Patient guide

Feeling worried is normal

Many patients hide a problem of the anus or bowel for months or years because talking about it or being examined is hard. This feeling is common and doctors see this situation every day. The aim of the first visit is to find out what the problem is, not to embarrass you. You can ask about every step, and at any time you can say “please wait” or “please stop”.

Before the visit

To make the conversation better, prepare these:

• Write down your symptoms: when they started, what makes them worse or better, whether there is blood and what color, whether there is pain, any change in bowel habit, weight loss, fever
• A list of all your medicines, supplements and herbal products, especially blood thinners and pain relievers
• Your history of illnesses and earlier operations, and whether anyone in the family has had bowel cancer, polyps or inflammatory bowel disease
• Reports of earlier tests, colonoscopy, pathology, CT or MRI, if you have them
• If you feel more comfortable, bring someone with you

What happens in the examination room?

ASCRS writes that assessing anal problems starts with a careful history and examination. It usually includes the following steps, but the surgeon decides each time according to your symptoms:

1. A conversation. First they ask what has happened, since when, what treatment you have tried, and about your own and your family’s history. Questions may be about toilet habits or private matters; honest answers help.
2. Looking at the area. Looking at the skin around the anus for hemorrhoids, a fissure, the opening of a fistula, or a lump.
3. A finger examination (rectal exam). The doctor, wearing a glove and using lubricating gel, puts one finger into the anus to feel the muscle, any lump or tenderness. ASCRS lists this as part of the examination, especially when there is a change in bowel habit or bleeding.
4. Anoscopy or proctoscopy. Sometimes a short, narrow tube is placed to see inside the anus and rectum. The NHS also names proctoscopy for a fistula.

If the pain is severe, a full examination may not be possible at the same visit. The NHS says if the doctor does not know the diagnosis or the examination is too painful, an examination under anesthesia may be advised. The doctor will discuss this with you.

Making the examination easier

• Ask the doctor to explain each step before doing it.
• If it hurts, say so at that moment.
• You can ask whether a companion or nurse can be present.
• You will be asked to undress in a way that allows the examination; you can ask whether a suitable cover is available.

After the examination

The doctor may suggest one of these:

• Simple treatment and a change of habits (fiber, water, warm sitz baths, medicine)
• Blood tests or imaging
• Colonoscopy: ASCRS says it may be advised for bleeding, a change in bowel habit, anemia or a history of polyps. The NHS says it means looking at the whole large bowel with a flexible tube and camera, and most of the time nothing worrying is found. See the article “When should I start screening colonoscopy?” and the guide “Bowel preparation”.
• Follow-up or an operation, if the condition needs it

Ask: What is the likely diagnosis? What happens if I do nothing? What are the options? How much will it cost and how long will it take? What warning signs should I watch for after I leave?

What should you not wait with?

If you have any of these, do not rely on an ordinary visit and see the guide “When should I call urgently?”: heavy bleeding, severe abdominal pain with fever, vomiting with no gas or stool, fever with throbbing pain beside the anus.

Every patient’s plan is different; ask your doctor about your own situation.

Why does preparation matter?

A colonoscopy is accurate when the bowel wall is not covered with stool. ASCRS says completing the cleansing exactly as instructed is the most important part of preparation. The NHS also warns that if you do not follow the instructions carefully, the test may not be done or may need repeating.

Rule one: your own center’s instructions

The method and product for preparation differ from one center to another. Only the general pattern from the sources is given here. If your center’s written instructions differ, follow them.

In the days before

• Medicines: give the doctor a list of all medicines, vitamins and supplements (NIDDK). Which ones to stop is decided only by the doctor; do not stop or take blood thinners or diabetes medicines on your own.
• Food: NIDDK says you may need to avoid high-fiber foods such as whole grains, raw vegetables, legumes, nuts and seeds for a few days.
• Clear liquid diet: may be needed for a day or more. Clear liquids are things you can see through: water, clear broth, plain tea or coffee without milk, juice without pulp such as apple. Cloudy juice such as orange or pineapple is not suitable. NIDDK says the doctor may also ban red and purple liquids or gelatin.
• A companion: arrange for someone to take you home; sedation affects judgment and coordination for a while.

The day before and the morning of the test

• Cleansing is done with oral laxatives (tablets, liquid or powder). NIDDK explains that usually a large amount of laxative liquid is drunk over a set period, often the evening before and the morning of the test. Sometimes an enema is also prescribed.
• The NHS says diarrhea may start a few hours after the first dose; stay near a toilet.
• The NHS says you must know, according to your instructions, what time to stop eating and drinking.
• Finish the laxative completely. If a problem (vomiting, severe pain, dizziness) stops you from finishing it, NIDDK says to contact the center.

Tips to make it easier

• Stay near a toilet and wear comfortable clothes.
• If the skin around the anus becomes sore or sensitive, dry it after each wash with soft tissue or water and ask the doctor about a suitable cream.
• If you are pregnant or have heart, kidney or diabetes problems, ask the doctor how the preparation differs for you. (The NHS says to tell them if you are pregnant.)

On the day of the test

• Bring your medicine list and the center’s instructions.
• The NHS says the test takes about 30 to 45 minutes but you may be at the center for about 2 hours in total; ASCRS says usually less than an hour.
• Most patients receive intravenous sedation and may remember nothing. The NHS says it may be uncomfortable but should not be painful; if you have pain, say so at that moment.

After the test

• You may have bloating or cramps for a few hours that ease as you pass gas (NHS: 2 to 3 hours).
• Slight bleeding for up to a few days is common if a sample or polyp was taken.
• Do not drive for 24 hours after sedation.
• Ask the doctor when to restart your medicines.

Results: a polyp or tissue sample goes to the laboratory and the answer may take a few days or longer (NIDDK, NHS).

How risky is a colonoscopy?

Complications occur in fewer than 1% of patients (ASCRS). The most common are bleeding and a hole in the bowel; in one screening study a hole occurred in about 3 per 10,000 and bleeding in about 15 per 10,000 (NIDDK). Late bleeding up to two weeks afterwards is also possible.

When to call

After a colonoscopy, if you have fever or chills, severe abdominal pain, bleeding from the anus that does not stop or gets heavier, persistent vomiting, or dizziness or weakness, contact the center immediately or call 115 (Iran’s emergency number). The NHS treats heavy or worsening bleeding, chest pain, severe and worsening abdominal pain and persistent vomiting as emergencies.

Every patient’s plan is different; ask your doctor about your own situation.

First of all

Preparing for an operation is mostly your treatment team’s instructions. This page only helps you ask the right questions and know what matters. Every hospital has its own program.

Questions to ask the surgeon

ASCRS advises asking the surgeon about length of stay, activity limits, help at home, return to work and pain control. Add your own questions to this list:

• Why is this operation suggested for me? Is there another option? What happens if I do not have it?
• Is the operation possible laparoscopically or does it have to be open? How likely is it to be converted to open during the operation?
• Might I need a bag (stoma)? Temporary or permanent?
• How many days will I stay in hospital?
• What activity limits will I have? What help will I need at home? When do I go back to work?
• How will pain be controlled?
• What are the risks of the operation in my case?

Write the questions down and bring them. You can bring someone to hear the explanations.

Tests before the operation

Blood tests, an ECG, an anesthesia assessment, a CT or an earlier colonoscopy may be needed. ASCRS names blood tests (including a blood count and, in cancer, CEA) and CT.

• Medicine list: give all medicines and supplements to the surgeon and the anesthetist. Which ones to stop or continue is decided only by them; do not change blood thinners or diabetes medicines on your own.
• Tell them about allergies and other conditions (diabetes, heart, kidney, lung).

Things that affect healing

ASCRS says smoking, steroids and diabetes can make healing of the join in the bowel worse and raise the risk of a leak. If you smoke, ask how you can cut down or stop before the operation. If you have diabetes, review blood sugar control with the doctor. This is not blame; it is only for your own safety.

Fasting and the drink before surgery

Follow the fasting instruction exactly. In the ERAS program that many hospitals use, ASCRS says a carbohydrate-rich drink may be given about 90 to 120 minutes before the operation. This depends on the hospital, so follow their instruction and do not eat anything on your own.

Bowel preparation

For some bowel operations preparation (a laxative) is needed and for some it is not. The doctor decides. If it is needed, follow the written instructions. General information is in the guide “Bowel preparation”, but that is mostly for colonoscopy.

If a stoma is possible

ASCRS says the site of a stoma is marked on the abdomen before the operation, on a flat surface, checked sitting, standing and lying, and away from folds, scars and the belt line. A specialist stoma nurse (WOC) teaches you. More is explained in the article “Will I need a bag after bowel surgery?”.

Preventing clots

The NHS says the risk of a blood clot is higher after an operation. The treatment team may give preventive medicine or compression stockings, and sometimes this continues after discharge. ASCRS also mentions early walking and a blood-thinning injection. The signs of a clot are in the guide “When should I call urgently?”.

Prepare your home

• Someone to stay with you for a few days after discharge
• Loose, comfortable clothes that do not press on the wound
• Food and fluids ready (see the guide “Eating after surgery”)
• The recommended medicines and pain relief, and a thermometer
• A soft pad or cushion for sitting if the operation was near the anus
• Time off work: ASCRS gives no fixed number, and for one type of operation with an ileostomy the NHS gives 6 to 8 weeks until recovery and 3 months without heavy lifting; this is only an example and your own time is set by the surgeon

The night before and the day of surgery

• Follow the fasting instruction and the morning medicines exactly.
• Bring your documents, medicine list and earlier reports, and follow the hospital’s instruction about personal belongings.
• If you develop a fever, cough, a cold or any new change in health, tell them before the operation.

Every patient’s plan is different; ask your doctor about your own situation.

Note

The instructions of your surgeon and nurse come before this page. The operation and the type of dressing differ. This page describes patterns found in general sources.

Warm sitz baths

After an operation near the anus, sitting in shallow warm water eases pain and muscle spasm and makes cleaning easier.

• For after a hemorrhoid operation ASCRS suggests warm water 2 to 3 times a day, 10 to 15 minutes each time. For a fissure, 10 to 20 minutes several times a day, especially after a bowel movement.
• For a fissure the NHS writes a shallow warm bath after a bowel movement.
• After the bath, pat the area dry gently; do not rub.
• The length and number are set by your own surgeon.

Keeping the wound clean and dry

• A closed wound (stitches): keep it clean, dry and hair-free (ASCRS for pilonidal). In one method the stitches come out after about 10 days (NHS).
• An open wound: for a pilonidal sinus or a fistula, the wound heals from the base. ASCRS says a dressing or packing helps drainage come out. The NHS says a daily dressing may be needed. The nurse or surgeon teaches you how to change it.
• A little discharge in the first days can be normal; if it increases, smells bad or redness spreads, report it.
• Wear loose cotton underwear (NHS).
• Do not touch the wound with unclean hands.

Bowel movements after surgery

Constipation and straining put pressure on the wound.

• Fiber, fluids and, if needed, a stool softener as instructed. After a hemorrhoid operation ASCRS advises passing stool within the first 48 hours.
• Opioid pain relievers cause constipation; for a fissure and fistula ASCRS advises avoiding them or using caution.
• Do not ignore the urge and do not stay long on the toilet.

Pain and medicine

• Pain after an operation on the anus is normal but can be controlled with medicine. ASCRS says a combination of opioid and non-opioid pain relief, aiming to limit opioids, is usually used.
• Take medicine as instructed. If pain does not ease after a few days, gets worse or comes with fever, report it.

Urination

After an operation on the anus some people cannot pass urine. ASCRS says you can try urinating in a sitz bath; if that does not work, contact the surgeon or go to the emergency department for a catheter, because delay may cause permanent bladder damage.

Activity

• Light walking from the first days is advised and helps. After a colon operation ASCRS advises light walking after discharge.
• Heavy lifting: ASCRS says after an abdominal operation it may be limited to reduce the risk of a hernia. For recovery after an operation with an ileostomy, the NHS writes 6 to 8 weeks, and avoiding strenuous activity and heavy lifting for up to 3 months. This is only an example.
• After a pilonidal operation: the NHS says avoid strenuous exercise and heavy lifting for about a week, no cycling for 6 to 8 weeks, and no swimming until the wound has fully healed. Most people return to work within about 2 weeks.
• After a hemorrhoid operation: ASCRS says full return to activity takes 2 to 4 weeks.
• After a fissure operation: most people return to work within a few days (ASCRS).
• Driving: for recovery after an ileostomy the NHS mentions at least about 6 weeks. Ask the surgeon about your own time.

These times are general ranges, not promises.

A stoma

If you have a stoma, a specialist stoma nurse teaches you how to care for the skin and change the bag. According to ASCRS, look at the skin around it at each change and report redness, swelling or itching; the bag is usually changed 2 to 3 times a week. More is in the article “Will I need a bag after bowel surgery?”.

When to report

• Fever of 38 degrees or higher, or chills
• Redness, warmth, swelling, pus or a bad-smelling discharge, or the edge of the wound opening
• Abdominal or wound pain that is getting worse
• Persistent vomiting, a swollen abdomen, or not passing gas or stool
• Being unable to pass urine
• New pain and swelling in a calf
• Bleeding more than expected

Chest pain, sudden shortness of breath or heavy bleeding: call 115 (Iran’s emergency number). The full list is in the guide “When should I call urgently?”.

Every patient’s plan is different; ask your doctor about your own situation.

The general idea

After bowel surgery, eating and drinking early and gradually usually helps. But your exact diet depends on the type of operation, whether you have a stoma, and your general health. The instructions of the surgeon and dietitian come first.

In hospital

According to ASCRS, in “enhanced recovery” (ERAS) programs:

• Patients are encouraged to get out of bed early and walk
• Eating starts early and moves to a normal diet as the patient tolerates it
• Combined pain relief is given; ASCRS reminds that opioid pain relievers slow the return of bowel movement

Your hospital may have a different program. The nurse tells you what to eat and at what time.

After discharge: normal food

For colon surgery, ASCRS says patients can generally go back to a normal diet with enough fluids. After operations that create a stoma, the NHS mentions a low-fiber diet for about 6 weeks for an ileostomy so the bowel can heal, and then foods are reintroduced one at a time to see which cause trouble. If the surgeon or nurse has given another diet, follow that.

Everyday tips

• Eat gradually and in several small meals.
• Chew well; the NHS and ASCRS advise good chewing with an ileostomy to reduce the risk of a blockage.
• Drink enough fluids.
• Very fatty, sweet or salty foods may increase diarrhea in some patients (for a stoma, ASCRS).

Fiber, water and preventing constipation

After an operation on the anus, avoiding straining matters.

• For constipation, ASCRS: 25 to 35 grams of fiber a day and about 6 to 8 glasses of water (1.5 to 2 liters), and about 30 minutes of walking.
• After a hemorrhoid operation, ASCRS mentions fiber and a fiber supplement, fluids and, if needed, a stool softener, and advises passing stool within the first 48 hours.
• Opioid pain relievers cause constipation; if one was prescribed, ask whether you also need a stool softener.
• Increase fiber slowly so you do not get bloated. After bowel surgery, if the doctor has given a low-fiber diet, do not increase fiber until you are told you can.

If you have had diverticulitis

The NHS says there is no particular food that has to be removed and advises a balanced diet with whole grains, fruit and vegetables. ASCRS says the old advice to avoid nuts, seeds and popcorn has not been confirmed in recent studies. During an acute attack, a temporary liquid or low-fiber diet is set by the doctor.

If you have a stoma

According to ASCRS:

• Many patients have a normal diet and adjust some foods to control volume and thickness.
• Ileostomy output is usually about 500 milliliters a day and can reach 1000 to 1500. Colostomy output is about 500, in a range of 200 to 700.
• Limit high-fiber and hard foods that may cause a blockage and try them gradually.
• Large, watery output carries a risk of dehydration; signs: dry mouth, dark and little urine, nausea, weakness, muscle cramps. A sudden fall in output with abdominal pain may be a blockage or constipation, and you should report it.

If you have no appetite

After a major operation appetite may be low. Small, higher-calorie meals and fluids through the day help. If you cannot drink fluids or you vomit, report it. If you have lost weight, tell the doctor.

When to report

• Persistent nausea or vomiting, or being unable to eat and drink
• A swollen abdomen and no gas or stool
• Abdominal pain that is getting worse
• Signs of dehydration (dry mouth, little dark urine, dizziness)
• Fever

Every patient’s plan is different; ask your doctor about your own situation.

First of all

This list does not replace the guidance of your treatment team. Write the number the doctor gives you for out-of-office hours on your phone and on a piece of paper. If you are worried, call; you are not a bother. If you are not sure whether a sign is dangerous, call.

Call 115 (Iran’s emergency number) or go to the emergency department now

If you have any of these, do not wait. Do not drive yourself; ask someone to take you or call an ambulance. Bring the medicines you take. The number 115 works only inside Iran; from abroad use your local emergency number.

Bleeding

• Heavy bleeding from the anus, bleeding that does not stop, a lot of blood or large clots. The NHS treats bleeding that will not stop, or a large amount of blood or clots, as an emergency.
• Bleeding with dizziness, weakness, paleness or fainting.

Abdomen

• Severe abdominal pain with fever, especially if the abdomen is hard or very tender
• Vomiting with no gas or stool and a swollen abdomen, which may be a bowel blockage. The NHS treats severe abdominal pain with vomiting, a swollen abdomen or being unable to pass stool or gas as an emergency.
• Signs of severe infection (sepsis): confusion, pale or blotchy skin, a very high fever or a very low temperature, fast or difficult breathing

Anus

• Fever with throbbing pain beside the anus, redness and swelling; this may be an abscess. ASCRS says anal pain with fever needs an earlier appointment. If you also have chills, feel very unwell or have a high fever, go to the emergency department.
• Very severe anal pain that you cannot bear, especially with bleeding (the NHS for hemorrhoids: severe pain is an emergency)

After surgery

• Chest pain or pain in the upper back, sudden shortness of breath, a very fast heartbeat, fainting or coughing blood. These may be signs of a clot that has traveled to the lung (pulmonary embolism). The NHS says a pulmonary embolism can be dangerous and needs urgent treatment.
• Swelling and pain in a calf together with shortness of breath or chest pain
• Heavy bleeding from the wound or anus that does not stop with pressure
• Confusion, sudden weakness on one side of the body or trouble speaking

Call the doctor or treatment center the same day

Signs of infection

• Fever of 38 degrees or higher, chills or feeling unwell
• Redness, warmth, increasing swelling or pus from the wound, or the edge of the wound opening
• A bad-smelling discharge
• Pus from a hemorrhoid or fever with it (NHS)

An infection that is seen early is easier to treat.

Abdominal pain

• Abdominal pain that gets worse after the operation or does not improve after a few days. ASCRS says complications such as a leak at the join in the bowel, an abscess and infection are possible after an operation.
• Persistent nausea and vomiting, or being unable to eat and drink
• A swollen abdomen or not passing gas or stool

Being unable to pass urine

After an operation on the anus (and sometimes other operations) urine may stop. ASCRS advises trying in a sitz bath, and if that does not work, calling the surgeon or going to the emergency department for a catheter, because delay can cause permanent bladder damage.

A blood clot in the leg

In the weeks after an operation the risk of a clot is higher. The NHS says a clot may occur weeks later. If you notice these in one leg:

• Throbbing or cramp-like pain in the calf or thigh
• New or worsening swelling in one leg
• Red, blue or dark skin that is tender to the touch
• Warmth in the calf

Call the doctor the same day or go to the emergency department. If it comes with shortness of breath or chest pain, go to the section “Call 115 now”.

Anus and bowel without an operation

• Painless bleeding from the anus. The NHS says in a person with hemorrhoids, painless bleeding should be seen soon. Do not assume any new bleeding is a hemorrhoid without an examination.
• Black or dark red stool, or bloody diarrhea (NHS: book soon)
• Unexplained weight loss, a lasting change in bowel habit, thinner stools, anemia or tiredness (warning signs of bowel cancer in the NHS and ASCRS)
• A painful lump at the top of the buttock cleft with discharge or blood (NHS for pilonidal)

After a colonoscopy

The NHS and NIDDK say bleeding that does not stop, severe abdominal pain, fever, dizziness or weakness after a colonoscopy needs an immediate call. Late bleeding up to two weeks afterwards is possible.

If you have a stoma

ASCRS says to report these to the surgeon or stoma nurse:

• Dehydration: dry mouth, dark and little urine, nausea, weakness, muscle cramps, very large watery output
• A sudden fall in output with abdominal pain or cramps (possible blockage)
• Redness, a sore or swelling of the skin around the stoma
• More bowel pushing out of the stoma, or a bulge beside it

A few suggestions

• Look at the wounds and calves every day and take your temperature when you feel unwell.
• Light exercise and walking as instructed reduce the risk of a clot (NHS).
• Take blood-thinning medicines only as instructed.
• Before you go home, ask: in what situation should I call, on which number? Who answers out of hours? Which situations go straight to the emergency department?

If you are not sure

Call. A doctor or nurse would rather be called once unnecessarily than hear late about a serious sign.