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Thursday 3 March 2005 3.00-3.30pm
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CHECK UP 2. - Sore bottoms


THURSDAY 03/03/05 1500-1530





Hello. And today we're going to be going down under to deal with your questions about bottoms - itchy bottoms, sore bottoms, bottoms that bleed. It's nothing that doctors can't deal with, in fact they're more than happy to help because as often as not they can offer simple and effective remedies that will save patients a lot of pain and embarrassment. Piles, for example, can be got rid of with rubber band treatment and you can stop them coming back; itching, which may be caused by worms, but it could be that you're trying too hard to keep scrupulously clean, are wipes really the answer? And while we might be happy enough to let the doctor have a look at a child's sore bottom trouble is we're often quite reluctant to report our own problems. So if there's any bleeding, it is vital to have it checked out, hopefully to rule out problems that might be occurring higher up in the bowel.

So your chance to put your questions today to GP Dr Ann Robinson. The number, as ever, 08700 100 444, or you can e-mail

Nick has phoned our number, Nick has got, as he says, anal psoriasis. Symptoms then Nick - is that itchy, painful?

Combination of both itching and pain and quite often severe discomfort.

And anything that you've used is working or not?

Well I do use several ointments and emollients but the problem's exacerbated by repeated flare ups of proctitis. I have been to see a consultant and my GP's been very good but I just wondered if your specialist might have some additional help for helping to alleviate the pain and discomfit.

Okay, she's ready and willing and I'm sure more than able. Dr Ann Robinson, first before we just address that - proctitis is actually just another word for a sore bottom is it or a pain in the bottom?

Exactly. Itis is inflammation and proct is your bottom.

Okay, and so this anal psoriasis - I mean psoriasis of course is a general skin condition isn't it, I suppose it can occur anywhere.

Yes it does and Nick I think you've highlighted a really useful point for everyone listening - the fact that generalised skin conditions, like psoriasis and eczema can affect the whole bottom area - around the vagina if you've got a vagina or penis and right round to the bottom. As you say it's a really tricky area to treat, partly because creams get rubbed off very easily - obviously on your underwear - and also because they don't see the light of day very much and as you know psoriasis is often helped by sunshine but you probably wouldn't be thanked by the neighbourhood for walking round without your underwear on. So maybe if you've got the privacy of your back garden sometimes getting a bit of sun on your bottom might be really helpful. In all seriousness the real problem, as I'm sure you've found out, is that if that it's a difficult area to keep clean, there are a lot of bacteria around in the faeces, in the poo that comes out, and so it's very common for the sore skin that's affected by psoriasis to get a bit infected. And when it gets infected that's when it gets painful and doesn't heal properly. So you're probably using steroid creams and ointments to keep the psoriasis at bay, which is great, but steroids are a real breeding ground for bacteria. So if you are getting flare ups you're probably getting infection and I'd suggest that whenever that happens you get down to your GP and get a short course of oral antibiotics and take those, as well as possibly a cream that's a combination of a steroid and an antibiotic. And you can put that inside the bottom as well to help the pain.

Nick I hope that's been helpful, thank you very much for starting us off on this sensitive topic. We've got an e-mail from Ann, who again, in her case, has suffered from a red and sore bottom for a long time, she's tried various lotions and potions and she says that she controls it by scrupulous washing using a bidet - that's where the French score I guess because bidets are not so common over here - but she also uses baby wipes and she's not entirely sure that this is the answer for her because sometimes she thinks it flares up. Could that be the wet wipes that she's using and in trying to be scrupulously hygienic maybe she's overdoing it?

Yeah absolutely, I mean I think you can be too clean and too zealous on that front. A really common cause of bottom itching is thrush and you get thrush from wiping out normal good bacteria, which keep thrush, which is a fungus, at bay. So if you're using too much stuff to get rid of bacteria on the skin, for instance if you're putting any kind of - some people put antiseptic and things in their bidets or even in their bath and that can be bad actually because it can wipe out good protective bacteria. And as you say Barbara you can also be allergic to the stuff you're using - like stuff in wipes which you can be allergic to. So if you notice that after using them your bottom feels more itchy or more sore then don't use them frankly.

Okay, thank you very much, good advice. Sally Stockton next, waiting to talk to us. I'm sorry Sally in Stockton. Hello Sally.


And your question please. It's about, I think, faecal incontinence, so explain a little bit for us what the problem is for you.

Yes I'm over 70 and I've had this problem approximately five years. It's when I walk or even sometimes take light exercise I can find that I have passed a small amount of faeces without knowing it. I get no sensation of passing anything, I only find out after an accident has happened.

When it comes to the washing.

When it comes to the washing or even the smell which is just quite awful. I do not know what causes this, I nearly always empty my bowels before I go out in the mornings. So it's not - it's not any form of constipation that causes it ...

Ah well it's interesting you say that because let's see what Ann has to say because I guess instinctively you think maybe - I mean I certainly have heard of this constipation whereby the bowel gets impacted and then you can get almost an overflow which you possibly wouldn't notice coming out. But Sally thinks not in her case, so Ann ...

No, I really don't think there's any case of constipation at all.

All right, let's see what Ann has to say then.

Hi Sally and thank you for sharing that with us because I think you've highlighted a problem that affects probably at least 10% of women of your age, you are certainly not alone in this. And it's a problem people often are very reluctant to talk about, so thank you for that. As Barbara said constipation is often ironically a cause of faeces leaking out because it tends - you get a kind of impacted lump of faeces in the bowel and then liquid stall above it leaks around and does come out, sometimes people think they're not constipated because they're going once a day but there is still impacted faeces further up and it is still worth just being checked out and sometimes taking a gentle laxative at night, like lactulose does help to keep things flowing in a more controlled way. But it does sound, to be honest, as if you've got a problem with the tone of the sphincter, which is the ring of muscle that controls continence and normally stops it leaking out, it sounds more as if that's the case. That's common in women and men as we get older, more common in women because sometimes we've given birth to children and that can affect it as well. It is something that can be treated. Sometimes it can just be a question of exercises and increasing the muscle tone but sometimes it's the question of a small operation. The operation is not as drastic as it may sound and a lot of people, elderly people as well, who have it done are actually quite pleased that they have finally bitten the bullet. So perhaps go and discuss that with your GP.

Sally, thank you very much.

Thank you very much.

A question now - a quick one - from John, I haven't got his details and he's not on the line but he's asking about a fishy discharge from the anus, can't tell you anymore, what could that indicate?

Well a fishy discharge from any orifice implies that there might be a foreign body there which is causing bacteria to collect around it. Now I wouldn't like to ask exactly what or why John might have foreign bodies inside his rectum but people do, sometimes, without going into too much detail. So it is always worth checking. I mean sometimes it can be a swab left after an operation, can be a common cause of a foreign body left inside, sometimes it's a little bit of toilet paper that's got stuck up the rectum. So it can be perfectly innocuous and there might not be anything to it. But it's really, really worth going to have a check and also when you go to the doctor's they'll take a swab and they'll see exactly which bug it is that is responsible and you can be given a suitable antibiotic which will probably be one called Flagyl because that's the one that attacks bacteria that are common in the back passage.

Okay, thank you much. And well we haven't got very far into the programme before we get to the subject of piles and that's not surprising because piles are one of the biggest problems when it comes to sore bottoms. Someone wanting to be known as Mrs H - we respect that - Mrs H wants to talk about having piles whilst being pregnant and now still having a problem. What sort of problem are you left with?

Yes hello. I think it was - I had piles when I was pregnant three years ago and I had quite a sort of strenuous labour and it sort of exacerbated the problem tremendously and I had absolutely enormous piles after I gave birth to my child which were so bad I couldn't actually sit down for six weeks. And I sort of - it's never been quite the same down there ever since and it even affects the sort of choice of underwear that I can wear. I certainly can't wear a thong.

Mmm I can imagine not.

And I'm sort of a young person, so you know you'd sort of quite like to be able to wear these things but the rectum is actually quite distended and sort of misshapen, which is sort of grim, so it would be nice to know if there's something you can do about that really.

Hi, yeah I mean it's such a common problem to have piles, especially while you're pregnant is often the price we pay for the lovely darlings that emerge afterwards and then we're left with the legacy. What you're probably left with are skin tags. After the pile, which is just a bit of sort of varicose vein really in the back passage shrinks, which it usually does after the pregnancy and childbirth, you're left with these dangling bits of redundant skin, is what they really are, and they look like your whole bottom's falling out. In fact it isn't, they're just skin tags and they can actually be removed. You can go and be referred to a surgeon and have them removed. So they can definitely be dealt with, they're completely harmless and they're not as scary as they appear.

What's the purpose of piles, I mean they're a part of the anatomy of that part of the body, I mean can you successfully remove them and you lose nothing valuable?

Yeah you don't lose much. The thing is that there's a really complicated network of veins, the same as you've got in your legs, round the back passage which collect up all the blood in that area and then ship it back to the heart. And they all come together and where they come together they tend to get very distended and that's what piles are - they're just distended veins. The minute you put any increased pressure in the pelvis, like the great big developing baby, you're much more prone to them.

Do you suppose there's anyone who hasn't experienced piles to some extent?

Well 40% of the adult population admit to having piles, so it's probably near enough to a hundred percent isn't it.

And if you don't need an operation, perhaps it's not as severe as our caller has just mentioned, you certainly see a lot of advertisements for over-the-counter creams, should you mess around, should you be using things that you can buy from the chemist?

Yeah it's fine, I mean the stuff you can buy from the chemist is really similar to the stuff we prescribe and there's no harm, as long as you're not worried about missing some other underlying condition, like ignoring severe bleeding for instance, if it's just a bit of itch and you can feel a pile just put on a bit of the cream you can buy, that's fine, or use a suppository.

So that would make you feel more comfortable perhaps but would it actually help them shrink back?

Probably not no.

So if it was severe then that's when you're talking about an operation? Reasonably straightforward operation?

You wouldn't - the operation for the skin tags, that I was suggesting, is a bit different from the operation you'd have for piles. Mostly with piles you don't need an operation, you can avoid constipation, wait till you have the baby, the piles usually shrink, you can use cream and suppositories, if necessary you can go and have, as you said, rubber banding - you said in your introduction - where they put a band around the neck of it and that makes them shrink. You can have them injected to make them shrivel up and only in the most dire circumstances would you go and have the operation.

And the operation would do what?

The operation basically cuts out that bit of vein.

Okay. We've had a question from Michael in Hammersmith asking does sitting on cold, wet surfaces cause piles? The sort of thing your mum says isn't it.

No, it's rubbish.

Rubbish - okay clearly rubbish. Thank you very much. But what isn't rubbish is constipation causing pressure then.

Definitely, constipation is the underlying cause.

Okay, let's take another caller if we may - Margaret in Potters Bar, yes another piles question. You've had this operation that we've just spoken about have you?

Yes I have indeed. Not only was I rubber banded and looking on my treatments form here it's times three, whether that's three rubber bands or three bits of pile I'm not too sure ...

And you can't see.

Well I have looked in a magnifying glass and I'm still not quite sure. But I can certainly account for the pain that it's caused me, which I'd like to be able to get some advice from the doctor on. Initially - I'd had piles for years after I had my two babies in the '70s and the '80s and I wasn't particularly bothered about them. But two years ago I had my bladder enlarged, not quite sure what you call that in medical terms, and unfortunately developed three things from that - I had lichen planus, thrush and warts.

Listen - we're not going to go into your whole medical history because that could be extensive but ...

Apparently - the point being is that they seem to thrive on the haemorrhoids and although I was given steroids and cryotherapy, it just made things worse. So I've had this op ...

And you're in agony.

In agony.

Okay let's get some very particular advice for that, sorry to cut you off Margaret, there's so many calls. Anything then that might help beyond the sort of op - obvious painkillers that she's presumably been given?

The most important thing for you is to avoid constipation now, because the last thing you want to do is to be passing a great big giant hard stool. So just drink loads, eat loads - dried apricots are the most efficient way of getting fibre into yourself - but increase your fluid intake as well. And lactulose I think is a good - fairly natural laxative and painkillers and also, best of all, the local anaesthetic gel - lignocane - which I think you can buy over-the-counter, but if not you can get on prescription, which will numb the area a bit.

I hope you feel a lot better soon Margaret, thank you very much. John now, also with a question of piles and wondering - I guess in connection with constipation and so on - whether you can do much to sort of train yourself - is that your question John?

No actually - good afternoon. The background was I had a haemorrhoidectomy, which was recommended by three or four doctors and consultants. I've ended up with a reduced size of anal orifice, which in fact was so bad I had to dilate it with these dreadful conical dilators. That's a bit better than it was. But what seems to have happened is I've got damaged muscle control and also an excess production of mucus in the lower bowel which results in leakage. I don't know what the solution is, it's very uncomfortable, it's far worse than the haemorrhoid ever was. But I was told that there is a possibility that you can re-educate the nervous system in the area of muscles to take over the damaged or take over the role of those that were damaged.

Let's put that question directly to Ann, yeah that's an interesting one.

Yeah I think in specialist centres where they really deal with a lot of bowel surgery there are some really interesting and useful projects to help retrain the bowel. And sometimes they use computer programs, sometimes they use sort of timing - where you're told to only empty your bowel at certain times of the day and you increase the amount of time you can go between bowel movements very gradually. And what you really need to do is make sure that the surgeon you saw is well aware of your problems and if they don't offer that kind of retraining programme in that hospital to refer you to a specialist centre because there is really good stuff out there to help people like you.

Right. I have done that and in fact I've had a second opinion or at least I've had tests in lieu of - when I supposed to get a second opinion and they've come up with everything's okay apart from the resting pressure is low and also there is a delayed response to a step change of pressure in the rectum.

I've think you've highlighted a really useful point, which is that these bowel operations are - they are not a kind of panacea and that it is so useful to explore all the other options before you go for them, as your case unfortunately has sort of highlighted.

Thank you John, good luck with that. Just a quick tip which has been handed to me and it's so wacky I have to read it out to ask if there's anything in it. Mrs Jacobson from Wales says that eating fried black pudding clears up piles within a couple of hours. I can't imagine why can you Ann?

How extraordinary but you never know, scientific sort of discoveries are sometimes made from chance comments like that so ...

Well give it a go I guess. Let's move on from piles though, if we may now, to another topic which we've flagged up and that's anal fissure and I just should so that's fissure - it's a difficult one to say but it's fissure. And Leonard Reeves I think has got an experience of this condition and is looking for some help. What is it you need to know Leonard?

Hello, I'm 72 years old, I had bowel problems and was worried about passing blood. I had an examination and a barium enema, which revealed no serious problems but it was confirmed that I had an anal fissure. I was invited to undergo treatment using botulinum toxin or botox. I was a bit concerned about this and declined but I'm interested to know if this is an effective treatment.

Wow, this is the one that ladies of a certain age maybe tempted to use for their frown lines. Botulinum or botox then for anal fissures - perhaps before you answer that directly, for those who are not entirely keyed in on this, just tell us a bit more if you would Ann please about anal fissures.

Right, well as Leonard will testify an anal fissure is an extremely painful horrible condition where you get a tear in the lining of your anal canal and you sometimes get itching round the bottom and sometimes a bit of bleeding as well. Now in most cases they heal up within six weeks, thankfully, although it can feel like the worst six weeks of your life while you've got them. But in a certain percentage of cases, as in yours Leonard, they become long term or chronic, which means they last more than six weeks. And actually once that becomes the case, unlike most things, the vast majority of them don't just heal up then and do require some treatment. So I think you're quite right to be pursuing treatment and botox is a very trendy and possibly effective treatment. Because what it does - like Barbara was saying - for the muscles of the face, it relaxes the muscles that are in spasm and that is the cause of the pain with an anal fissure, so if you can relax that very tight anal sphincter, we obviously need a tight anal sphincter to keep us continent, if it weren't tight we'd leak faeces all the time. But when you've got a cut in it that kind of spasm that gets even worse is really, really painful and botox will ease that up just enough to help the pain, without making you faecally incontinent. So it's a good treatment and it's quite widely available. It doesn't always work and it sometimes wears off but sometimes it works long enough to allow the fissure to heal. So I might try that but it probably works as well as putting a cream on which is - I must just tell you about this because it's very clever. This cream is the same stuff they use for angina and it relaxes the blood vessels around the heart and some bright spark - I don't know who - must have thought to themselves well if it relaxes the arteries round the heart it might relax the smooth muscle around the anus, why don't we put some on someone's bottom and see if it helps their fissure. And what kind of genius would think of that? And it sometimes works, although it doesn't always work. So now they've made it into a paste and you can put it on your bottom. And personally I'd rather try the paste before I had a botox injection.

And would you get that from your GP?


Okay, well thanks very much for raising the question and we will move on, if we may, very quickly to Mick who's in Merseyside and taking us on to the subject of bleeding, very serious or maybe very serious. Mick what's your issue?

Hi, yeah, what it is, is when I go to the toilet and I use - when I wipe myself with tissue there's usually a lot of blood on it and sometimes like in the water, in the pan, there's blood in there. And it feels like I've got discomfit round my anus. My brother had something wrong with him where he had a finger come out his bum and I don't know whether it was called thrombosis or something like that but he got told it was a clot. Could that be a hereditary thing?

Okay, lots of questions there, I wonder ...


... no not at all, that's what we're here for but if we can see a simple line of answering through that.

I mean you and your brother have almost certainly got piles ...

Yeah we had the piles when we were kids, well I had it when I was about 17.

Yeah, I mean that's almost certainly what it's due to. However, it is so important to say you can't assume that all bleeding from the back passage is due to piles, even though most of it is. And it's always worthwhile, especially if it's started again, go and get it checked out because you don't want to miss bowel cancer. Now almost certainly you haven't got bowel cancer but someone out there who is assuming it's piles will have. So everyone should get it checked if they have rectal bleeding.

We can't emphasise this enough as we come to the end of the programme - if you've got bleeding it may be from the piles, if it's not you may need to get a further examination. Is that absolutely right - that's the case is it?

Yeah, just don't assume it's always piles.

Okay, well thank you very much for that. We're going to have to leave it, as usual we never have quite enough time to get to all the many callers who wish to speak to us but thanks very much to everyone who tried to get through today, those who phoned and those who e-mailed. And our thanks to Dr Ann Robinson, our expert today. If you'd like to hear the whole programme again you can do that - go to our website, follow the trail to Check Up. Or if you want to speak to our help line you can call 0800 044 044 and if you've been disappointed that we didn't tackle chronic pain, that's our subject next week.

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