All’s Well if Your End’s Well

Flying requires much time on our backsides. Our sit-upon. Tush. Or in English parlance, bum. Discussing the anus, the end of the intestinal tract, inspires much embarrassment and trepidation. Given how often aviators discreetly ask me questions, how much time is spent on our rears, and how common and problematic to pilots' medical issues are “down there,” instead of mooning about such topics, let’s expose them to the cold light of day. Not literally, of course. 

Before getting to the bottom of the matter, here’s some good news. Most anal ailments can be avoided by eating a healthy, fiber-rich, low-fat diet; enjoying relaxing breakfasts and the inevitable bathroom visit that follows; and keeping weight in check. If you do all those things, maybe you can move on to my column in the latest AOPA Pilot magazine. However, if you have any fanny fears, sit comfortably and read on – unless you are reading in that room.

The most ubiquitous and socially challenging issue, pruritus ani or itchy bottom, is sometimes symptomatic of other problems; it may indicate poor diet and hygiene. If present, start a food diary to identify specific items causing flare-ups: spices, tomatoes, caffeine, and citrus fruits are often culprits. Unfortunately, the more one scratches this particular itch, the longer it will likely persist. Avoid perfumed soaps; pamper your nether regions with good-quality tissue but pat, don’t rub. Wear loose-fitting undies and sleep with a duvet, which prevents sweating while asleep. Creams, often steroid-based, are advertised for treatment, but use cortisone sparingly as it eventually thins tissue, worsening itching. If symptoms continue, see your doctor (or rather, let your doctor see you) as pruritus may suggest another problem. In kids, threadworms may be diagnosed, especially if the itching comes on in the early evening hours when the worms start their squirming. Charming, isn’t it?

Everyone has heard of hemorrhoids; these vein clusters, resembling a small bunch of grapes, can swell – impeding cleaning, causing bleeding and itching, and if the blood inside clots (thrombosis), pain ensues. Again, have your doctor investigate your intestine to ensure the hemorrhoid is not something more sinister. Unfortunately, many colon cancers are initially mischaracterized by patients as hemorrhoids, so please get checked out sooner, rather than later. Many cases are managed with lifestyle modifications, lassoing the errant vessels with rubber bands, injecting them with shrinking chemicals, or zapping them with laser beams. Sometimes surgery is required, and although many surgeons offer such therapy, choose carefully – a bad result can cause a lifetime of misery.

“A porcupine reversing out your tailpipe.” Does that prosaic description grab your attention? This is how the pain of anal fissure was once described to me – agony intense enough to cause one to pass out or vomit. As poor diet is to blame, if you want to steer clear of spikes between your cheeks, make a granola grab and avoid corned beef hash for your first meal of the day. A bowel motion rendered hard by a low-fiber diet can tear delicate anal skin, and subsequent attempts to evacuate a BM may cause a rectal revolution. Other than learning to eat properly, treatment includes application of medicines and possibly surgery to remove the damaged area. Again, pick an expert; don’t let just anyone work on your undercarriage.

The title of this narrative parodies Shakespeare’s play All’s Well that Ends Well, a central theme of which is the treatment of fistula-in-ano, a condition also believed to have troubled King Charles V and King Louis XIV of France. So what is this royal pain in the rear? Shakespeare’s ancestor, John Arderne, wrote a treatise on the topic: an abnormal connection or tunnel develops from the inside of the rectum to buttock skin with unpleasant sequelae; feces come out the wrong way causing pain, swelling, infection, and a great deal of misery. Fistula can be treated by placing a suture “seton” through the tunnel (basically a piece of thread or plastic) that allows any infection to drain and slowly cuts through the errant tissue. Alternatively, if no major muscle is involved it can be opened up surgically or blocked with a “plug” that allows healthy tissue to grow in.

A bit of a bum rap, but a number of infections can set up shop and cause skin breakdown, abscesses, and warts. As is so often the case in medicine, early medical intervention equates to better results, so put your embarrassment aside and drop ’em.

I mentioned colon cancer earlier, and with more than 140,000 cases per year, please consider a screening colonoscopy even if your main asset ain’t misbehavin’. Eat well, look after yourself, and in passing, can anyone tell me why Uranus is the butt of so many jokes?

Jonathan Sackier
Dr. Jonathan Sackier is an expert in aviation medical concerns and helps members with their needs through AOPA Pilot Protection Services.

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