Proctology

Anatomy or system affected: Gastrointestinal system, intestines

Definition: The branch of medicine that treats diseases of the colon, rectum, and anus.

Science and Profession

The term “proctology” arises from the Greek proktos, meaning “anus.” In 1961, this field was renamed colon and rectal surgery. The original term, which is still widely used, will be employed for simplicity. Specialists in proctology are surgeons who are experts in surgery of the colon, rectum, anal canal, and perianal area near the anus. They also carry out surgery on other tissues and organs close to and involved in serious colorectal disease. Moreover, proctologists have special skills in endoscopy of the rectum and colon for the diagnosis and medical treatment of these regions. Proctology involves emergency situations less frequently than many other specialties. Consequently, the hours of these specialists are relatively regular, although no shorter than those of other physicians.

Many conditions encountered by proctologists are clear-cut in diagnosis and treatment. Hence, they often have the satisfaction of providing patients with quick, effective relief of serious pain and discomfort.

Training a proctologist is time-consuming, involving a five-year residency in general surgery, followed by a one- to two-year fellowship in colon and rectal surgery. The specialty is not easily entered because its practitioners are not numerous, and there are usually several applicants for each open training position.

The main organ treated in proctology is the large intestine, or colon. This portion of the digestive tract starts at the cecum, a pouch joined to the small intestine. At the far end of the cecum, the colon is subdivided into ascending, transverse, and descending regions. Together, these regions absorb water and minerals from food that has not been digested and absorbed by the stomach or small intestine. The result is feces, which are stored in the colon for elimination from the body. The ascending colon extends upward on the right side of the abdominal cavity and is called the right colon. The transverse colon crosses from right to left in the cavity, and the descending colon (left colon) passes downward along the cavity’s left side, ending in the rectum. The short, S-shaped portion of the left colon above the rectum is the sigmoid colon.

The entire colon is made of pouches whose complex series of contractions and expansions moves its contents through quite slowly, enabling optimum water and mineral recovery. The sluggish colon movement enables bacteria to thrive, sometimes causing uncomfortable gas. Normal synchronization of the digestive system leads to absorption of most of this gas, however, as well as the transfer of feces into the rectum for storage and a defecation reflex that releases feces at varied but appropriate intervals. Also synchronized with these digestive processes is the production of both mucus and bicarbonate, which help to propel colon contents through the large intestine and neutralize acid made by bacteria in the colon. These events usually prevent damage to the colorectal system or diseases of its components.

The digestive system does not exhibit frequent dysfunction in early life. Therefore, proctologists, for the most part, see middle-aged or older patients. Furthermore, 60 percent of the problems that they encounter are anorectal, and 40 percent are associated with a diseased colon. Conditions that are often treated by proctologists include, but are not restricted to, anal fissures, cancers, colitis, diverticular disease, hemorrhoids, pilonidal disease, and polyps.

Diagnostic and Treatment Techniques

Thorough colorectal examination starts with a medical history to ensure the clarification of potential problems. Then the proctologist checks the perianal region for abnormalities such as dermatitis, abscesses, hemorrhoids, or lesions that may prove to be tumors. This is followed by digital examination with a lubricated glove, after a warning to patients that this procedure will result in the urge to defecate and cause some discomfort. Tissue irregularity, nodules, or tender areas are sought, and the prostate gland in men and the cervix in women are examined. To ensure complete exploration, a fecal sample is obtained and tested for the presence of occult blood. Other clinical tests of colon, rectum, and related tissues, including biopsy, are also carried out as needed.

Anal fissures may be discovered during this portion of the examination. An anal fissure is a linear tear of the lining of the anal canal, usually originating in the anorectal region. These fissures are common causes of acute anal pain, cutting or burning sensations beginning at defecation and continuing more mildly for several hours. They are thought to arise from trauma to the anal canal caused by large, dry, hard feces. Other causes of anal fissures include persistent diarrhea, inflammatory bowel disease (IBD), syphilis, leukemia, and anorectal cancer. The treatment of choice is the use of fecal softeners, increased fluid intake, and application of steroids. Surgery is usually carried out only for cases in which treated fissures do not heal.

Pilonidal disease may also be detected; this is the formation of pits that contain pubic hair that has become trapped under the skin. If an abscess results, the problem is handled by its drainage under local anesthesia. Cleaning out of the pit and the removal of causative hair are also useful. Surgery is required only if the problem becomes chronic.

Anorectal cancers are relatively uncommon. They are treated in an individualized fashion with a varying combination of surgery, chemotherapy, and radiation therapy. Often, they are squamous cell carcinomas. In a smaller number of cases, melanomas, for which the survival rate is less than 5 percent, will occur. Other types of serious anorectal cancers include Paget’s disease and basal cell carcinomas. These cancers have better survival rates.

Rectal prolapse, passage of the rectum through the anus, is another common anorectal problem. It is seen either in children under the age of two years or in much older adults. In childhood, the problem is frequently attributed to anatomic underdevelopment, which cures itself. In adults, rectal prolapse may be partial or complete. Complete rectal prolapse results in the externalization of the entire rectum, bleeding, and excessive mucus discharge.

Rectal prolapse eventually causes anal incontinence, which may become irreversible. For cases in which a patient is feeble, the rectum is first manipulated to return it to a more normal placement. Then, a tightening steel or plastic loop is inserted under the skin at the anal opening to prevent future prolapse. When patients are robust enough for surgery, the rectum is often secured internally by a mesh sling anchored to internal fascia.

The treatment of internal or external hemorrhoids is another major aspect of proctological practice. Internal hemorrhoids are rarely painful because they are covered by insensitive colon mucosa tissue. The external variety, however, are rich in nervous tissue and may be very painful. Internal hemorrhoids are classified into four stages ranging from the relatively innocuous first-degree hemorrhoids, which do not prolapse, to fourth-degree hemorrhoids, which always prolapse.

Treatment for internal hemorrhoids, which depends on the severity of the bleeding and discomfort, ranges from education about proper diet and bowel habits to surgical removal (hemorrhoidectomy). Surgical removal is most often accomplished with a banding technique in which a tight rubber band is placed around the base of the hemorrhoid. Banding normally results in the sloughing off of dead tissue and the creation of a scar that prevents future problems. In cases of severe external hemorrhoids, banding is not used because it is too painful. Instead, more complex surgical excision is required.

Such symptoms as occult blood and lower abdominal pain may signal the need for a colon examination. Barium enemas and colonoscopy are the visualization techniques that are utilized. With a barium enema, a solution of radiopaque barium salt is placed into the colon after fasting and preliminary washing enemas have cleansed the organ. Then the colon containing the radiopaque solution is examined by X-ray techniques. This procedure can reveal diverticula, many colon cancers, large polyps, and other severe colorectal problems.

Colonoscopy, in its various forms, has become a mainstay in the diagnosis of colorectal disease. It is particularly valuable in finding smaller polyps, less developed cancers, and colitis. In addition, because patients who have had colon polyps removed have a one-in-four chance of new polyps forming within the next five years, colonoscopy provides minimally invasive and valuable follow-up. It can also prove useful in the follow-up of cancers and of inflammatory bowel disease.

Furthermore, an endoscope may be used to remove a smaller polyp directly or to determine that a large polyp or extensive carcinoma must be removed by laparoscopy or laparotomy. Colonoscopy is generally safe, and the entire large bowel from rectum to cecum may be examined with little risk to a patient. Moreover, endoscopic surgery greatly reduces hospital stays, recovery time, and the frequency of postsurgical mortality. The most common problems associated with colonoscopy are infrequent colon perforation as a result of diverticula, limited endoscopic access to the colon because of scarring from previous surgery, and flare-ups of ulcerative colitis.

Diverticular disease is quite common after the age of fifty. It is caused by small saclike pouches in the colon, often arising after colon spasms. In mild cases, diverticula can be observed by barium enema in patients exhibiting nonspecific abdominal pain and gas. In many instances, bleeding will occur. In some cases, diverticulitis (widespread diverticular infection and inflammation) can lead to serious colon blockage requiring colostomy, and in those cases where perforation occurs, peritonitis will result. Diverticulitis is most common in the lower left colon, originating in the sigmoid region. It may be painful enough to justify the nickname left-sided appendicitis.

Polyps, masses arising from the bowel wall, are asymptomatic in many cases but may cause bleeding and pain when they are large. The larger that a polyp becomes, the greater the risk that it will become cancerous. Polyps are often identified after rectal bleeding and/or cramps and abdominal pain lead to barium enema and colonoscopy. They are then removed completely via colonoscopy or laparoscopy, depending on their size. Thereafter, it is suggested that the entire colon be examined via colonoscope at intervals dependent on symptoms over a five-year period. Polyps tend to recur and may be associated with cancer.

More than 50 percent of colorectal cancers occur in the sigmoid colon and rectum. These very common visceral cancers are seen most in people over the age of sixty. Treatment is usually surgical removal of the diseased area, and barring spread to noncolon sites, the five-year survival rate is near 90 percent. Considerable variation exists in the size, location, and treatment of this very serious disease. Disease that has spread beyond the colon wall requires chemotherapy or radiation, or both, and the prognosis is not as good.

Major aspects of colitis are Crohn’s disease in the colon (most often ileocolitis), ulcerative colitis, and spastic colon. Crohn’s disease often appears in early life and is associated with fever, pain, and diarrhea. There is no permanent cure for this baffling disease, which recurs repeatedly. Treatments used include diet manipulation, immunosuppressive drugs, steroids, antibiotics (when colitis is accompanied by bacterial infection), and surgery (when intractable pain and bowel obstruction require it).

Ulcerative colitis is another disease that may appear in early life. It is recurrent, varies in severity from mild to fatal, and in less severe cases, manifests as intermittent attacks of bloody diarrhea. Treatment varies as with Crohn’s disease. Particularly dangerous is toxic colitis; very severe cases require immediate surgery.

Spastic colon, or irritable bowel syndrome (IBS), is a much milder form of colitis. It has no known anatomic cause, but emotional factors or other causes of hormone imbalance have been proposed. Periodic abdominal pain, constipation, and/or diarrhea are its usual symptoms. Happily, more than half of colitis complaints are attributable to this relatively mild problem, which is treated by diet modification, observation, and painkillers once the possibility of more serious types of colon disease has been eliminated by physical examination and other methodologies.

Perspective and Prospects

Many advances in proctology have occurred since the 1970s, including the wide use of screening for occult blood in stools, which is easily done and often provides early detection of colorectal cancer. In addition, sophisticated endoscopic and laparoscopic techniques have been developed. The use of various types of endoscopes has enabled the precise examination of the colon and rectum, allowing the detection of colorectal problems that once would have gone unnoticed even after barium enema and related radiologic techniques were used. Furthermore, endoscopic surgery via colonoscopy and laparoscopy has reduced the severity of surgical intervention and the size of incisions, decreased hospital stays and recovery time, and resulted in higher surgical survival rates and facile follow-up after surgery.

The development of fiber-optic systems to be used with video camera techniques has improved colorectal examinations. Proctologists can review data rather than relying on single-shot views through a colonoscope. Such video records and their ongoing improvement may constitute the most significant innovations in colorectal diagnosis and surgery.

The development of additional clinical tests and drug therapy, including the wide use of steroids and immunosuppressive drugs, has also made some colorectal diseases much more manageable; examples are improved treatment of Crohn’s disease and ulcerative colitis. Further advances in drug therapy, laparoscopy, and clinical testing may be major foci of future advances in this field.

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