited genetic abnormality. As genetic researchers continue to define certain syndromes, more genes that predispose one to CRC will likely be identified. Currently, some of the syndromes include:

• Hereditary Non-Polyposis Colon Cancer, Lynch Syndrome (HNPCC).
• Familial Adenomatous Polyposis (FAP).
• Attenuated Familial Adenomatous Polyposis (AFAP).
• APCI 1307K.
• Peutz-Jehger’s Syndrome.
• MYH Associated Polyposis (MAP).
• Juvenile Polyposis.
• Hereditary Polyposis.

There are three broad classifications of CRC, two of which have a genetic component. The data below show the respective percentages for each type.

• Sporadic Colorectal Cancer: 50% to 60%.
• Familial Colorectal Cancer: 30% to 40%.
• Hereditary Colorectal Cancers: 4% to 6%.

Some families are predisposed to CRC. If a family has more than one relative with CRC, especially if it occurred before age 50, there is reason for concern. The risk for family members doubles when a first degree relative (parent, sibling or child) has it.

People with a close relative with CRC or colorectal polyps should receive their first screening at age 40, or 10 years before the youngest age at which the relative was diagnosed. These screenings should be done every five years, even if the test was normal.

Family history information enables your colon and rectal surgeon to assess your risk of CRC and formulate the best plan for prevention and treatment. It is important to share the following:

• A list of all family members diagnosed with colorectal polyps or cancer, with estimated age(s) at time of diagnosis.
• Family history of breast, ovarian or uterine cancer.

Additional patient evaluations can help detect and identify family cancer syndromes. These may include genetic counseling, formal genetic testing, colonoscopy, regular follow-up exams and possible referral to other medical specialists.

Colorectal polyps are commonly found during standard screening exams of the colon (large intestine) and rectum (the bottom section of your colon). They affect about 20% to 30% of American adults. Polyps are abnormal growths that start in the inner lining of the colon or rectum. Some polyps are flat while others have a stalk.

Colorectal polyps can grow in any part of the colon. Most often, they grow in the left side of the colon and in the rectum. While the majority of polyps will not become cancer, certain types may be precancerous. Having polyps removed reduces a person’s future risk for colorectal cancer.

The most common test used to detect colorectal polyps is a colonoscopy. During this outpatient test, your colon and rectal surgeon will examine your colon using a long, thin flexible tube with a camera and a light on the end. If polyps are found, they are removed at the same time.

CT colonography (called virtual colonoscopy) may be used to examine the colon indirectly. However, If polyps or a tumor are found during this test, follow-up colonoscopy may be needed to remove or biopsy them. Other tests used to detect polyps include a digital rectal exam, fecal occult blood testing (this tests for microscopic or invisible blood in the stool), barium enema, and sigmoidoscopy, which uses a flexible tube to inspect the sigmoid colon.

Once a colorectal polyp is completely removed, it rarely comes back. However, at least 30% of patients will develop new polyps after removal. For this reason, your physician will advise follow-up testing to look for new polyps. This is usually done 3 to 5 years after polyp removal. Taking a daily aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the risk of new polyps forming. If you had polyps removed, ask your physician if you should take this medication to help prevent them from coming back.

Most colorectal polyps do not cause any symptoms unless they are large. That is why screening for polyps and cancer is so important. While uncommon, polyps can cause these symptoms:

• Blood in the stool
• Excess mucus
• A change in bowel habits (such as frequency)
• Abdominal pain

Removal of colorectal polyps is advised because there is no test to determine if one will turn into cancer. Nearly all polyps can be removed or eliminated during a colonoscopy. Large polyps may require more than one treatment. Rarely, some patients may require surgery for complete removal.

The colon and rectum (i.e., large intestine) serve to remove water and certain electrolytes and store fecal material prior to elimination. The range of “normal” is quite wide, but in general, bowel movements should occur at least every third day and no more than three per day; stool should pass easily and not require excessive straining; and lastly, one should experience a sense of completeness of elimination. The belief that one should have a bowel movement every day simply is not accurate and can lead to unnecessary concern and even abuse of laxatives. 

Most often, constipation is due to any combination of three factors: a low fiber diet, poor fluid intake, or a lack of physical activity or exercise. However, there are other causes that must be considered. First, specific medical conditions can cause constipation, including diabetes, low thyroid hormone (hypothyroidism), depression or other less common diseases. Medications may contribute to constipation, including those commonly prescribed for pain relief, high blood pressure, antidepressants, psychiatric drugs and antacids.

Unfortunately, there are serious causes of constipation that are more mechanical in nature. Diseases that cause inflammation, such as diverticulitis or Crohn’s disease, can cause excessive scarring and narrowing. In addition, tumors or growths in the colon can physically block the bowel. Although less likely to be the cause, these more serious causes should be evaluated and ruled out by your physician. 

Medical attention should be sought if:

• There is a new onset of persistent constipation.
• Longstanding constipation becomes progressive either in frequency or severity, and it is not manageable with the simple measures described above.
• Constipation is associated with a change in bowel habits from the normal pattern (narrow stools or loose stools), excess weight loss or bleeding.

Given the range of normal, constipation may mean different things to different people. For some, constipation may mean infrequent bowel movements. To others, it is a hard, difficult-to-pass stool that requires excessive straining and causes pain as it passes. And to others still, constipation may mean a bowel movement which does not completely evacuate and leaves the person with a sense of dissatisfaction as if they “still need to go.” Constipation is often associated with a bloating sensation, mild nausea and mild cramping pain, all of which are generally relieved by bowel movements.

Generally, constipation is avoided by following the basics of good intestinal health: healthy diet, proper fluid intake and physical activity. Twenty-five to thirty-five grams of fiber per day is the recommended daily amount of dietary fiber. Eating a diet rich in whole grain breads, cereals and fiber bars, in addition to fresh fruits and vegetables, often will improve bowel habits by adding bulk to the stool.

Drinking six to eight glasses of water per day will help keep the stool from being hard and make it easier to pass the stool. Lastly, regular exercise, which can be as simple as taking a brisk walk for 30 minutes per day, will likely improve bowel movements.

There are many different laxatives available over the counter in grocery stores and pharmacies. The way in which laxatives work varies by laxative but they can be very effective for acute relief of constipation. Although it may be necessary to take laxatives on a regular basis, you should only do so after consultation with your medical provider.

• Abscess formation and perforation of the colon with peritonitis. An abscess is a pocket of pus walled off by the body. Peritonitis is a potentially life-threatening infection that spreads freely within the abdomen, causing patients to become quite ill.
• Rectal bleeding
• Formation of a narrowing of the colon that prevents easy passage of stool (called a stricture)
• Formation of a tract or tunnel to another organ or the skin (called a fistula). When a fistula forms, it most commonly connects the colon to the bladder. It may also connect the colon to the skin, uterus, vagina, or another part of the bowel.

Most patients with diverticulosis have no symptoms or complications. Some patients with diverticulitis experience lower abdominal pain and a fever or they may have rectal bleeding.

Most people with diverticulosis have no symptoms. However, as a preventative measure, it is advised to eat a diet high in fiber, fruits, and vegetables, and to limit red meat.

Most cases of diverticulitis can be treated with antibiotics in pill form or intravenously (IV). Diverticulitis with an abscess may be treated with antibiotics with a drain placed under X-ray guidance.

Surgery for diverticular disease is indicated for the following:

• A rupture in the colon that causes pus or stool to leak into the abdominal cavity, resulting in peritonitis, which often requires emergency surgery.
• An abscess than cannot be effectively drained.
• Severe cases that do not respond to maximum medical therapy including IV antibiotics and hospitalization.
• Patients with immune system problems (e.g. related to an organ transplant or chemotherapy).
• A colonic stricture or fistula.
• A history of multiple attacks may result in a patient deciding to undergo surgery to prevent future attacks.

Surgery for diverticular disease usually involves removal of the affected part of the colon. It may or may not involve a colostomy or ileostomy (intestine brought out through the abdominal wall to drain into a bag). A decision regarding the type of operation is made on a case-by-case basis.

The most commonly accepted theory ties diverticulosis to high pressure within the colon. This pressure causes weak areas of the colon wall to bulge out and form sacs. A diet low in fiber and high in red meat may also play a role. Currently, it is not well understood how these sacs become inflamed and cause diverticulitis.

Diverticulosis often causes no symptoms. It may be diagnosed during screening tests such as a colonoscopy. A CT scan of the abdomen and pelvis may be used to confirm the diagnosis of diverticulitis.

• Cancer
• Trauma
• Inflammatory bowel disease (IBD) such as Crohn’s disease or ulcerative colitis.
• Bowel obstruction
• Infection
• Fecal incontinence (inability to control bowel movements)
• Diverticular disease (small bulges or sacs that form in the wall of the large intestine)

After an ostomy is created, bowel movements occur through the opening in the abdominal wall or stoma. The ostomy appliance consists of a wafer and bag. The wafer sticks to the abdominal wall with adhesive and is made of plastic.  The bag catches and holds the stool. The bag is disposable and emptied or replaced as needed. This system is secure, odor-free and accidents are uncommon.

• You will be taught how to use the ostomy bag by a WOC nurse or enterostomal therapist and your colon and rectal surgeon. The doctors and nurses will work with you on any necessary changes to your diet.
• The frequency and volume of bowel movements vary from person to person. Your bowel movements will depend on how often you went to the bathroom prior to surgery, the type of ostomy that was placed, the type of surgery that was done and your dietary habits.

An ostomy appliance is a plastic pouch. It is held to the body with an adhesive skin barrier. It provides secure and odor-free control of bowel movements.

All activities including recreational sports and activities may be resumed once healing from surgery is complete. Public figures, famous entertainers and even professional athletes have ostomies that do not limit their activities.

Most patients with ostomies are able to resume their usual sexual activity. Some patients worry that their sexual partner will not find them attractive due to the ostomy bag. This change in body image can be overcome. A strong relationship, time, patience and support groups all help address these problems.

An ostomy can have complications. In the beginning, it may take some time to adjust to the way the appliance fits and empties. During this time, accidents, or leakage from the bag, may happen. Once you are used to the stoma wafer and bag, most common problems, such as local skin irritation, are easily treated. Major changes in weight loss or gain can affect how the ostomy sits on your abdomen. Some people develop a hernia (weakening of the abdominal wall around the ostomy) or prolapse (a protrusion of the bowel). These problems require surgery only if they cause major symptoms.

Living with an ostomy requires a period of learning and adjustment. Your colon and rectal surgeon and WOC nurse will provide necessary assistance and support. With a little time, you will discover ways to live an active and full life with an ostomy.

Ask your surgeon if you do not know what type of ostomy you have.

• Ileostomy: Connects the last part of the small intestines (ileum) to the abdominal wall.
• Colostomy: Connects a part of the colon (large intestine) to the abdominal wall.
• Temporary ostomy: This is an ostomy that can be removed surgically at a later time.  It is generally made from the small intestines (ileostomy).  It prevents the passage of stool through the intestines below the stoma. A temporary ostomy is created to allow the intestines to heal after surgery or from a disease such as diverticular disease or Crohn’s disease. 
• Permanent ostomy: This is an ostomy that is used when parts of the rectum, anus and colon have been removed due to disease or treatment of a disease.  It is generally made from the large intestines (colostomy). It may also be done when the muscles that control elimination are removed or no longer function properly. A permanent ostomy may be removed under some circumstances.  

Prior to surgery, your surgeon or Wound, Ostomy and Continence (WOC) nurse will examine your abdomen to find a suitable place on your abdominal wall for the opening or stoma. An ostomy is best placed on a flat portion of the front of your abdomen that is easy to see. A colostomy is usually placed to the left of the navel and an ileostomy to the right.  

Depending on the type of ostomy, you may need to change what you eat to control the number of and consistency of bowel movements. You will learn to monitor the effect of food on ostomy function. After a period of time, many patients are able to slowly introduce foods back into their diets. It helps to chew food well, drink plenty of fluids and avoid certain high roughage foods, such as green leafy vegetables. After recovering from surgery, most patients do not have dietary limitations.

Unless you tell someone, they won’t know that you have an ostomy. An ostomy is easily hidden by most clothing. You have probably met people with an ostomy and did not realize it.

Men and women are affected equally and people of all ages can develop UC. A family history of UC slightly increases the risk of the disease.

Most patients develop symptoms in their 40s. A smaller number experience symptoms for the first time later in life (ages 60 to 70). The symptoms of UC are similar to Crohn’s disease, when the latter only affects the colon and rectum. The most common symptoms of UC include:

• Abdominal cramping.
• Pain.
• Diarrhea.
• Bleeding with bowel movements.
• Fever.
• Fatigue.
• Weight loss.

Medical treatment is always the first choice unless emergency surgery is required. The goal of medical therapy is to improve a patient’s quality of life. Initially, the most common therapy is corticosteroids (steroid hormones) combined with anti-inflammatory agents. Based on the extent of the disease, these are taken orally or as a rectal suppository.

Because emergency surgery is done for potentially life threatening conditions, it is most often done as an open procedure. During emergency surgery, the large bowel (colon) is removed. The rectum and anus are left in place temporarily. The end of the small bowel (ileum) is brought out through the abdominal wall to the skin level. An ileostomy is created through which fecal matter is allowed to empty into a bag attached to the skin. 

After recovery, a second procedure can be performed. During this surgery, the diseased rectum is removed. A new rectum (ileal pouch) is created using the small bowel. The new rectum is connected to the anal opening. A loop ileostomy is created to protect the area until it has healed. 

When healing is complete, a third procedure is done to close the ileostomy. This three-stage UC procedure ultimately results in patients being able to live without an ileostomy.

After surgery, five to six bowel movements a day and one at night can be expected. Infection may develop in the pouch. This is usually treated effectively with antibiotics. Due to complications, about 10% of pouches must be removed and an ileostomy created.

The exact cause of UC is unknown, but it is not contagious. Potential causes include immune system abnormalities and bacterial infection.

The first step is to undergo a thorough medical history and physical exam. Following this, additional testing may be needed. This may include blood tests, a complete colonoscopy of the rectum, colon and terminal ileum (the end of the small intestine that intersects with the large intestine), as well as x-rays. This evaluation helps determine the extent and severity of UC, rules out other diseases such as Crohn’s disease, and guides management. 

Surgery is considered for patients when medical management is no longer effective.  Other reasons that a patient may require surgery include cancer or precancerous lesions that are found during a colonoscopy.  Sometimes surgery needs to be performed when a complication of the disease occurs such as a perforated bowel (hole in the bowel), severe bleeding or serious infection (toxic colitis).

Since UC involves only the colon and rectum, complete removal of both may be done in some cases. This treatment option is curative, but requires an ileostomy. Some patients may be candidates for a J-pouch. This procedure involves the removal of the entire colon and all of the rectum with the exception of the last section where the sphincter muscles are located.  The small bowel is then used to create a “new” rectum (the pouch) which is attached just above the sphincter muscles. The patient will have a temporary ileostomy during the healing period however ultimately this will be taken down and the patient will be able to pass stool through their anus again.   

Elective and emergency surgeries can be performed through traditional “open” procedures or minimally invasive (laparoscopic) approaches depending on the circumstances. The safest, most effective approach is determined on an individual basis.

Regular follow-up medical appointments are scheduled. During these periodic visits, your physician will evaluate the function and health of the pouch.

Small glands just inside the anus are part of normal anatomy. If the glands in the anus become clogged, this may result in an infection. When the infection is serious, this often leads to an abscess. Bacteria, feces, or foreign matter can also clog the anal glands and cause an abscess to form. Crohn’s disease, cancer, trauma and radiation can increase the risk of infections and fistulas.

Most anal abscesses or fistulas are diagnosed and managed based on clinical findings. Occasionally, imaging studies such as ultrasound, CT scan or MRI can help in the diagnosis and management of deeper abscesses and may be used to visualize the fistula tunnel.

Your surgeon will advise you on proper postsurgical care. Unfortunately, despite proper treatment and complete healing, an abscess or a fistula can come back. If an abscess comes back, it suggests that perhaps there is a fistula that needs to be treated. If a fistula comes back, additional surgery will likely be required to treat the problem.  

A patient with an abscess may have pain, redness or swelling in the area around the anal area or canal. Other common signs include feeling ill or tired, fever and chills. Patients with fistulas have similar symptoms, as well as drainage from an opening near the anus. A fistula is suspected if these symptoms tend to keep coming back in the same area every few weeks. 

The treatment of an abscess is surgical drainage under most circumstances. It is important that your surgeon be very familiar with treating abscesses and fistula. Colorectal surgeons are experts in this area. For most patients, an abscess can be drained surgically through a simple procedure. An incision is made in the skin near the anus to drain the infection. This can be done at your surgeon’s office with local anesthetic or in an operating room under general anesthesia. Some patients with more severe disease may require multiple surgeries to take care of the problem. Patients who tend to get more severe infections due to diabetes or immunity problems may need to be hospitalized

Surgery is nearly always needed to treat an anal fistula. In many patients, if the fistula is not too deep, a fistulotomy is performed. During this surgery, the fistula track will be opened to allow healing from the bottom up. The surgery may require dividing a small portion of the sphincter muscle. A large amount of the sphincter muscle is not divided as this could lead to problems with bowel control (fecal incontinence) in some patients. If the fistula track does involve a large portion of the sphincter muscle, other more involved surgeries are done to treat the fistula without harming the sphincter muscle. More difficult cases may require multiple surgeries. 

Antibiotics alone are not effective in treating abscesses or fistula. Antibiotics may be needed, in addition to surgery, if a patient has immunity issues, specific heart valve conditions or widespread cellulitis (a bacterial infection of the skin and tissues under the skin). Providing your physician with an accurate medical history and undergoing a physical exam are important steps in deciding if antibiotics are required.

No one knows the exact causes of rectal cancer. Rectal cancer is more likely to occur as people get older, and more than 90% of people with this disease are diagnosed after age 50. Other risk factors include a family history of colorectal cancer (especially in close relatives), and a personal history of inflammatory bowel disease such as ulcerative colitis, colorectal polyps or cancers of other organs.

Many rectal cancers cause no symptoms at all and are detected during routine screening examinations. The most common symptoms of rectal cancer are a change in bowel habits, such as constipation or diarrhea, narrow shaped stools, or blood in your stool. You may also have pelvic or lower abdominal pain, unexplained weight loss, or feel tired all the time.  Other common health problems can cause the same symptoms. Hemorrhoids do not cause rectal cancer but can produce similar symptoms. Anyone with these symptoms should see a doctor to be diagnosed and treated as early as possible. Abdominal pain and weight loss are typically late symptoms, indicating possible extensive disease.

• The stage of the cancer (how far advanced the cancer is).
• Where the cancer is found in the rectum.
• Whether the bowel is blocked or has a hole in it.
• Whether all of the tumor can be removed by surgery.
• The patient’s general health and ability to tolerate different treatment regimens.
• Whether the cancer has just been diagnosed or has recurred (come back).

For a complete cure, surgery to remove the rectal cancer is almost always required.  Depending on the location and stage, this may be performed through the anus (opening of the rectum) or through the abdomen. Rectal cancer surgery removes the cancer and lymph nodes, along with a small portion of the normal rectum on either side of the tumor. The creation of a colostomy (opening the intestine to a bag on the skin) is typically needed only in a very small number of patients. Trained surgeons may use minimally invasive surgical techniques depending on certain features of your cancer. Your surgeon will discuss these features with you prior to the operation. Additional treatment with chemotherapy or radiation therapy may be offered either before or after the surgery, depending on the stage of the cancer.

After treatment for rectal cancer, a blood test to measure amounts of CEA (a substance in the blood that may be increased when cancer is present) may be done to see if the cancer has come back. Routine CT scans, clinical examinations, and colonoscopy are also performed at intervals determined by the stage.

Rectal cancer is preventable. Nearly all rectal cancer develops from rectal polyps, which are benign growths on the rectal wall. Detection and removal of these polyps by colonoscopy reduces the risk of getting rectal cancer. Your doctor can provide exact recommendations for rectal cancer screening based on your medical and family history. Screening typically starts at age 45* in patients with average risk, or at younger ages in patients at higher risk for rectal cancer.

Though not definitely proven, there is some evidence that diet may play a significant role in preventing colorectal cancer. As far as we know, a diet high in fiber (whole grains, fruits, vegetables, nuts) and low in fat is the only dietary measure that might help prevent colorectal cancer.

*In 2018, secondary to new data on the increased risks of colon cancer in those under 50, the American Society of Colon and Rectal Surgery changed recommendations to consider starting screening at age 45.

• Physical exam and medical history
• Digital rectal exam (DRE)
• Proctoscopy: An office based exam of the rectum using a proctoscope, inserted into the rectum.
• Colonoscopy: A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer.
• Biopsy: The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer.

Distant Staging:

• CT scan can accurately detect the presence of most cancer cells that have spread outside of the rectum.
• PET scan
• CEA assay

Local Staging:

• MRI is one of the tests used for local staging. This will help determine if the tumor has spread through the wall of the rectum and if it has invaded nearby structures.
• Endoscopic ultrasound (EUS): A procedure in which an endoscope or rigid probe is inserted into the body through the rectum.

The outcome of patients with rectal cancer is most clearly related to the stage at the time of diagnosis, with cancer that is confined to the lining of colon having the best chance of success. This is one reason why early detection through screening methods like colonoscopy is crucial.

Fissures are usually caused by trauma to the inner lining of the anus from a bowel movement or other stretching of the anal canal. This can be due to a hard, dry bowel movement or loose, frequent bowel movements. Patients with a tight anal sphincter muscle are more likely to develop anal fissures. Less common causes of fissures include inflammatory bowel disease, anal infections, or tumors. 

Your physician will discuss the benefits and side effects of treatments.

Treatment includes:

• A high-fiber diet and over-the-counter fiber supplements (25-35 grams of fiber/day) to make stools soft, formed, and bulky.
• Over-the-counter stool softeners to make stools easier to pass.
• Drinking more water to help prevent hard stools and aid in healing.
• Warm tub baths (sitz baths) for 10 to 20 minutes, a few times per day (especially after bowel movements to soothe the area and help relax anal sphincter muscles). This is thought to help the healing process.
• Medications, such as lidocaine, that can be applied to the skin around the anus for pain relief.
• Medications such as diltiazam, nifedipine, or nitroglycerin ointment to relax the anal sphincter muscles which helps the healing process.

Narcotic pain medications are avoided because they can cause constipation which could make the situation worse. 

Most patients can return to work and go back to daily activities a few days after surgery. Complete healing after both medical and surgical treatments can take 6 to 10 weeks. Even when the pain and bleeding lessen, it is important to maintain good bowel habits and eat a high-fiber diet. Continued hard or loose bowel movements, scarring, or spasm of the internal anal muscle can delay healing.

• Botox® injections are associated with healing of chronic anal fissures in 50% to 80% of patients.
• Sphincterotomy is successful in more than 90% of patients. Although uncommon, this procedure may affect the patient’s ability to fully control gas or bowel movements.

Fissures often come back. A fully healed fissure can come back after a hard bowel movement or trauma. Medical problems such as inflammatory bowel disease (Crohn’s disease), infections, or anal tumors can cause symptoms similar to anal fissures. If a fissure does not improve with treatment, it is important to be evaluated for other possible conditions. 

Anal fissures typically cause a sharp pain that starts with the passage of stool. This pain may last several minutes to a few hours. As a result, many patients may try not to have bowel movements to prevent pain.

Other symptoms include:

• Bright red blood on the stool or toilet paper after a bowel movement
• A small lump or skin tag on the skin near the anal fissure (more common when chronic)

Although most anal fissures do not require surgery, chronic fissures are harder to treat and surgery may be the best option. The goal of surgery is to help the anal sphincter muscle relax which reduces pain and spasms, allowing the fissure to heal. Surgical options include Botulinum toxin (Botox®) injection into the anal sphincter or surgical division of an inner part of the anal sphincter (lateral internal sphincterotomy). Your colon and rectal surgeon will find the best treatment for you and discuss the risks of surgery. Both types of surgery are typically done as same-day outpatient procedures. 

Anal fissures do not increase the risk of colon cancer nor cause it. However, more serious conditions can cause similar symptoms. Even when a fissure has healed completely, your colon and rectal surgeon may request other tests. A colonoscopy may be done to rule out other causes of rectal bleeding.

1. Thrombosed External Hemorrhoid 

This is a blood clot that forms in an outer hemorrhoid in the anal skin. If the clots are large, they can cause pain when you walk, sit, or have a bowel movement. A painful anal mass may appear suddenly and get worse during the first 48 hours. The pain generally lessens over the next few days. You may notice bleeding if the skin on top opens. Nonsurgical treatment includes warm tub baths (sitz baths), pain medications, and stool softeners. Most experts recommend that the blood clots be removed surgically. This short surgery can be done in the surgeon’s office or at the hospital under local anesthesia.

2. Anal Fissure

The anal canal is a short tube surrounded by muscle at the end of your rectum. The rectum is the bottom section of your colon (large intestine). An anal fissure (also called fissure-in-ano) is a small rip or tear in the lining of the anal canal. Fissures are common, but are often confused with other anal conditions, such as hemorrhoids. The goal of all nonsurgical treatments is to make stools soft, formed, and bulky. Treatments include a high-fiber diet and over-the-counter fiber supplements (25-35 grams of fiber/day); over-the-counter stool softeners; warm tub baths (sitz baths) for 10 to 20 minutes, a few times per day; and several types of medication. Although most anal fissures do not require surgery, chronic ones are harder to treat and surgery may be the best option. The goal of surgery is to help the anal sphincter muscle relax, which reduces pain and spasms, allowing the fissure to heal.

3. Anal Abscess and Fistula

An abscess is an infected cavity filled with pus near the anus or rectum. In most cases, an abscess is treated by draining it surgically. A fistula is a tunnel that forms under the skin, connecting the clogged, infected glands to the abscess and out to the skin near the anus. Surgery is often needed to cure an anal fistula. Sometimes these surgeries are simple; however, more difficult cases may need multiple surgeries to take care of the problem.  

4. Fungal Infection or Sexually Transmitted Diseases

Patients with fungal infections or infections caused by sexually transmitted diseases (STDs) may have mild to severe anal or rectal pain. STDs include gonorrhea, chlamydia, herpes, syphilis, HPV, etc. The pain is not always tied to having bowel movements. Other signs may include minor anal bleeding, a discharge, or itching. Treatment includes topical or oral antibiotics and antifungal medications.

5. Skin Conditions

Skin disorders that affect other parts of the body (e.g. psoriasis, warts) may also affect skin around the anus. Anal itching, bleeding, and pain may come and go. In some cases, a skin biopsy is needed. Treatment is tied to the results of the skin biopsy and/or physical exam. Early diagnosis is key so treatment can begin as soon as possible.

6. Anal Cancer

While most cases of anal pain are not cancer, tumors can cause bleeding, a mass, and changes in bowel habits, as well as pain that gets worse over time. If you have pain or anal bleeding that does not go away or gets worse, see a colon and rectal surgeon as soon as possible. The first office visit includes a physical exam, exam of the anal canal with a small, lighted scope (anoscopy) to visualize any abnormal areas, and biopsy of the mass. If the pain is too bad for an exam in the office, your surgeon may need to perform an exam under anesthesia to make a proper diagnosis. Treatment of anal cancer or other anal tumors may involve chemotherapy, radiation and/or surgery.

You should see a physician if:

• Pain comes back or doesn’t go away
• There is ongoing rectal bleeding
• You can feel a mass that does not get better 

Sexual intercourse is a common way to get infected with HPV. However, a person can become infected with HPV without having sexual intercourse. Any direct contact to the anal area (e.g. hand contact, fluids from an infected sexual partner) can cause HPV and anal or genital warts. 

Warts are usually painless, so people may not realize they have them. The primary symptom is soft, moist bumps near or in the anus that are light brown or flesh-colored. Additional symptoms may include:

• Itching
• Bleeding
• Mucus discharge
• Feeling like there is a lump in the anal area

If warts are not removed, they can grow larger and multiply. Left untreated, warts may lead to an increased risk of anal cancer in the affected area. Internal anal warts may not respond to topical medications, so surgery may be required. Treatment options include:

• Topical medication: These creams usually work best if the warts are very small and located only on the skin around the anus.
• Topical medications that will freeze the warts (liquid nitrogen)
• Topical medications that will burn the warts (Trichlorocetic acid, podophyllin)
• Surgery: When the warts are either too large for the above mentioned treatments or are internal, surgery is considered. During surgery, the warts are surgically removed. The patient will be anesthetized for the procedure. The type of anesthetic depends on the number and exact location of the warts being removed. When there are many warts, your surgeon may perform the surgery in stages. An internal examination will also be performed so that any lesions on the inside can also be found and treated.

The HPV virus often remains in the body without any signs. There are steps you can take to help prevent anal warts.

• Do not have sexual contact with people who have anal (or genital) warts
• Limit sexual contact to a single partner
• Abstinence: Do not have any sexual contact
• Always use condoms (this reduces, but does not eliminate the risk)
• Sexual partners should be checked for HPV and other STDs even when there are no symptoms

Your physician will look at the skin around the anus, as well as the entire pelvic area, including the genitals. He or she may perform an exam of the anal canal with a small, lighted scope (anoscopy) to see if there are any warts inside the anal canal (internal anal warts). 

Mild pain and discomfort generally last for a few days. Pain medication may be prescribed. Patients treated in the clinic can return to work immediately. Those that have surgery can usually return to work the next day, while others that have more extensive surgery may stay home for several days to weeks.

Warts may come back repeatedly after successful removal. This happens because the HPV virus stays inactive for a period of time in body tissues. When warts come back, they can usually be treated at your surgeon’s office. If a large number of new warts develop quickly, surgery may be needed again.

It is important to discuss with your surgeon how often to schedule follow-up visits. During these visits, an exam will be done to make sure that all the warts are gone and no new ones have formed. 

There are many causes of fecal incontinence such as injury, disease and age.

• Childbirth-related injury: This is the most common cause, resulting from a tear in the anal muscles. The nerves controlling the anal muscles may also be injured, which can lead to incontinence. Some injuries may be detected right after childbirth; however, many go unnoticed until they cause problems later in life. Since it may be years after giving birth, childbirth is often not recognized as the cause of the problem.
• Trauma to anal muscles: Anal operations or traumatic injury to the tissues near the anal region can damage the anal muscles and lessen bowel control.
• Age-related loss of anal muscle strength: Some people gradually lose anal muscle strength as they age. A mild control problem may have existed when they were younger, but this gets worse later in life.
• Neurological diseases: Severe stroke, advanced dementia or spinal cord injury can cause lack of control of the anal muscles, resulting in incontinence.

An initial discussion of symptoms with your physician will help determine the degree of incontinence and the effect on your life. Possible underlying factors are often found during a review of your medical history, such as:

• Multiple pregnancies, large weight babies, forceps deliveries or episiotomies (surgical incisions to aid childbirth).
• History of prior anal or rectal surgeries.
• Medical illnesses or conditions.
• Medication side effects.

A physical examination of the anal region should be performed. An exam may easily identify an obvious injury to the anal muscles. Your physician will decide if tests are needed to confirm the diagnosis. An ultrasound probe may be used in the anal area, which provides photographs of potentially injured anal muscles. Other tests may be required to assess the function of muscles and nerves that help control bowel movements.

Dietary changes: Mild problems may be treated simply by changing one’s diet.

Constipating medications: Specific medications can result in firmer stools, enabling more bowel control.

Medications: Inflammatory bowel diseases (such as ulcerative colitis or Crohn’s disease) can cause diarrhea and contribute to bowel control problems. Treating these underlying diseases may eliminate or improve incontinence symptoms.

Muscle strengthening exercises: Simple home exercises to strengthen the anal muscles can help in mild cases.

Biofeedback: A type of physical therapy to help patients strengthen anal muscles and sense when stool is ready to be evacuated.

Symptoms can range from mild to severe. Mild cases may only involve difficulty controlling gas. Severe cases can lead to an inability to control liquid and formed stools. A patient may have a feeling of urgency or experience stool leakage due to frequent liquid stools or diarrhea.

If there is bleeding with lack of bowel control, consult your physician as soon as possible. This may indicate inflammation within the colon and rectum, such as ulcerative colitis, Crohn’s disease, a rectal tumor or rectal prolapse. All of these conditions require prompt evaluation by a physician.

There are nonsurgical and surgical treatment options that vary based on the cause and severity of the problem. Your colon and rectal surgeon will discuss different treatment methods and help you decide what approach is best for you.

There are several surgical options for the treatment of fecal incontinence. Keep in mind that surgery is not the right choice for every patient.

Surgical muscle repair: Injuries to the anal muscles may be surgically repaired.

Stimulation of the nerves: Insertion of a nerve stimulator can help nerves that control muscles and skin of the anus work more efficiently.

Bulking agent injections: Injecting a substance into the anal canal can bulk it up and strengthen the “squeeze” mechanism of the anal muscles used during bowel movements.

Surgical colostomy: In severe cases, a colostomy may be the best option for improving quality of life. During this procedure, part of the colon (large intestine) is brought out through the abdominal wall to drain into a bag.

Obstructed Defecation: Obstructed defecation is difficulty getting bowel movements out of the body. Although the stool reaches the rectum, or bottom of the colon, the patient has difficulty emptying. This often makes patients feel that they need to go the bathroom more often, or that they cannot empty completely, as if stool remains in their rectum. Obstructed defecation may be caused by pelvic floor prolapse (discussed below), pain symptoms or muscles not functioning normally. 

Rectocele: A rectocele is a bulge of the front wall of the rectum into the vagina. Normally, the rectum goes straight down to the anus (picture). When a patient with a rectocele strains, the stool may get caught in an abnormal pocket of the rectum which bulges into the vagina. This prevents the patient from emptying the rectum completely. Generally, rectoceles do not produce symptoms. As they grow larger, rectoceles may cause difficulty going to the bathroom, or cause leakage of stool after having a bowel movement. Rectoceles are more common in women who have given birth. Rectoceles are usually caused by thinning of the tissue between the rectum and vagina and weakening of the pelvic floor muscles.

Pelvic Floor Prolapse: The pelvic floor consists of the muscles and organs of the pelvis, such as the rectum, vagina, bladder. Stretching of the pelvic floor may occur with aging, collagen disorders or after childbirth. When the pelvic floor is stretched, the rectum, vagina, or bladder may protrude through the rectum or vagina, causing a bulge, which can be felt. In addition to a rectocele, patients may have rectal prolapse, a cystocele (prolapse of the bladder) or protrusion of the small bowel. Symptoms generally include difficulty in emptying during urination or defecation, incontinence or pressure in the pelvis.  

Paradoxical Puborectalis Contraction: The puborectalis muscle is part of the control muscles that control bowel movements. The puborectalis wraps like a sling around the lower rectum.   During a bowel movement, the puborectalis is supposed to relax to allow the bowel movement to pass. If the muscle does not relax or contracts during paradoxical contraction, it may feel like you are pushing against a closed door.

Levator Syndrome: Levator syndrome is abnormal spasms of the muscles of the pelvic floor. Spasms may occur after having bowel movements or without a known cause.  Patients often have long periods of vague, dull or achy pressure high in the rectum. These symptoms may worsen when sitting or lying down. Levator spasm is more common in women than men.

Coccygodynia: The coccyx, or tailbone, is located at the bottom of the spine. Coccygodynia is pain is of the tailbone. The pain is usually worsened with movement and may worsen after defecation. It is usually caused by a fall or trauma involving the coccyx, although in a third of patients no cause is noted.

Proctalgia Fugax: Proctalgia fugax is a sudden abnormal pain in the rectum that often awakens patients from sleep. This pain may last up to several minutes and goes away between episodes.  Proctaliga fugax is thought to be caused by spasms of the rectum and/or the muscles of the pelvic floor.

Pudendal Neuralgia: The pudendal nerves are the main sensory nerves of the pelvis. Pudendal neuralgia is chronic pain in the pelvic floor involving the pudendal nerves. This pain may first occur after childbirth, but often comes and goes without reason.  

Treatment is based on the cause of the dysfunction and severity of symptoms. Surgical treatment is rarely needed for pelvic floor dysfunction, except for large, symptomatic rectoceles or other pelvic prolapse. In the case of prolapse, surgery may help to restore the normal location of pelvic organs. This may be performed through the abdomen or through the bottom, depending on the specific problem. 

For pelvic pain syndromes, the goal of treatment is to relieve or reduce symptoms. In some cases, a combination of treatment methods helps reduce pain.

• Dietary changes such as increasing fiber and fluid intake to make bowel movements easier. 
• Biofeedback, a special form of pelvic floor physical therapy aimed at improving rectal sensation and pelvic floor muscle contraction. This may include electrical stimulation of the pelvic floor muscles, ultrasound, or massage therapy. In addition, there are exercises that may be done at home which can help improve symptoms. 
• Injection of a local anesthetic and/or anti-inflammatory agents.

A complete medical history and thorough physical examination are key to evaluating pelvic floor dysfunction. The physician should ask about other pain issues in the body, as well as difficulty having bowel movements, passing urine or pain during sexual intercourse. It is important to have a full physical exam, including rectal and vaginal exams. 

The function of the various nerves and muscles involved in bowel movements is complex and the physician may need additional testing to determine the cause of the problem. The tests that may be ordered by your colon and rectal surgeon can help make a diagnosis and guide treatment.

• Endoanal/Endorectal Ultrasound: Provides pictures of the structures of the pelvis, including the anus, rectal wall and control muscles. It may also demonstrate rectocele, rectal prolapse or enterocele (small bowel prolapse). This is generally performed in the office.  
• Anorectal Manometry: Evaluates the ability for the control muscles and rectum to function and the strength of muscles. This is also generally performed in the office or at an endoscopy center. This test requires the patient to push and strain, so that it can correctly determine the strength of the muscles. 
• Electromyography (EMG)/ Pudendal Nerve Motor Latency Testing: These are tests that check to determine how the nerves of the pelvic floor are working. Pudendal nerve motor latency tests evaluate just the pudendal nerve, while EMG is a more complex testing of several nerves in the anal sphincter and pelvic floor. These tests may require needles and small doses of electricity. 
• Colonic Transit Study: A colonic transit study is a series of X-rays that evaluate the passage of stool through the colon to identify potential causes and locations of constipation. The patient takes a small pill containing metal markers, which will be seen on the X-rays over the next several days. 
• Videodefecogram: A defogram is a special X-ray that is taken while you are having a bowel movement to test muscle movement. This test is very helpful in determining the cause of pelvic floor dysfunction. This test may include regular X-rays, fluoroscopy or an MRI machine.   

The success rate of prolapse surgery depends on the specific symptoms and their duration. Risks of surgical correction include bleeding, infection and pain during intercourse (dyspareunia). There is also the chance of the pelvic prolapse recurring or worsening.

Hairs often grow in the cleft between the buttocks. These hair follicles can become infected. Further, hair can be drawn into these abscesses worsening the problem.  

Nearly all patients have an acute abscess episode (the area is swollen, tender and pus may drain from it). After the abscess goes away, either by itself or with medical care, many patients develop a pilonidal sinus. The sinus is a cavity below the skin surface that connects to the surface through one or more small openings. Some sinus tracts may resolve on their own, however, most patients need minor surgery to remove them.  

Treatment depends on the disease pattern. The primary treatment for an acute abscess is drainage. An incision is made that allows pus to drain, reducing inflammation and pain. This procedure can usually be done in a physician’s office under local anesthesia. 

When the wound is closed, it must be kept clean and dry until the skin is fully healed. If the wound is left open, dressings or packing are used to help remove secretions and allow the area to heal from the bottom up.

After healing, the skin in the buttocks crease must be kept clean and free of hair. It is necessary to shave or use a hair removal agent every 2 or 3 weeks until the age of 30. After that age, hair shafts thin out and soften and the depth of the buttock cleft lessens. Pilonidal disease can be a chronic, recurring condition so it is important to follow your physician’s postsurgical care instructions.

Symptoms can vary from very mild to severe.  The symptoms may include:

• Small dimple
• Large painful mass
• Clear, cloudy or bloody fluid drainage from affected area
• If infected, the area becomes red and tender and the drainage (pus) smells foul
• If infected, may have fever, nausea or feel ill

Diagnosis is typically confirmed by a physician examining the buttock area.

Complex or recurring infections must be treated surgically, either through excision or unroofing the sinuses. Unroofing the sinuses, as shown in Figure 2, involves opening up the abscess and tracts and trimming the edges of skin. 

Larger, open operations often result in better outcomes, although healing takes longer. Closure with flaps has a greater risk of infection, but may be required in some patients. Your colon and rectal surgeon will discuss all the options and help you choose the most appropriate surgery.

Rectoceles are usually caused by thinning of the rectovaginal septum (the tissue between the rectum and vagina) and weakening of the pelvic floor muscles. There are many things that can lead to weakening of the pelvic floor, including:

• Vaginal deliveries
• Trauma from vaginal delivery (e.g. the use of forceps or vacuum during delivery, tearing or episiotomy, which is a surgical cut in the muscular area between the vagina and the anus made just before delivery)
• History of constipation
• Chronic straining with bowel movements
• Gynecological (e.g. hysterectomy) or rectal surgeries

Colon and rectal surgeons as well as gynecologists are trained in the diagnosis and treatment of this condition. A rectocele is often found during a routine physical examination. However, other tests may be needed to help evaluate its severity or possible connection to symptoms. The following test may be ordered to confirm the diagnosis.

• Defecography: A special X-ray test that shows the rectum and anal canal as they change during defecation. This study is very specific and can pinpoint the size of the rectocele and the degree to which the rectum is emptied. 

The goal is to have good daily bowel habits and softer stools. Avoiding constipation and straining with bowel movements will reduce the risk of a bulge associated with a rectocele.

Preventive and Medical Tips

• Eating a high-fiber diet and taking over-the-counter fiber supplements (25-35 grams of fiber/day)
• Drinking more water (typically 6-8 glasses daily)
• Avoiding excessive straining with bowel movements
• Applying pressure to the back of the vagina during bowel movements
• Pelvic floor exercises such as Kegel
• Biofeedback, a special form of pelvic floor physical therapy aimed at improving rectal sensation and pelvic floor muscle contraction
• Stool softeners
• Hormone replacement therapy

The success rate of surgery depends on the specific symptoms and their duration. Risks of surgical correction include bleeding, infection and pain during intercourse (dyspareunia). There is also the chance of the rectocele recurring or worsening.

Most people with a small rectocele do not have symptoms. When the rectocele is large, there is usually a noticeable bulge into the vagina.

Rectal Symptoms

• Difficulty having a complete bowel movement
• Stool getting stuck in the bulge of the rectum
• The need to press against the vagina and/or space between the rectum and the vagina to have a bowel movement
• Straining with bowel movements
• The urge to have multiple bowel movements throughout the day
• Constipation
• Rectal pain

Vaginal Symptoms

• Pain with sexual intercourse (dyspareunia)
• Vaginal bleeding
• A sense of fullness in the vagina

Rectocele treatment is needed only when they cause symptoms that interfere with daily living. Before any treatment, your physician will assess whether all your symptoms are related solely to the rectocele. There are nonsurgical and surgical treatment options for rectoceles. Most symptoms associated with a rectocele can be resolved with nonsurgical treatment, however, this depends on the severity of symptoms.

The surgical management of rectoceles should only be considered when nonsurgical methods have not resolved or improved symptoms and the condition interferes with daily living. This can be done through abdominal, rectal or vaginal surgery. The choice of procedure depends on the size of the rectocele and its symptoms. The goal of surgery is:

• To remove the extra tissue caused by the rectocele
• To strengthen the wall between the rectum and vagina with surrounding tissue or use of a mesh patch