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Incontinence and defecatory difficulties are commonly reported among women and are often ascribed to traumas sustained during childbirth. Specifically, injuries to the anal sphincters (tears) and conformational changes in the various structures that comprise the pelvic floor (prolapse and perineal descent) have been considered as important contributors to the development of anal incontinence, or difficult defaecation (straining, incomplete evacuation), in later life. An understanding of both the effects of pregnancy and parturition on these structures and the natural history of any traumas sustained are, therefore, of key importance. Unfortunately, the literature on these issues, though vast, is far from complete. While it is evident that pregnancy, per se, imposes changes, primarily through hormonal influences, on colonic, ano-rectal and pelvic floor physiology, the long-term impact of such effects is far from clear. Risk factors for the occurrence of significant, though often occult, anal sphincter injuries during birth have been identified and the role of these tears in the etiology of post-partum incontinence has been well delineated. In contrast, the contribution of such intra-partum events to the later onset of incontinence is far from clear and may well have been over-estimated.

In a prospective study of 103 consecutive cirrhotic patients a high prevalence (43%) of anorectal varices was found compared with only 2% in 103 age- and sex-matched control subjects (p less than 0.001). However, there was no significant difference between the prevalences of hemorrhoids in cirrhotic patients and in control subjects (79% vs. 83%, p greater than 0.05). The hepatic venous pressure gradient of cirrhotic patients with anorectal varices was similar to cirrhotic patients without anorectal varices (14 +/- 6 mmHg, n = 22, vs. 16 +/- 7 mmHg, n = 39, p greater than 0.05. There was no significant difference in the hepatic venous pressure gradient between cirrhotic patients with and without hemorrhoids (15 +/- 6 mmHg, n = 47, vs. 16 +/- 8 mmHg, n = 14, p greater than 0.05). The prevalence of anorectal varices and hemorrhoids in cirrhotic patients had no relation to Child-Pugh's grading, esophageal varices with and without sclerotherapy and ascites. We conclude that anorectal varices are common in cirrhotic patients. Anorectal varices and hemorrhoids are not related to the degree of portal pressure.

We have tried to present a comprehensive survey of present-day management of hemorrhoids, fistulae and fissures, be it in the office or in the hospital. There is great socioeconomic pressure lately for cost-containment, which is apt to effect better medical judgment in the selection of type and place of management. Minor operations can and should be done, as always, on an outpatient basis. General anesthesia is not a minor matter and hemorrhoidectomy is not a minor operation. The major function of outpatient service in the management of anal disease is that of accurate and comprehensive diagnosis. Hundreds of patients come to us only because they fear cancer and it is not enough for us to hunt for and treat the vague little disorders of which they complain. The incidence of cancer of the colon rectum in this country just recently has slightly surpassed that of lung cancer. Adjuvant treatments (e.g., chemotherapy, radiotherapy, immunotherapy and their combinations) are promising but still in the investigational stage. Early diagnosis is our finest weapon with subsequent surgical management. The challenge and responsibility for early diagnosis of colorectal cancer is ours alone. We must first recognize it and then meet it firmly and squarely. We must feel for (digital rectal), look for (sigmoidoscopy), and search for (barium enema x-ray examination) colorectal cancer in all of our patients regardless of the insignificance of anal symptoms and anal findings. Our countrymen fear cancer. We have the devices to allay their fears or to cure their cancers if they are found early enough. We have a straightforward moral commitment and a national trust.