Category Archives: Anal And Rectal Disorders
What Is Rectal Prolapse
Rectal prolapse is the displacement of the rectum from its normal position, resulting in its protrusion through the anus.
- Straining to make bowel movements is the usual cause.
- Physical examination, sigmoidoscopy and x-rays help in diagnosis.
- Infants and young children may have prolapse of the rectal lining which heals without treatment
- Surgery may be required to correct the rectal prolapse occurring in adults.
The prolapsed part of the rectum may be visible as a finger-like bulge in the anus. It appears darker red in color and moist to touch because it is the inner wall of the rectum that is being visible. Urinary incontinence and bleeding are the usual symptoms. Occasionally, a rectal prolapse may bulge into the vagina causing pain during sex.
In infants, the lining of the rectum may temporarily prolapse due to straining while emptying the bowels; it usually resolves without treatment. The rectal prolapse in adults steadily worsens resulting in more portion of the rectum bulging out into the anus. Procidentia is a condition mainly occurring in older women in which the rectum is completely prolapsed.
A physical examination of the anus and rectum with the patient in a squatting position, or sitting as if straining to empty the bowels, helps the doctor assess the extent to which the rectum has prolapsed. The muscle tone of the anal sphincter can be judged by feeling the sphincter with a gloved finger.
Further tests such as barium enema x-rays and viewing the anus and rectum with a sigmoidoscope may help determine the reason and extent of prolapse. A colonoscopy also may be done to view the interiors of the large intestine.
Treatment
Using stool softeners is a standard part of the treatment to prevent straining while passing the bowels. Binding together of the buttocks, between subsequent bowel movements, may help the rectal prolapse in infants and children to heal.
Surgical correction is the usual treatment for rectal prolapse in adults, especially for those suffering from procidentia. During an abdominal surgery, the supporting tissue is pulled up to bring the rectum back into normal position, and then it is tied to the sacral bone. In another type of surgery, the prolapsed part of the rectum is surgically removed and the remaining parts are stitched together and attached to the sacral bone to keep it in place.
Since an abdominal surgery has its own risks and the older people who need surgical correction may not be suitable candidates for such major surgeries, rectal surgery is often preferred to the former. Thiersch procedure is a technique in which a plastic loop is fitted around the sphincter to prevent prolapse. Surgical removal of the prolapsed portion is also a fairly common practice.
Share and Enjoy
What Is Proctitis
Proctitis is an inflammation occurring in the lower part of the rectum, affecting the rectal lining.
- Radiation proctitis caused by radiotherapy or infections may be the cause of inflammation.
- Proctitis is not always painful, but severe pain may be present in some cases.
- Examination of the rectal cavity with a viewing scope helps in diagnosis.
- If the inflammation is caused by infections, antibiotics can cure the condition.
Ulcerative colitis or Crohn’s disease may lead to the development of proctitis. Many sexually transmitted infections, mainly in homosexual men, are known to cause proctitis. Herpes simplex virus and cytomegalovirus infections as well as bacterial STDs such as Chlamydia trachomatis, syphilis and gonorrhea are some of the usual causes.
People with immunodeficiency are understandably more prone to proctitis due to the prevalence of cytomegalovirus and herpes simplex virus infections in them. Occasionally, when the benign bacteria which usually inhabit the intestines are destroyed by the use of antibiotics, other organisms which gain prominence in their absence may cause proctitis. Salmonella infection is also known to cause this condition. Radiation damage caused during the treatment of rectal, cervical or prostate cancer also may result in proctitis.
Symptoms and Diagnosis
Draining of mucus or bleeding from the rectum are the usual symptoms of proctitis. Painless bleeding is typical of this condition but if it is caused by infections such as herpes, cytomegalovirus or gonorrhea, severe anal and rectal pain may be present.
Examining the rectum with a viewing scope like sigmoidoscope helps in diagnosing the condition while a biopsy of the rectal lining and swabs taken during sigmoidoscopy may help identify the exact causative agent. A colonoscopy too may be done, to view the rest of the large intestine, to rule out tumors.
Treatment
When the infection causing the condition is identified to be bacteria, antibiotic therapy usually cures the disease completely. When proctitis is found to be caused by previous antibiotic usage, vancomycin or metronidazole is used to kill the newer inhabitants.
When radiation damage or some other allergic reaction is the reason for proctitis, corticosteroids or other anti inflammatory drugs may help. Corticosteroid drugs such as mesalamine and hydrocortisone are given rectally as suppositories, foam tablets or as enema, in addition to taking them orally. Olsalazine and sulfasalazine are two other anti inflammatory drugs that can be used. Formalin can be applied directly to the affected area. Other treatments which have been tried to resolve the condition include electrocoaguation, argon plasma treatment and laser treatment.
Proctitis Video Summary
Share and Enjoy
What Is Levator Syndrome
Levator syndrome is repeated episodes of sudden pain felt in the rectum due to the spasm of the levator ani muscle of the pelvic area.
A sudden fleeting pain in the rectum is termed as Proctalgia fugax and an unexpected pain near the coccyx or the tail bone is called coccydynia. Both of these are considered as belonging to Levator syndrome. The pain due to the spasm of the muscle does not last long, usually getting resolved within 15 -20 minutes. However, it can occur suddenly and may be so intense as to awaken a sleeping person. Sometimes it may be felt as a dull ache in the rectal region but not related to a bowel movement. It may feel as if passing gas or having a bowel discharge would relieve the pain but in spite of such measures, it may last for several hours and appear intermittently. Various treatments undergone by the patient, including surgical interventions, may not have brought any relief.
Diagnosis
The main aim of diagnosis is to rule out other disorders of the rectum and the anus which may have similar symptoms. Doctors usually look for the presence of anorectal abscess and fissures as well as thrombosed external hemorrhoids during a physical examination. Since lower back troubles or prostrate problems may also cause pain in the rectal area, tests to rule out such disorders may be done. But usually, nothing much directly related to levator syndrome may be observed besides a tightness or tenderness of the muscle.
Treatment
Educating the patient about this harmless condition helps relieve stress. Depending on the severity of the symptoms, general measures that may bring temporary relief such as emptying the bowels, passing gas or sitting in a warm bath may be tried. Mild pain killers like aspirin may be taken. For severe cases, electrogalvanic stimulation of the offending muscle can stop the spasm. In this procedure, an electric current of high voltage is applied to the muscle through electrodes inserted into the anorectal cavity.
Share and Enjoy
What Is Pilonidal Disease
Pilonidal disease is a chronic skin infection in the upper part of the buttock crease resulting from hairs embedded in the skin.
Some people with copious hair growth in the region of the buttocks may have a few hairs growing into the skin and irritating the skin in the crease between the buttocks. No specific reasons can be attributed to the occurrence of this condition but it is more often found in hairy, white men in the age group 20-40 years. Occasionally, women also may develop this condition.
The ingrown hairs irritating the skin result in the formation of a cyst containing hairs inside. This pilonidal cyst may remain without causing any problems or it may contract infections and get filled with pus, becoming a pilonidal abscess. It may result in redness, swelling and pain in the area. The abscess has to be drained by cutting it open, usually in the doctor’s office.
Eventually, a large space filled with fluid and pus forms under the skin with a few openings on the skin surface through which it keeps draining pus. This is called a pilonidal sinus. The tiny holes oozing pus is a characteristic symptom of pilonidal disease and the diagnosis of the condition can be made based on this. Surgery is often necessary for exposing the sinus and facilitating healing.
After the disease is cured by surgery, the patients are advised to keep the area hair free by regular shaving or by using hair removal lotions every two or three weeks, to avoid recurrence.
Share and Enjoy
What Are Hemorrhoids
Hemorrhoids are enlarged veins occurring in the walls of the anus and rectum, often causing pain and bleeding.
- Increased pressure in the veins causes them to enlarge.
- The enlarged veins get twisted and form lumps that result in bleeding and pain.
- Physical examination of the anus and viewing the interiors of the rectum with a sigmoidoscope help diagnose hemorrhoids.
- Symptoms of hemorrhoids appear and disappear on their own; fiber rich diet and use of stool softeners help relieve symptoms.
- A procedure using rubber bands is used to treat hemorrhoids. Surgical repair also is done
The walls of the anus and rectum have a rich network of veins. When some of the veins become swollen, they form hemorrhoids. They can get twisted and lumps can form. They may become prolapsed and hang down from their original location. Sometimes they protrude out of the anus. Hemorrhoids are classified according to the place of their origin. Internal hemorrhoids are those which originate above the anorectal junction and external hemorrhoids are those which originate in the area below the junction. Both types of hemorrhoids can protrude out of the anus when they are prolapsed.
Causes Of Hemorrhoids
When the pressure inside the veins of the anus and rectum is increased, they become swollen and result in hemorrhoids. Straining to pass stools due to constipation and strain during lifting heavy weights are the usual causes of increased pressure in the veins. Pressure during pregnancy and high blood pressure in the portal vein also may lead to hemorrhoids.
Symptoms
Pain and bleeding are the usual symptoms associated with hemorrhoids. When the hemorrhoids in the anus form lumps, blood clots develop inside them. They are called thrombosed external hemorrhoids and they cause pain and bleeding. Internal hemorrhoids also may bleed during a bowel movement, streaking the stool with blood and coloring the toilet bowl red. Anemia due to bleeding hemorrhoids is not very common as the blood loss is not usually heavy.
Itching in the anal area is not a direct symptom of hemorrhoids but cleaning of the anus becomes difficult if hemorrhoids protrude out of it, which in turn causes anal itching. Internal hemorrhoids and the mucus discharge from them may cause a feeling of fullness in the rectum even after emptying the bowel.
Complications: Formation of external thrombosed hemorrhoids and bleeding internal hemorrhoids are the usual complications that can develop.
Diagnosis
A physical examination of the anal region followed by viewing the inside of the anal canal with an anoscope helps the doctor in detecting external hemorrhoids. To detect internal hemorrhoids inside the rectum, a longer, flexible tube called sigmoidoscope is used. To rule out the presence of tumors, the lower part of the large intestine is also examined by colonoscopy. These tests are necessary if there is bleeding from rectum.
Treatment
For hemorrhoids which do not cause any disturbing symptoms, doctors advice general measures to ease bowel movements. Diet rich in fiber, stool softeners and natural laxatives like psyllium husk help in easy motions and reduce the need of straining. Sitting in a bowl of warm water called a sitz bath helps in relieving minor symptoms. A thrombosed external hemorrhoid causing pain can be treated by pain killers such as NSAIDs or by local application of anesthetic ointments. Gradually, as the clot gets resolved in about a month or so, the pain also subsides. Removing the blood clot surgically or injecting anesthetics into the hemorrhoid are options in case of severe pain.
Injection sclerotherapy is a procedure to cut off a hemorrhoid from its place of origin by forming scar tissue. A certain substance is injected into the hemorrhoid to initiate the development of scar tissue.
A procedure called rubber band ligation is used to destroy internal hemorrhoids when sclerotherapy does not produce the desired effect. It is also used for internal hemorrhoids which are large. The rubber bands extended over the tip of a ligator are pushed on to the base of the hemorrhoid to cut off the blood supply to it. Eventually they drop off without causing any pain. The procedure is repeated at two-week intervals if several hemorrhoids have to be ligated. Other procedures used to destroy internal hemorrhoids include infrared photocoagulation and electrocoagulation. Laser destruction is another such technique that has become available now.
Several newer techniques are being developed in this field because surgical removal of a hemorrhoid involves many side effects such as retention of urine and severe pain. It may also cause constipation which would further complicate matters. The arterial blood supply to the hemorrhoid is identified with a Doppler and it is cut off to destroy the hemorrhoid in a procedure called Doppler-guided hemorrhoid artery ligation. Circumferential stapled hemorrhoidopexy is another new procedure. A surgical stapler circular in shape is used to cut off the hemorrhoid- suspending tissue, at the same pinning back the hemorrhoid in its original position.
Hemorrhoids Video Summary
Share and Enjoy
Foreign Objects in the Rectum
Objects accidentally swallowed constitute the major part of the foreign objects in the rectum. They include swallowed chicken and fish bones, tooth picks, needles, buttons and marbles. They may pass through the digestive tract along with other food substances but on reaching the rectum, they may get stuck at the anorectal junction. Occasionally, foreign objects introduced through the anus such as thermometers, surgical sponges and other instruments and objects employed for sexual stimulation may reach the rectum and get lodged there.
Following the ingestion of an object, if a sudden, sharp pain is felt in the pelvic region, usually just before or during a bowel movement, it indicates that the object has reached the anorectal junction and is piercing the wall of the rectum or anus. Depending on the size and structure of the foreign body and the amount of damage it has caused to the walls, bleeding or other symptoms due to obstruction of bowel movements may be present. If infection has occurred due to the object piercing or damaging the walls of the rectum or anus, fever also may be present.
A physical examination is done by inserting a gloved finger into the anal cavity to feel the object and determine its position. Further testing include viewing the rectum and lower part of the large intestine using a flexible viewing scope called sigmoidoscope to rule out any perforation or damage to the wall that may have happened due to the movement of a sharp foreign body. X-rays of the abdomen and pelvic area are also taken.
Treatment
Usually, the natural peristaltic movements of the large intestine push a free-moving object down into the rectum and nearer to the anus, making it more accessible. When the object can be seen or felt by the doctor and if it is located in a position which can be accessed through the anus, it can be removed under local anesthesia. The doctor injects the anesthetic under the lining of the anus before a rectal retractor is used to distend the anal opening for easy access into the anal canal. The object is manually removed and the area is checked for any perforations or other damage which may require repair.
Sometimes, when an object cannot be seen or felt by the doctor, or when it is not easily accessible for removal through the anus, surgery may be necessary to locate it and manipulate it into the rectum. Under general anesthesia or regional block, an incision is made in the rectum to reach the object and remove it. There is a chance of perforation or other damage to the lower part of the large intestine or to the rectum. A flexible viewing scope called sigmoidoscope is inserted up to the large intestine to check for any such damage which require immediate surgical repair.
Share and Enjoy
What Is An Anorectal Fistula (Perianal fistula)
An anorectal fistula (perianal fistula) is a narrow abnormal tunnel originating in the anus or rectum and extending to the surface of skin surrounding the anus, or occasionally into vagina, or other adjoining structures
- They usually develop in people with tuberculosis or Crohn’s disease and in those who have previously had anorectal abscesses.
- They may discharge pus constantly and may cause pain.
- Physical examination and probing with viewing scopes can confirm the diagnosis.
- Surgical treatments are the usual option but latest advancements include minimally invasive as well as non-surgical options.
When anorectal abscesses have drained spontaneously, or by the doctor, the resulting empty space may not close completely by tissue repair. In half the cases of drained abscesses, fistulas or channels open up which often leads to the surface of the skin around the anus. The origins of most fistulas are in the glands found deep in the anal and rectal walls and often, no specific reason is found for their abnormal development. People who have tuberculosis and those who have Crohn’s disease are found to be more prone to developing anorectal fistulas. Those who have had injuries involving the anus and rectum, and those suffering from diseases like diverticulitis, tumors or different types of cancers, also have a greater chance of developing this abnormal condition. In infants, more often in boys, fistulas may be present as a birth defect. Injuries to the vaginal area during childbirth may cause fistulas to open between the rectum and the vagina. Cancer and radiation therapy also may result in such fistulas.
Symptoms and Diagnosis
Constant discharge of pus is the most common symptom of anorectal fistula. If infection is present, it may precipitate pain. It may be possible for the doctors to see the outlets of the fistulas in the area around the anus or it can be felt under the surface of the skin. The depth and the direction of the fistula can be assessed by inserting a probe into the channel; and viewing through an anoscope inserted into the rectum, the opening of the channel on the other side can be detected. The disorder that may be causing the abnormal condition, such as Crohn’s disease or cancer, can be detected by the help of a long flexible viewing tube called sigmoidoscope.
Treatment Of Perianal Fistula
Surgery to open up the fistula called fistulotomy used to be the only option for anorectal fistula until recently. It often included an incision being made on the sphincter, and consequently, it had the risk of causing loss of control of bowel movements, if the sphincter is cut too deeply. In latest procedures, a flap is stretched over the internal opening to seal off the fistula or fibrin glue or tissue plugs are used to fill up and close the tunnel.
Drug treatment for Crohn’s disease often helps an existing fistula to close and decreases the chances of new ones developing. Surgery is not usually attempted in people having frequent diarrhea or Crohn’s disease, due to the additional risk of delayed healing of wounds making matters worse.
Share and Enjoy
What Is An Anorectal Abscess
An anorectal abscess is a painful, swollen cavity filled with pus, often resulting from the bacterial infection of an anal or rectal gland.
- When a mucus gland in the anal or rectal wall is blocked, pus filled abscesses form due to bacterial infections.
- Pain and swelling in the anal area are the usual symptoms.
- Physical examination of the anus and tests using viewing scopes diagnose the condition.
- Abscess may be surgically drained by lancing.
The origin of an abscess is usually from an anal or rectal gland which normally produces the mucus that lubricates the anal and rectal canals to facilitate smooth bowel movements. A blockage in the gland can cause bacteria to multiply inside and the gland may get enlarged and become filled with pus, resulting in an abscess. Because of the rich blood supply to the anus, infections rarely occur there in spite of large number of bacteria present in fecal matter. But once infection sets in, it can spread and damage surrounding areas. Occasionally, fecal incontinence or loss of bowel control may result. People with pelvic inflammatory disease or Crohn’s disease are more at risk of complications. Diverticulitis may lead to the formation of abscesses.
Symptoms
Abscesses nearer to the skin cause more discomfort. Pain and tenderness may be felt and the area may have swelling and redness. Deeper abscesses may not have visible symptoms in the anal area, but pain may felt in the lower abdomen and the person may develop fever.
Diagnosis
Abscesses nearer to the skin may be visible to the doctor on physical examination. The anus and rectum may be examined with a gloved finger to detect any painful swelling and tenderness which may indicate a deep abscess. A CT scan may be done to detect the exact location and size of an abscess which is deep and inaccessible.
Treatment Of Anorectal Abscess
The primary treatment of anorectal abscesses usually involves surgical draining of the abscess, as antibiotics have very little role in curing the condition. However, they are prescribed for people with diabetes and immunodeficiency to control the infection. Abscesses nearer to the surface of the skin may be lanced under local anesthesia but the deeper abscesses may have to be drained by surgery in the operation theatre under general anesthesia. Hospitalization also may be necessary. The down side is that following the surgical draining of the abscess, in more than half the cases, the drained abscess develops into an abnormal channel, called anorectal fistula, between the surface skin and the rectum or anus.
Share and Enjoy
What Are The Causes Of Anal Itching (Pruritis Ani)
Anal itching or pruritis ani is severe itching of the anus as well as the immediate area surrounding the anus.
Causes Of Anal Itching
Itching may result from the lack of proper hygiene. However, more often than not, the cause may not be identifiable. Some of the probable reasons for anal itching are:-
- Pinworms
- Fungal infections
- Food allergy
- Lack of hygiene
- Inflammatory bowel disease
- Cancer (rarely)
Itching may appear suddenly without any apparent reason and may disappear without any particular treatment. Lack of hygiene being the most common reason for anal itching, doctors may advise measures to be taken to maintain proper hygiene. If pinworm infestation or fungal infection is suspected, appropriate drug treatments can be initiated. Itching due to cancer is rare but it is a serious issue requiring immediate medical attention. Inflammatory bowel disease also is a cause of concern. For all other unidentified causes, a wait and watch approach is taken initially, with medication to reduce itching. Only if the condition does not clear up in a week, further investigations are initiated.
Lack of hygiene as well as too much hygiene can result in anal itching. Particles of stool left behind by insufficient cleaning of the anal area after bowel movements, and sweat accumulating in the area, can cause irritation to the delicate skin in and around the anus. On the other hand, vigorous rubbing and repeated cleaning with wipes and soap can irritate the skin, making it tender and sore. Allergic reaction to certain ingredients in the soaps and other cleansing solutions can also result in itching. Presence of hemorrhoids poses additional hindrance to proper cleaning after passing stools. Hemorrhoids leaking mucus, blood or stool can cause severe itching in the area.
Anal itching often sets off a vicious cycle of itching and scratching, and then more itching and more scratching until the area becomes too tender and sore, eventually resulting in a burning sensation and pain. It can invite infections which may make matters worse. Allergic reaction to the very ointments used for relieving itching, may precipitate more itching.
Self evaluation
More often than not, anal itching may not have a serious underlying disorder that requires medical intervention. Self evaluation based on the pointers provided here may help a person assess the seriousness of the condition and decide on the next course of action.
- Pinworms, usually found in children, cause severe itching especially at night – de-worming should be done.
- Allergy from certain foods and chemicals like soaps can cause anal itching – avoid them.
- Extremes of hygiene – have good hygiene practices and avoid severe rubbing and cleaning with harsh soaps.
Warning signs: If the following symptoms appear along with itching, it should be investigated.
- A draining fistula which causes pus to exude from the anus.
- Diarrhea with traces of blood in the stool
- Hemorrhoids protruding out of anus.
- Particles of stool spontaneously appearing in the anal area.
- Thickened and hard skin around the anus
Medical intervention may be required in the first two instances i.e., if there is pus formation or if stools are bloody. For the rest of the cases, doctors can be consulted, if the itching and other symptoms do not resolve in a few days with proper measures of hygiene, keeping the area dry and avoiding irritation.
On a visit to the doctor, the symptoms should be described in detail. A physical examination of the anus and the surrounding area may be done and previous medical history may be studied before reaching a diagnosis. Doctor may check for thickening and hardness of the perianal area, the presence of abnormalities such as fistula, hemorrhoids, fissures and lesions during the physical examination. Information about the following may be required by the doctor.
- Food habits, especially regarding foods which are spicy and acidic in nature.
- Level of hygiene, frequency of wash and use of cleansing agents.
- Presence of disorders such as psoriasis, diabetes, hemorrhoids and infections like scabies and pinworm infestation.
- Medications used, including antibiotics and creams for topical application to relieve itching.
- Frequency and condition of bowel movements, including the use of suppositories and other stool softeners.
Testing
In the absence of abnormalities and infections in the anal area, treatment may be initiated to relieve itching. A sample from the anal area is collected using a transparent sticky tape, to examine under the microscope, to detect the presence of pinworm eggs. A scraping may be sent for culture to detect fungal infection. Rarely, a skin biopsy may be done under local anesthesia. Anoscopy may be done, during which doctors can detect the presence of hemorrhoids inside the rectum and anal canal by looking inside, using a short viewing tube.
Treatment
To treat the anal itching successfully, its cause should be treated first. De-worming treatments appropriate for pinworm infestation should be done. Measures to avoid re-infestation should also be taken. Anti-fungal ointments or dusting powder should be used to clear fungal infections. Foods suspected or identified, to be causing irritation or allergic reaction, should be avoided. Antibiotics which produce irritation should be substituted with suitable alternatives.
Soft tissue or cotton dipped in warm water should be used to clean the anal area after every bowel movement. Mild cleansing agents specially designed for hemorrhoids may be used, but soaps and pre-moistened wipes should be avoided. Non-medicated talcum powder or plain cornstarch may be used to keep the area dry. In case of severe symptoms, topical application of ointments containing 1% hydrocortisone may bring relief. Tight fitting clothing should be avoided, especially at night.
Share and Enjoy
What Is An Anal Fissure (Perianal Fissure)
What Is An Anal Fissure ? A painful tear in the skin of the anus or an ulcer developing on the lining of the anus is called anal fissure or sometimes perianal fissure.
Injuries caused by hard bowel movements are the usual cause of anal fissure. Frequent loose motions can irritate the anus and result in fissures. Rarely, anal sex may result in a tear. If the anal sphincter develops spasms due to the fissure, it may delay healing and make the pain worse.
Severe pain and occasional bleeding may be caused by the fissure at the time of a bowel movement and for short while following it. The pain may recur at subsequent bowel movements too. Fissures are suspected from the typical symptoms and the diagnosis can be confirmed by physical examination of the anus.
Treatment of Anal Fissure
Treatment focuses on measures to avoid repeated injury to the anus, while allowing time for the fissure to heal. Increasing the fiber content in food may facilitate easier bowel movements. Doctors may prescribe stool softeners or advise psyllium to make motions smooth enough to pass without straining. Suppositories like glycerin may be inserted into the lower part of the rectum for lubrication and easy passage of stool. Ointments containing zinc oxide may offer relief and protection and may help in the healing process. Lidocaine or benzocaine may be applied for pain relief. Sitting in a warm bath for a few minutes following a bowel movement may accelerate healing by increasing blood flow to the area.
If sphincter spasm develops, it should be treated for faster healing. Botox injection to the sphincter may stop spasms. Local application of nitroglycerin or calcium channel blockers also may help.
Surgical repair is an option considered when other treatments are not effective. Internal anal sphincterotomy or cutting a piece of internal sphincter may relieve the spasm. Controlled dilation of the anal passage is helpful in preventing repeat episodes.
Perianal Fissure Video Summary