Rania Habib, MD, DDS (Host): This is Community Connect presented by TGH. I'm your host, Dr. Rania Habib. Joining me is Amy Moan, Physician Assistant with the Department of Colorectal Surgery at Tampa General Hospital. Amy, welcome to the podcast.

Amy Moan PA-C: Thank you for having me.

Host: Let's begin right away with just a very simple question. What are the most common causes of painful bowel movement?

Amy Moan PA-C: Well, some of the most common reasons for having a painful bowel movement are going to be anal fissures, thrombosed external hemorrhoids, abscesses, or even just some normal skin breakdown. The external anal canal has a lot of pain fibers. So it doesn't take much to cause a lot of pain down there when you're going to the bathroom.

When you have a large, hard bowel movement, it can cause some tearing of the skin, and that can make it very painful to go. And that's what an anal fissure is. People hear about external hemorrhoids and those are some blood clots that kind of form outside of the anal canal and when that hurts, it will hurt until your body breaks down the blood clot.

Other things are an abscess, which is an infection of a skin gland, or like I said, even just skin breakdown from having extra moisture or frequent bowel movements or leaking fluid. And all of those things can be very painful.

Host: So when someone has a painful bowel movement, what are some common over-the-counter things that we could possibly try at home to get relief? 

Amy Moan PA-C: Well, people always think I'm holding out on them when I say sitz baths. So with all of modern medicine, I'm telling you soaking your bottom in warm water is very cleansing and soothing. It can help with a fissure by getting the sphincter to relax. It can help to kind of break down that clot from a hemorrhoid faster.

It's just good in helping to clean the area in general and that just means soaking in warm water for 10 minutes a day. Otherwise you can also try a topical over-the-counter steroid cream that may help to shrink a hemorrhoid, but it won't help for the other conditions. And we don't want you using those creams for more than a week because then they can actually cause more problems.

And things like just a simple diaper rash cream or petroleum jelly really will help protect the skin. But let's not forget, the main thing you need to do is keep your stool soft. So we don't want it too hard, we don't want it too loose. We want to aim for about one to two bowel movements per day.

And so if you need to increase your fiber intake with supplemental fiber or stool softeners, that's really important.

Host: Now for the patients that do have hemorrhoids, what do you think about hemorrhoid cream? Is that a good thing to use? Is it not?

Amy Moan PA-C: So any of the over-the-counter, like, witch hazel pads and things like that, if it helps and if it makes it feel better, try it. But the steroid cream in particular, can help, but like I said, after about seven days, it can actually cause some skin breakdown and it can actually make things worse. So you can use it for five to seven days and then take a week off.

And again, if it's not helping, then you need to get checked out to make sure that that's really what the problem is.

Host: Perfect. Thank you for sharing that information. Now I know you mentioned just the simple sitz bath, and I bet a lot of people were surprised, like, wow, just sitting in warm water for 10 minutes can, you know, create this wonderful environment. What about adding bath salts or any essential oils? Cause I know that's really on the craze right now. Do any of those help?

Amy Moan PA-C: It's extremely popular. Everybody wants to put stuff in the sitz bath, and we say that's fine. The problem with using Epsom salt is that if you do it every day, it can cause the skin to dry out. So I would say do it every other day.

Host: Okay. That is perfect advice. Now, if a patient continues to have painful bowel movements, when should we go to the doctor?

Amy Moan PA-C: In general, I would say if you aren't improving after about two weeks or if you start having some significant bleeding or even worsening pain, that's when I would go see the doctor because there are prescription medications they can try for an anal fissure. If it's an abscess, it might need to be drained or they might need antibiotics. 

It's always a good idea to get an exam, other than you looking with your phone, trying to take a picture and Googling it yourself. We prefer you go get an exam to rule out some of the less common causes of pain that can be more concerning.

Host: Now, I know a common question we might have is, what type of doctor should we see when we're finally ready to make that move? Should it be my PCP, my primary care physician, or a specialist?

Amy Moan PA-C: I think it's always a good idea to start with your PCP. And they can do an exam or sometimes they might not want to because they might not be able to identify exactly what's wrong. But if they don't, then they can refer you to the specialist. And most of the time they're going to start with a gastroenterologist, just a GI doctor, and they'll be able to kind of help you on the way.

Usually, there's nothing wrong with coming to see me at colorectal surgery. That doesn't necessarily mean that surgery is going to be warranted. But usually the primary care, the GI doctor, or the colorectal surgeon will be able to get you fixed up.

Host: Now, once they see the primary care physician or the specialist, let's say the gastroenterologist, before they're even referred to a colorectal surgeon, what is involved in the workup for painful bowel movements?

Amy Moan PA-C: So, for the most part, the workup is really just going to be an exam. And that also will consist of doing a digital rectal exam. And that's everybody's least favorite part of coming to see me. We're not very popular when it comes to that. But, it should be pretty quick and not overly uncomfortable, and then from there, most of the time we're going to be able to diagnose enough to say, all right, this is what the problem is.

Very rarely we would do an anoscopy to look inside that anal canal in the office, or sometimes we'd say, okay, let's schedule a flexible sigmoidoscopy or an exam under anesthesia so we can give a little sedation and get a better understanding of what's going on.

Host: Now, once we have a diagnosis, a lot of patients would probably be very nervous. In what scenarios might a patient actually need to come see you in colorectal surgery and need surgery?  

Amy Moan PA-C: Well, sometimes surgery is needed and the goal is to definitively treat the pain. So we are all about trying conservative measures and trying to let things heal on their own, but sometimes that's not going to happen. With something like an anal fissure, if the medications fail, then the next step is just a Botox injection.

And again, we do this under anesthesia because most people wouldn't tolerate that in the office. A hemorrhoid, if it's not improving, then we might need to excise it or an abscess might need to be drained or explored to make sure there's not an underlying cause of the abscess. And we can also perform a biopsy if it does appear that there's maybe one of those rare conditions causing the pain. We can do a biopsy. We can rule out cancer. We can give the patient some peace of mind. And most of these are outpatient procedures and you go home the same day.

Host: Amy, how often in your line of work do you see the benign side of these conditions? Just like you mentioned. An anal fissure, an abscess, or a hemorrhoid versus something more serious. 

Amy Moan PA-C: Well, that's the big question and that's why people are afraid to come to the doctor. But I would say probably 95 percent of the time it's going to be a benign condition and not cancer.

But it's best to let the specialist do the exam so we can rule it out or catch it early. And we have patients all the time that just put up with painful bleeding hemorrhoids or what they think are hemorrhoids for years when it's really something else

or it's something that we could have taken care of, and they say, man, I wish I had done that sooner.

Host: So when we look at some of the signs and symptoms of painful bowel movements, when should a patient actually be concerned that it's something more serious? 

Amy Moan PA-C: So typically if there's pain, and a palpable bump outside that is bleeding and it's not going away. So again, don't just assume it's a hemorrhoid because that's what I have patients say. I've had this hemorrhoid for years. And it's not a hemorrhoid. So, don't ignore it. That's why give it some time. You don't have to, the day it shows up, you don't have to run to the doctor.

But, if a week or two goes by and we're not seeing any improvement, just go get it checked out.

Host: Now, in that workup, you did mention, if you see something more serious, you're going to do a biopsy. And that's obviously going to tell you if what you're looking at is benign or if it's cancerous. And as a patient, obviously that is something we're very worried about. So how do we know if we might have cancer?

Amy Moan PA-C: So, usually an anal cancer would be what would cause the pain if it was due to a cancer. The only way to tell would be if it was a painful, bleeding mass that is not getting better. And typically it's going to be getting bigger. We would need to biopsy it.

Host: Now with patients who are diagnosed with anal cancer, do they ever have, besides the bleeding, the mass, and the bowel movements, which you know are three big telltale signs, do they ever have any other systemic signs and symptoms?

Amy Moan PA-C: Usually not. Because normally when we find the anal cancers, they are fairly superficial. So it's kind of like a skin cancer, but in that area. So, luckily, we're able to treat them or remove them, and the patients don't typically have the typical side effects you would think of, like weight loss or fatigue. 

Host: So it's really kind of isolated just to that anal area.

Amy Moan PA-C: Correct.  

Host: Well, Amy, you have provided us with wonderful information about everything we need to know that if we're having pain with bowel movements. As we wrap up, what is your final take home message for our audience, Amy?

Amy Moan PA-C: Well, I would say, if you have pain, don't be overly alarmed, but you also don't need to live with it. So, common things being common, you probably don't have cancer. But if the pain's not improving with over-the-counter remedies, it's best to get it checked out and we will make your visit as painless as possible.

Host: That's wonderful. Thank you so much for being with us today, Amy, and for sharing all of this very helpful information.

Amy Moan PA-C: Thank you so much for having me!

Host: Once again, that was Amy Moan, Physician Assistant with the Department of Colorectal Surgery. For more information, please visit tgh.org/cancer. If you enjoyed this episode, please be sure to like, subscribe, and follow Community Connect presented by TGH on your favorite podcast platform. I'm your host, Dr. Rania Habib, wishing you well. This is Community Connect presented by TGH. Thanks for listening.