1) I just turned 50 and my doctor says I need a colonoscopy, but I feel fine. Should I have it?

Screening colonoscopy is recommended by the American Cancer Society and the National Cancer Institute to look for polyps and colorectal cancer. There are no early symptoms of colon and rectal cancer and most patients have an advanced cancer before there is any sign of a problem. However, most colon cancers spend many years as benign polyps that gradually become more abnormal before turning into cancer. These polyps can be found and removed with colonoscopy, dramatically reducing the risk of colon or rectal cancer. More detailed information can be found at: www.colorectal-cancer.net/prevention.htm.

2) My doctor says I should have colonoscopy to look for colon cancer. No one in my family has had colon cancer, so why should I worry about it?

There are inherited forms of colon cancer: Familial Adenomatous Polyposis (FAP) and Hereditary Non-Polyposis Colon Cancer (HNPCC, also called Lynch Syndrome). Having a primary family member (mother, father, sibling) with colon cancer also increases your risk of developing polyps or cancer. However, the vast majority of patients with colon cancer (over 80%) do not have any family members with colon cancer. For that reason, everyone should start getting screening colonoscopy at age 50. If you have a close relative with colorectal cancer before age 60, then you should get colonoscopy 10 years younger than the cancer was found in your relative.

3) I have heard that colonoscopy can prevent colon cancer. Does insurance cover colonoscopy?

That depends on the reason for the colonoscopy and your insurance policy. If there is a problem with your colon or rectum, such as rectal bleeding or changes in bowel habits, then most policies will cover colonoscopy as a "diagnostic service". However some policies have limited coverage for "preventive services". If you are getting a colonoscopy to make sure you don’t have cancer, and there is nothing wrong before the colonoscopy, then your insurer may consider this "preventive" and only pay a small portion of the cost or none at all. Also some insurance plans will only pay if you have the procedure done at one of their contracted healthcare facilities by one of their contracted physicians. Since everyone's policy is different, you should check this one out yourself by calling your insurance company and asking specifically about your policy coverage and if the physician and place you plan to go to are contracted on your plan.

4) What is virtual colonoscopy? Is it easier than a conventional colonoscopy?

Virtual colonoscopy (also called CT Colonography) is a high speed, high resolution CAT scan that images the inner lining of the colon. The CT uses air in the colon and the difference in density between the air and the bowel wall to create the images. This requires filling the colon and rectum with air "to the maximum degree tolerable". Polyps 1cm or larger in size can be detected but cannot be removed during the procedure. Like conventional colonoscopy, cleansing of the colon (called a bowel prep) is required before the CT procedure. The bowel prep is often the hardest part of a conventional colonoscopy. At least 25% of patients will have a polyp and will need conventional colonoscopy for removal usually at a different date with yet another bowel prep. In conventional colonoscopy, polyps as small as 3mm (3 tenths the size of what the CT can detect) can be detected and removed during the procedure. Currently most insurance companies do not cover virtual colonoscopy as a screening procedure.

5) I have heard that colonoscopy is painful. Is that true?

Screening colonoscopy is the best way to find colon polyps that could become colon cancers, so getting a colonoscopy is important. Newer sedating medications make colonoscopy quite comfortable for most patients. In fact, most patients do not remember the procedure at all. Since colonoscopy looks at the lining of the colon (where polyps and colon cancers start) the colon must be cleansed of stool before the examination. This is also true of any of the other methods of screening for colon cancer such as barium enema or Virtual colonoscopy. More detailed information can be found at: www.colorectal-cancer.net/prevention.htm.

6) I understand that a colonoscopy could find an early colon cancer. Wouldn’t I need surgery and a colostomy if they found colon cancer?

Most of the time colonoscopy finds polyps BEFORE the polyps get abnormal enough to turn into cancer. Most patients who do have cancer will need an operation to remove the cancer. Only patients with a cancer very close to the anal sphincter muscles need a colostomy. The best chance of survival with colon cancer comes from finding it early. Colonoscopy is the best method to find early colon cancer. More detailed information can be found at: www.colorectal-cancer.net/prevention.htm.

7) What is constipation? What can be done about it?

Constipation means different things to different people: hard stool, pain with stool or infrequent stool. "Normal" stool frequency is at least 3 times per week. The most common cause of hard stool in America is insufficient fiber and water in the diet. Stool gets hard as the colon takes water out of the stool. Stool will be soft if there is enough water left in the stool at the time of elimination. Increasing fruits and vegetables in your diet is beneficial but usually inadequate. Most people with constipation need a fiber supplement. There are many types of fiber supplements. The best one is the one you can take regularly. They all work by holding water in the stool. If increasing water and fiber does not relieve your constipation then you should talk with your primary physician. There are some problems that can be corrected surgically. You can find more information at: www.fascrs.org/brochures/constipation/.

8) I was told I have an anal fissure. It really hurts. What can be done about it?

Anal fissure is a tear or crack in the skin of the anal canal. It really hurts! The pain is actually from spasm of the internal anal sphincter muscles under the fissure. Spasm in the sphincter muscle also reduces blood flow to the fissure, delaying healing. Many fissures will heal (and hurt less) with consistently soft stool so fiber and stool softeners are always good. A hot bath will also help relax the muscle. Up to 2/3 will heal with medicated ointment that will also help the sphincter relax. Healing is reliable (98%) with division of the spastic muscle. More detailed information can be found at: http://www.fascrs.org/displaycommon.cfm?an=1&subarticlenbr=3 .

9) My doctor says I should eat more fiber. Do I need to use those fiber powders?

Many of the intestinal problems in America (diverticulosis, constipation, colorectal polyps and cancers) are rarely seen in parts of the world with much higher dietary fiber intake. The best source of fiber is unprocessed grains. In western diets most of our grains are highly processed with very little fiber remaining. Fruits and vegetables do have fiber, but relatively little compared to whole grains. A very large amount of fruits and vegetables would be required to add a meaningful amount of fiber to the diet. The reality is that most of us will need to use a fiber supplement to really increase our fiber intake. Which fiber is best? The one you can continue to take regularly over the long term. Fiber is available in powders to mix with juice or water and as tablets. Both are effective if taken with the proper amount of water. Both are also usually available in generic form as well as the more costly brand name products. Fiber is also usually the first line of therapy for irritable bowel syndrome.

10) Is it safe to assume that a little bright red rectal bleeding is just hemorrhoids?

The odds are that painless bright red rectal bleeding with bowel movements, especially in small amounts, will be due to hemorrhoids. HOWEVER, tumors can also bleed. They usually only bleed a little bit and will most likely bleed when traumatized such as with a bowel movement. The risk that bleeding could be from a polyp or tumor increases with age over 50. The only way to be sure that bleeding is "only hemorrhoids" is to look inside the colon to make sure no polyps or tumors are present. This is best done with either sigmoidoscopy or colonoscopy as recommended by your physician. More detailed information can be found at: www.colorectal-cancer.net/prevention.htm

11) What are hemorrhoids?

Hemorrhoids are swollen vessels under the surface of the lower rectum (internal hemorrhoids) or under the skin at the anal opening (external hemorrhoids) or both. The vessels are always present and assist with complete seal of the anal canal to prevent leakage between stools. When the connective tissue surrounding the vessels and attaching the vessels to the underlying tissues stretches or breaks then the vessels swell and descend into or through the anal canal. The connective tissue damage is usually a result of straining at stool with chronic constipation but can also occur with diarrhea and is common in late pregnancy. The enlarged vessels and the overlying surface can be traumatized with stools passage, especially large stools or with diarrhea. More detailed information can be found at: www.fascrs.org/brochures/hemorrhoids.html.

12) What can I do to ease pain from hemorrhoids?

Hemorrhoids do not typically hurt unless there is a clot in an external hemorrhoid or internal hemorrhoids are trapped outside the rectum. These are both obvious by the rapid appearance of swelling. An abscess can also cause this rapid presence of pain and swelling. When pain is present without rapid appearance of swelling then other conditions such as an anal fissure or, more seriously, an anal cancer must be considered. Bottom line, hemorrhoids that hurt either have an acute problem, or it isn’t hemorrhoids. Either way you should get it checked out, sooner rather than later. More detailed information can be found at: www.fascrs.org/brochures/hemorrhoids.html.

13) Can external hemorrhoids cause problems?

Most of the time external hemorrhoids are simply a nuisance. The chronically swollen tissue interferes with hygiene leading to itching and burning. A thrombosed external hemorrhoid (blood clot in the external hemorrhoid) can be quite painful for several days. This shows up as a rapidly appearing painful swelling near the anal opening. It is painful, may bleed and can take 3-4 weeks to resolve but is not really a problem otherwise. Hot baths 2-3 times daily and over-the-counter stool softeners will reduce the pain. There are some other more serious conditions that present as rapidly appearing anal lumps, such as infections or anal tumors, so you should be examined by your doctor if you think you may have a thrombosed external hemorrhoid. Early excision of the clot under local anesthesia in the office can reduce the duration of the pain. You can learn more at: www.fascrs.org.

14)My hemorrhoids are getting worse. What can be done about them?

Treatment for hemorrhoids depends on size and severity of symptoms. When fiber and stool softeners fail there are several office procedures that are successful in up to 80% of smaller hemorrhoids. Larger hemorrhoids, especially those that come out (or "prolapse") with bowel movements, need to be removed surgically. Unfortunately, hemorrhoidectomy tends to be painful because of the number of nerves in the anal area. A new operation is available for internal hemorrhoids. Called "stapled hemorrhoidectomy", this operation is actually done higher in the rectum at the top of the internal hemorrhoids. At that level there are far fewer nerve endings, reducing the pain of the operation. More information can be found at: http://www.pslgroup.com/dg/215926.htm.

15) What can I do about anal itching?

Anal itching (pruritus) is most often the result of moisture or trauma, or both. Some patients traumatize the anal skin by wiping too much. Pre-moistened cloths (baby wipes) are much more effective than toilet paper with much less trauma. Some patients have a minor degree of leakage between bowel movements, leaving moisture and injuring the skin, no matter how much effort was spent cleaning an hour ago. Protecting the skin with a moisture barrier ointment will also help. Caffeine intake increases itching in some people. If you drink more than 3-4 cups of coffee or sodas per day then try cutting back. If none of these help then you should be examined by your doctor. You can find more information at: http://www.fascrs.org/displaycommon.cfm?an=1&subarticlenbr=17.

16) What can be done about anal warts?

Anal or genital warts are caused by a virus: human papilloma virus. Typical symptoms are bleeding, pain, itching, and difficulty with cleansing in the anal area. There are several strains of the virus, some of which have been associated with cancer of the cervix in women. Because of this association, women with anal warts should have a vaginal examination and PAP smear. Anal warts can be transmitted sexually so sexual partners of both men and women should be examined. Warts on the surface can be treated with medications. If these recur then internal warts may be responsible and may require laser or cautery treatment. Repeated treatment is often required. If you notice new lumps around your anus or genitals, then you should be examined by your doctor. You can find more information at: http://ascrs.affiniscape.com/displaycommon.cfm?an=1&subarticlenbr=4.

17) I sometimes have trouble controlling passing gas or stool. What can be done?

Control of stool and gas often gets worse with age in both men and women. Women tend to have more problems with severe loss of control. Multiple children, long difficult childbirth or severe tears with childbirth increase the risk of control problems later as scar tissue softens and stretches. Using fiber tablets to thicken the stool (using less water than the bottle directs) will often improve control. Dietary factors, such as more rice, toast etc, can also make stool more formed and easier to control. Training of the muscles of the pelvic floor with the help of a trained therapist will improve control in many patients. If there is a defect in the circle of sphincter muscle then repair will often dramatically improve control. If the problem is from stretch on the nerves then repair is less reliable and may require more complex techniques. If you have more questions talk to your doctor or go to: http://www.fascrs.org/displaycommon.cfm?an=1&subarticlenbr=5.

18) I have heard of Crohn’s disease and colitis. How are they different?

In many ways Crohn’s disease and ulcerative colitis are similar. Together they are referred to as "inflammatory bowel disease" because they are both uncontrolled inflammation of the intestine. However there are also many differences. Ulcerative colitis (UC) is always found only in the colon and rectum, while Crohn’s disease (CD) can involve any portion of the intestine. UC only involves the inner lining of the colon and rectum but CD can involve all the layers and penetrate into adjacent organs like the bladder, vagina or another portion of intestine. Both are initially treated medically. UC can be cured by removing the colon and rectum. CD will often come back in another portion of the intestine after being removed surgically. More information can be found at: www.ccfa.org.

19) A family member was recently diagnosed with colitis. What is that? Can I get it?

"Colitis" usually refers to a problem with the immune system where the immune system attacks the lining of the colon instead of a virus or bacteria. It can get confused with "spastic colitis" which is a problem with poor coordination of the muscles of the colon leading to pain, but no bleeding or other serious problems. True colitis is a complex condition involving errors in the genetic code that controls the building of certain antibodies. When the patient is exposed to the antigen for these antibodies the chemical structure has an error that makes it attack the bowel wall instead of the foreign protein. The result is damage to the lining of the colon. It can usually be treated with medication but may require surgery. More information can be found at: www.ccfa.org.

20) How is ulcerative colitis different from spastic colitis?

"Colitis" usually refers to a problem in which the immune system attacks the lining of the colon instead of a virus or bacteria (Ulcerative colitis). The term "colitis" can get confused with "spastic colitis" which is a problem with poor coordination of the muscles of the colon leading to pain, but no bleeding or other serious problems. Ulcerative colitis is a complex condition involving errors in the genetic code that controls the building of certain antibodies. When the patient is exposed to the antigen for these antibodies the chemical structure has an error that makes it attack the bowel wall instead of the foreign protein. The result is damage to the lining of the colon. It can usually be treated with medication but may require surgery. More information can be found at: www.ccfa.org.

21)My doctor says I have diverticulosis. What should I do about it?

Diverticulosis is a very common disorder, affecting 30% of Americans by the age of 50 and up to 50% by age 80. The problem is actually small hernias of the lining of the colon out through the muscle layers. Since it consists of a hernia, or actually many hernias, it cannot be reversed by diet or medication. Most patients with this condition with never experience any problems but diverticular pockets can get infected (diverticulitis) or bleed. These complications are primarily related to stool trapped in a pocket and either causing an infection or rubbing into the adjacent artery. Eating a high fiber diet to keep your stool soft reduces the risk of complications. More information can be obtained at: http://www.niddk.nih.gov/health/digest/pubs/divert/divert.htm.

22) My doctor says I have diverticulosis. What complications should I be concerned about it?

Diverticulosis is a very common disorder, affecting 30% of Americans by the age of 50 and up to 50% by age 80. The condition is actually small pockets, or hernias, of the lining of the colon out through the muscle layers. Most patients with this condition will never experience any problems. But stool can become trapped in a diverticular pocket and cause infection (called diverticulitis). Also hard stool in a pocket may rub the adjacent artery causing the artery to bleed. Since it consists of many hernias, diverticulosis cannot be reversed by diet or medication. However, eating a high fiber diet to keep your stool soft reduces the risk of complications. More information can be obtained at: http://www.niddk.nih.gov/health/digest/pubs/divert/divert.htm.

23) My doctor told me I have diverticulosis. Is that the same as diverticulitis?

Diverticulosis is a very common condition in America and western Europe. It is usually found a lower segment of the colon called the "sigmoid colon". Actually it is small hernias of the lining of the colon, called the mucosa, out through the muscle layers of the colon. This occurs in small weakened areas where the blood vessels come through to the inside from the outside. Diverticulitis occurs when stool become trapped in one of these pockets and it becomes infected. This occurs eventually in about 25% of patients with diverticulosis. If the infection is found early it will often respond to oral antibiotics. More severe infections require intravenous antibiotics in the hospital and may require surgery. More information can be obtained at: http://www.niddk.nih.gov/health/digest/pubs/divert/divert.htm.

24) My friends say I should not eat seeds or nuts if I have diverticulosis. Is this true?

Over the years many have suggested that diverticulitis might be caused by seeds and nuts getting trapped in the diverticulosis pockets. There is no evidence that this is actually true. In fact, most of the evidence suggests that hard constipated stool trapped in the pockets is actually the problem. This can be avoided by eating a high fiber diet that helps keep the stool soft and aids with regular bowel movements. Seeds are a major source of dietary fiber. Most seeds, such as sesame, poppy and most berry seeds are too small to be of concern about getting "trapped" anyway. More information can be obtained at: http://www.niddk.nih.gov/health/digest/pubs/divert/divert.htm.

25) My doctor says I have a rectocele? What is that and what should be done about it?

A rectocele is a bulge of the back wall of the vagina. In most women it is due to trauma to the tissues between the rectum and the vagina during childbirth. Chronic constipation can also damage these tissues. A rectocele is often found in combination with a "cystocele" (bulge of bladder into the front of the vagina) and/or an enterocele (a bulge of small bowel from the top of the vagina). Rectocele (or cystocele/enterocele) are only important if they cause symptoms. In many women the rectocele can be demonstrated on examination but causes no problems and no treatment is needed. The rectocele can make bowel movements difficult, especially when stool is hard. In other women there is a sense of a lump or bulge, worse when up for a long time. Stool softeners and fiber supplements are the first line of treatment. If the symptoms are worrisome, even with soft stool, then repair can be considered. More information can be found at: www.fascrs.org/brochures/rectocele.html.

 26) My doctor says I have rectal prolapse. Is that bad?

Rectal prolapse is a condition where the rectum turns inside out and comes out of the anus. It most often effects women as they get older, usually over 60, but can effect younger women and men. The underlying problem is stretching of the tissues that hold the rectum against the inside of the tailbone and too large an opening in the pelvic floor muscles. Prolapse will rarely cause a true emergency but if it persists for very long it will damage the ability to control passage of stool. Surgical correction is usually required. If you think this may be happening to you then you should be examined by your doctor. You can find more information at: www.fascrs.org/brochures/rectal-prolapse.html/.

27) What is a Cystodefecography? Why would I need one? What does it involve?

Csytodefecography is a very helpful x-ray study in patients with chronic constipation and prolapse. The "simple" act of passing stool is actually a very complex process involving the coordination of many muscles and can be affected by several adjacent organs. Examination in the office, in any position, does not show how the pelvic organs move during attempts to pass stool. In some patients small intestine can move deep into the pelvis, causing a feeling of more stool to pass, even after the rectum is empty. In others the rectum can fold in on itself, causing only partial emptying. These are only 2 of many problems that can only be seen in "real time", by doing a video x-ray while passing stool.