This article provides an expert overview of common anorectal diseases and emphasises the importance of lifestyle modifications for prevention and management.

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Anorectal diseases

Anorectal diseases are a significant aspect of colorectal practice, encompassing various conditions that can significantly impact patient well-being and healthcare resources. Common anorectal issues include haemorrhoids, anal fissures, anal abscesses, anal fistulas, and rectal prolapse.

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Epidemiology and pathophysiology

Haemorrhoids

Haemorrhoids are blood vessels in the anal canal that cause symptoms when they become swollen or inflamed. Epidemiological studies suggest that up to 40% of adults experience hemorrhoidal disease at some point in their lives. The pathophysiology involves increased venous pressure and weakening of supporting connective tissues, often exacerbated by chronic straining, constipation, and prolonged sitting.

Anal fissures

Anal fissures, or tears in the anoderm, are commonly associated with the passage of hard stools. The aetiology often involves hypertonicity of the internal anal sphincter, leading to reduced blood flow and impaired healing. Chronic fissures may develop into a cycle of pain and sphincter spasms, necessitating comprehensive management approaches.

Anal fistulas and abscesses

Perianal abscesses result from infection of the anal glands, leading to localised collections of pus. Fistulas frequently follow abscess formation, presenting as abnormal tracts between the anal canal and perianal skin. These conditions require prompt surgical intervention to prevent recurrence and complications.

Rectal prolapse

Rectal prolapse occurs when the rectal mucosa or the full-thickness rectal wall protrudes through the anal opening. This condition is commonly observed in elderly patients and individuals with a history of chronic straining. The underlying cause involves weakening of the pelvic floor muscles and supporting ligaments.

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Lifestyle modifications: Evidence-based recommendations

Lifestyle modifications play a crucial role in preventing anorectal diseases, and there is growing evidence to support this. Let’s explore specific interventions that can be recommended to patients:

Dietary fibre: High dietary fibre intake is essential for preventing constipation, a significant risk factor for various anorectal conditions. Fibre increases stool bulk and promotes regular bowel movements, thereby reducing straining. A systematic review of randomised controlled trials has shown that fibre supplementation improves haemorrhoid symptoms and helps prevent recurrence. Recommended sources of dietary fibre include:

• Fruits and vegetables: These are rich in both soluble and insoluble fibres.
• Whole grains: Incorporate oats, barley, and brown rice into your diet.
• Legumes: Beans, lentils, and peas are excellent sources of fibre.

Hydration: Adequate fluid intake is crucial for maintaining stool consistency. Dehydration can lead to hard stools, increasing the risk of fissures and haemorrhoids. Guidelines recommend a daily fluid intake of approximately 2-3 litres, including water and other non-caffeinated beverages.

Physical activity: Regular physical activity is beneficial for gastrointestinal motility and overall anorectal health. Exercise promotes peristalsis, reducing the likelihood of constipation. Clinical guidelines recommend at least 150 minutes of moderate aerobic activity per week. Additionally, specific exercises targeting the pelvic floor, such as Kegel exercises, can strengthen supportive muscles and prevent prolapse.

Bowel habits: Educating patients about proper bowel habits is essential. Here are some recommendations:

1. Prompt response to bowel urges:

• Advise patients not to delay defecation, as doing so can lead to harder stools.

2. Avoiding straining:

• Encourage patients to avoid prolonged straining during bowel movements. Using a footstool to simulate a squatting position can facilitate easier defecation.

Time management:

Encourage patients to allocate sufficient time for bowel movements without feeling rushed.

Hygiene and skin care: Proper perianal hygiene is vital to prevent infections and dermatitis. Advise patients to use gentle, unscented cleansing products and to pat the area dry after washing. Overzealous cleaning or the use of harsh soaps can disrupt the skin barrier and predispose to fissures and irritation.

Weight management: Obesity is a known risk factor for haemorrhoids and prolapse due to increased intra-abdominal pressure. Weight reduction through a combination of diet and exercise can mitigate this risk. In cases of morbid obesity where conservative measures fail, bariatric surgery may be considered.

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Special considerations

Pregnancy

Pregnancy poses unique challenges due to hormonal changes and increased pelvic pressure. Obstetric guidelines emphasise the importance of dietary fibre, hydration, and pelvic floor exercises. Postpartum women should be counselled on bowel management and perineal care to prevent complications.

Geriatric population

In older adults, decreased mobility and changes in gastrointestinal motility necessitate tailored interventions. Fibre supplementation, hydration, and mild physical activity are particularly important. Regular assessment of bowel habits and proactive management of constipation are critical in this demographic.

Patients with chronic digestive disorders

Patients with conditions like irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD) require specialised dietary and lifestyle recommendations. For instance, a low-FODMAP diet may be beneficial for those with IBS, while maintaining remission in IBD involves a combination of pharmacological and lifestyle interventions.

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Conclusion

Anorectal diseases, while common, can significantly impact patient quality of life and healthcare resources. As specialists, it is imperative to incorporate evidence-based lifestyle modifications into preventive strategies. Dietary fibre, adequate hydration, regular physical activity, and proper bowel habits are fundamental components of these strategies. Special considerations must be given to pregnant women, older adults, and patients with chronic digestive disorders to address their unique needs.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Alpa Modi, MS(Gen Surg) is a practising surgeon from Thane.