Anal itching is a common condition. The itch, situated in or around your anus, is often intense and may be accompanied by a strong urge to scratch. You may find anal itching to be embarrassing and uncomfortable.

Also called pruritus ani (proo-RIE-tus A-nie), anal itching has many possible causes, such as skin problems, hemorrhoids, and washing too much or not enough.

If anal itching is persistent, talk with your doctor. With proper treatment and self-care, most people get complete relief from anal itching.

Anal itch, also known as pruritus ani, is an irritating, itchy sensation around the anus (the opening through which stool passes out of the body). Anal itch is a symptom, not an illness, and it can have many different causes. In most cases, a person with anal itch does not have a disease of the anus or rectum. Instead, the itchy sensation is a sign that one or more of the following has irritated the skin in the area:

• Stool on the skin around the anal opening — If the anal area isn’t cleaned properly after a bowel movement, a small amount of stool may be left behind on the skin, causing the area to itch. Less often, watery stools may leak out of the anal opening and cause itching. This sometimes happens in otherwise healthy people whose diets include very large amounts of liquids.
• A diet containing foods or beverages that irritate the anus — A number of foods and drinks can irritate the anus, including spices and spicy foods, coffee (both caffeinated and decaffeinated), tea, cola, milk, alcoholic beverages (especially beer and wine), chocolate, citrus fruits, vitamin C tablets and tomatoes. Once a person eats or drinks something that can irritate the anus, it usually takes 24 to 36 hours before anal itching begins. That’s the time it takes the food to travel through the digestive tract.
• Treatment with antibiotics — Some powerful antibiotics that work against many different bacterial species can trigger anal itch by disturbing the normal ecology of the intestines. These drugs are called broad-spectrum antibiotics, and include tetracyclines and erythromycin (both sold under several brand names).
• A local chemical irritation or skin allergy in the anal area — In sensitive people, chemicals and medications that are applied to the anal area can cause local irritation or allergic reactions. Some major culprits include dyes and perfumes used in toilet paper (especially scented toilet paper), feminine hygiene sprays and other deodorants for the area around the anus or genitals, medicated talcum powders, and medicated skin cleansers and soaps, especially perfumed soaps. Anal itch also can be triggered by over-the-counter medications (suppositories, creams, ointments) intended to treat anal problems.
• Intense cleaning after a bowel movement — Although the anal area should be cleaned after every bowel movement, this cleaning must be gentle. Aggressive rubbing and scrubbing, especially with soaps or other skin cleansers, can irritate the skin and trigger anal itch.

Less often, anal itch is a symptom of some illness or condition that either affects the anal area alone, or involves larger areas of the digestive tract or skin. Some examples include:

• Local diseases and conditions involving lower portions of the digestive tract — These include hemorrhoids, skin tags, rectal fistulas, rectal fissures and, rarely, anorectal cancer.
• Infections and parasites — These include pinworms (especially in children), scabies, pediculosis, condyloma acuminata and skin infections due to Candida or tinea fungi.
• Skin problems — These include psoriasis, eczema and seborrhea. In many cases, these conditions cause symptoms in several different areas of the skin surface, not only around the anus.

Worldwide, anal itch is a very common problem that occurs in up to 45 percent of people at some time during their lives. Men are affected two to four times more often than women. People who are overweight, perspire heavily or routinely wear tight-fitting underwear or hosiery are more likely to get anal itch.

causes

Most anal itching is

• Idiopathic (the majority)
• Hygiene-related

Sometimes the cause of anal itching isn’t identifiable. Possible causes of anal itching include:

• Irritants. Fecal incontinence and long-term (chronic) diarrhea can irritate the skin. Or your skin care routine may include products or behaviors that irritate the skin, such as using harsh soaps or moist wipes and washing too aggressively.
• Infections. These include sexually transmitted infections, pinworms, and yeast infections.
• Skin conditions. Sometimes anal itching is the result of a specific skin condition, such as psoriasis or contact dermatitis.
• Other medical conditions. These include diabetes, thyroid disease, hemorrhoids, anal tumors.

Symptoms

Anal itch is an irritating sensation around the anus that is relieved temporarily by scratching or rubbing. The problem is often worse at night and may interfere with sleep. In most cases, the skin in the area is red.

If anal itch becomes a chronic (long-term) problem, the skin around the anus may become raw and tender from repeated scratching, or it may thicken and become leathery. Repeated scratching also can cause breaks in the anal skin that can lead to painful local infections.

additional symptoms

• The intensity of anal itching and the amount of inflammation increases from the direct trauma of scratching and the presence of moisture.
• At its most intense, anal itching causes intolerable discomfort that often is described as burning and soreness, especially during and after bowel movements.
• There also may be small amounts of bleeding.

Diagnosis

To help identify the cause of your anal itch, the doctor may ask you to describe your current diet and medications, your bowel habits, and the way you routinely clean your anal area after a bowel movement. The doctor will review your medical history, including any history of rectal problems (hemorrhoids, fissures or fistulas) or skin problems (psoriasis, eczema or seborrhea). Your doctor’s questions will be followed by a physical examination of your anal area and sometimes, by a digital rectal examination. If you have a history of skin symptoms involving other parts of your body, your doctor will want to examine these skin areas as well.

If your anal itch is due to a local irritation in the anal area, the doctor usually can diagnose the problem based on your history, diet and personal hygiene routine, and the results of your physical examination. Sometimes, the doctor will request a stool sample if he or she suspects a worm or parasite infection. Rarely, your doctor may need to examine the area by inserting a special viewing instrument called an anoscope into your anus. This can help your doctor determine whether the itch is being caused by a problem inside your rectum.

Prevention

In many cases, you can prevent anal itch by taking the following steps:

• Practice good anal hygiene — When possible, gently cleanse the anal area after every bowel movement by using wet toilet paper (unscented and dye-free) or a wet washcloth. Wipe gently or blot the area. Never rub or scrub. If you are in a public toilet, use dry toilet paper temporarily, then finish your cleansing regimen when you return home.
• Use only water to clean the anal area, never soap.
• Avoid using medicated powders, perfumed sprays or deodorants on the anal area.
• Eat a sensible diet that is low in the foods and beverages known to cause anal irritation.
• Wear cotton underwear that is not too tight.
• If you are taking oral antibiotics, eat yogurt to help restore the normal ecology of your colon.

Treatment

In most cases, anal itch can be treated by:

• Thoroughly but gently drying the anal area after every bowel movement, using unscented toilet paper, a clean cloth towel or a hair dryer if necessary.
• Dusting the anal area with nonmedicated talcum powder between bowel movements, or laying a clean square of cotton gauze against the anus to absorb any excess moisture.
• Resisting the urge to scratch, no matter how itchy the area becomes. The itch will pass, or at least decrease in intensity, over a short time, but the more you scratch, the longer it will take for the itching to go away.
• Applying topical remedies such as zinc oxide or hydrocortisone ointment (1 percent) on a regular schedule, or as needed, to help you avoid scratching.
• Wearing soft cotton gloves while in bed if you scratch at night or in your sleep.

Initial self-care for simple itching is directed toward relieving symptoms, like burning and soreness. It is important to clean and dry the anus thoroughly and avoid leaving soap in the anal area.

• Cleaning efforts should include gentle showering without direct rubbing or irritation of the skin with either the washcloth or towel.
• After bowel movements, moist pads (such as baby wipes, flushable moist wipes, and flushable anal cleansing wipes) should be used for cleaning the anus instead of toilet paper.
• If there is constant moisture present in the anus or stool incontinence, it may be necessary to clean the anus with wet wipes between bowel movements.

Many over-the-counter (OTC) products are sold for the treatment of an itchy anus and are available as ointments, creams, gels, suppositories, foams and pads. These products often contain the same drugs used to treat hemorrhoids.

• When used around the anus, ointments, creams, and gels should be applied as a thin covering.
• When applied to the anal canal, these products should be inserted with a finger using finger cots (latex covers for the fingertips) or a “pile pipe.” Pile pipes are most efficient when they have holes on the sides as well as at the end. Pile pipes should be lubricated with ointment prior to insertion.
• Suppositories or foams do not have advantages over ointments, creams, and gels.

Most products contain more than one type of active ingredient. Almost all contain a protectant in addition to another ingredient. Only examples of brand-name products containing one ingredient in addition to the protectant are discussed in this article.

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Gallstones are hardened deposits of digestive fluid that can form in your gallbladder. Your gallbladder is a small, pear-shaped organ on the right side of your abdomen, just beneath your liver. The gallbladder holds a digestive fluid called bile that’s released into your small intestine.

Gallstones range in size from as small as a grain of sand to as large as a golf ball. Some people develop just one gallstone, while others develop many gallstones at the same time.

People who experience symptoms from their gallstones usually require gallbladder removal surgery. Gallstones that don’t cause any signs and symptoms typically don’t need treatment.

Gallstone Types

The two main kinds of gallstones are:

• Cholesterol stones. These are usually yellow-green. They’re the most common, making up 80% of gallstones.
• Pigment stones. These are smaller and darker. They’re made of bilirubin..

Causes

It’s not clear what causes gallstones to form. Doctors think gallstones may result when:

• Your bile contains too much cholesterol. Normally, your bile contains enough chemicals to dissolve the cholesterol excreted by your liver. But if your liver excretes more cholesterol than your bile can dissolve, the excess cholesterol may form into crystals and eventually into stones.
• Your bile contains too much bilirubin. Bilirubin is a chemical that’s produced when your body breaks down red blood cells. Certain conditions cause your liver to make too much bilirubin, including liver cirrhosis, biliary tract infections and certain blood disorders. The excess bilirubin contributes to gallstone formation.
• Your gallbladder doesn’t empty correctly. If your gallbladder doesn’t empty completely or often enough, bile may become very concentrated, contributing to the formation of gallstones

Symptoms

Gallstones can lead to pain in the upper right abdomen. You may start to have gallbladder pain from time to time when you eat foods that are high in fat, such as fried foods. The pain doesn’t usually last more than a few hours.

You may also experience:

• nausea
• vomiting
• dark urine
• clay-colored stools
• stomach pain
• burping
• diarrhea
• indigestion

These symptoms are also known as biliary colic.

Asymptomatic gallstones

Gallstones themselves don’t cause pain. Rather, pain occurs when the gallstones block the movement of bile from the gallbladder.

According to the American College of Gastroenterology, 80 percent of people have “silent gallstones.” This means they don’t experience pain or have symptoms. In these cases, your doctor may discover the gallstones from X-rays or during abdomen surgery.

diagnosis

Your doctor will perform a physical examination that includes checking your eyes and skin for visible changes in color. A yellowish tint may be a sign of jaundice, the result of too much bilirubin in your body.

The exam may involve using diagnostic tests that help your doctor see inside your body. These tests include:

Ultrasound: An ultrasound produces images of your abdomen. It’s the preferred imaging method to confirm that you have gallstone disease. It can also show abnormalities associated with acute cholecystitis.

Abdominal CT scan: This imaging test takes pictures of your liver and abdominal region.

Gallbladder radionuclide scan: This important scan takes about one hour to complete. A specialist injects a radioactive substance into your veins. The substance travels through your blood to the liver and gallbladder. On a scan, it can reveal evidence to suggest infection or blockage of the bile ducts from stones.

Blood tests: Your doctor may order blood tests that measure the amount of bilirubin in your blood. The tests also help determine how well your liver is functioning.

Endoscopic retrograde cholangiopancreatography (ERCP): ERCP is a procedure that uses a camera and X-rays to look at problems in the bile and pancreatic ducts. It helps your doctor look for gallstones stuck in your bile duct.

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Risk factors-

Many risk factors for gallstones are related to diet, while some factors are uncontrollable. Uncontrollable risk factors are things like age, race, gender, and family history, which can’t be changed.

Lifestyle risk factors	Uncontrollable risk factors	Medical risk factors
being overweight or obese	being female	having cirrhosis
eating a diet that’s high in fat or cholesterol or low in fiber	being of Native American or Mexican-American descent	being pregnant
having rapid weight loss in a short period of time	having a family history of gallstones	taking certain medications for lowering cholesterol
having diabetes mellitus	being 60 years or older	taking medications that have a high estrogen content

While medications can increase your risk of gallstones, don’t stop taking them unless you have discussed it with your doctor and have their approval.

Complications

Complications of gallstones may include:

• Inflammation of the gallbladder. A gallstone that becomes lodged in the neck of the gallbladder can cause inflammation of the gallbladder (cholecystitis). Cholecystitis can cause severe pain and fever.
• Blockage of the common bile duct. Gallstones can block the tubes (ducts) through which bile flows from your gallbladder or liver to your small intestine. Severe pain, jaundice and bile duct infection can result.
• Blockage of the pancreatic duct. The pancreatic duct is a tube that runs from the pancreas and connects to the common bile duct just before entering the duodenum. Pancreatic juices, which aid in digestion, flow through the pancreatic duct. A gallstone can cause a blockage in the pancreatic duct, which can lead to inflammation of the pancreas (pancreatitis). Pancreatitis causes intense, constant abdominal pain and usually requires hospitalization.
• Gallbladder cancer. People with a history of gallstones have an increased risk of gallbladder cancer. But gallbladder cancer is very rare, so even though the risk of cancer is elevated, the likelihood of gallbladder cancer is still very small.

Prevention

You can reduce your risk of gallstones if you:

• Don’t skip meals. Try to stick to your usual mealtimes each day. Skipping meals or fasting can increase the risk of gallstones.
• Lose weight slowly. If you need to lose weight, go slow. Rapid weight loss can increase the risk of gallstones. Aim to lose 1 or 2 pounds (about 0.5 to 1 kilogram) a week.
• Eat more high-fiber foods. Include more fiber-rich foods in your diet, such as fruits, vegetables and whole grains.
• Maintain a healthy weight. Obesity and being overweight increase the risk of gallstones. Work to achieve a healthy weight by reducing the number of calories you eat and increasing the amount of physical activity you get. Once you achieve a healthy weight, work to maintain that weight by continuing your healthy diet and continuing to exercise.

treatment

You don’t need treatment if you don’t have any symptoms. Some small gallstones can pass through your body on their own.

Most people with gallstones have their gallbladders taken out. You can still digest food without it. Your doctor will use one of two procedures.

Laparoscopic cholecystectomy. This is the most common surgery for gallstones. Your doctor passes a narrow tube called a laparoscope into your belly through a small cut. It holds instruments, a light, and a camera. They take out your gallbladder through another small cut. You’ll usually go home the same day.

Open cholecystectomy. Your doctor makes bigger cuts in your belly to remove your gallbladder. You’ll stay in the hospital for a few days afterward.

If gallstones are in your bile ducts, your doctor may use ERCP to find and remove them before or during surgery.

If you have another medical condition and your doctor thinks you shouldn’t have surgery, they might give you medication instead. Chenodiol (Chenodol) and ursodiol , Urso 250, Urso Forte) dissolve cholesterol stones. They can cause mild diarrhea.

You may have to take the medicine for years to totally dissolve the stones, and they may come back after you stop taking it.

Surgery

Your doctor may need to perform a laparoscopic gallbladder removal. This is a common surgery that requires general anesthesia. The surgeon will usually make 3 or 4 incisions in your abdomen. They’ll then insert a small, lighted device into one of the incisions and carefully remove your gallbladder.

You usually go home on the day of the procedure or the day after if you have no complications.

You may experience loose or watery stools after gallbladder removal. Removing a gallbladder involves rerouting the bile from the liver to the small intestine. Bile no longer goes through the gallbladder and it becomes less concentrated. The result is a laxative effect that causes diarrhea. To treat this, eat a diet lower in fats so that you release less bile.

Foods to avoid

To help improve your condition and reduce your risk of gallstones, try these tips:

• Reduce your intake of fats and choose low-fat foods whenever possible. Avoid high-fat, greasy, and fried foods.
• Add fiber to your diet to make your bowel movements more solid. Try to add only a serving of fiber at a time to prevent gas that can occur from eating excess fiber.
• Avoid foods and drinks known to cause diarrhea, including caffeinated drinks, high-fat dairy products, and very sweet foods.
• Eat several small meals per day. Smaller meals are easier for the body to digest.
• Drink a sufficient amount of water. This is about 6 to 8 glasses per day.

If you plan to lose weight, do it slowly. Aim to lose no more than two pounds per week. Rapid weight loss may increase your risk of gallstones and other health problems.

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Hemorrhoids (HEM-uh-roids), also called piles, are swollen veins in your anus and lower rectum, similar to varicose veins. Hemorrhoids can develop inside the rectum (internal hemorrhoids) or under the skin around the anus (external hemorrhoids).

Nearly three out of four adults will have hemorrhoids from time to time. Hemorrhoids have a number of causes, but often the cause is unknown.

Fortunately, effective options are available to treat hemorrhoids. Many people get relief with home treatments and lifestyle changes.

In many cases, haemorrhoids don’t cause symptoms, and some people don’t even realise they have them. However, when symptoms do occur, they may include:

• bleeding after passing a stool (the blood is usually bright red)
• itchy bottom
• a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool
• a mucus discharge after passing a stool
• soreness, redness and swelling around your anus

Haemorrhoids aren’t usually painful, unless their blood supply slows down or is interrupted.

causes

The exact cause of haemorrhoids is unclear, but they’re associated with increased pressure in the blood vessels in and around your anus. This pressure can cause the blood vessels in your back passage to become swollen and inflamed.

Many cases are thought to be caused by too much straining on the toilet, due to prolonged constipation – this is often due to a lack of fibre in a person’s diet. Chronic (long-term) diarrhoea can also make you more vulnerable to getting haemorrhoids.

Other factors that might increase your risk of developing haemorrhoids include:

• being overweight or obese
• age – as you get older, your body’s supporting tissues get weaker, increasing your risk of haemorrhoids
• being pregnant – which can place increased pressure on your pelvic blood vessels, causing them to enlarge (read more about common pregnancy problems)
• having a family history of haemorrhoids
• regularly lifting heavy objects
• a persistent cough or repeated vomiting
• sitting down for long periods of time

Types of haemorrhoids

After you’ve had a rectal examination or proctoscopy, your doctor will be able to determine what type of haemorrhoids you have.

Haemorrhoids can develop internally or externally. Internal haemorrhoids develop in the upper two-thirds of your anal canal and external haemorrhoids in the lower third (closest to your anus). The nerves in the lower part can transmit pain messages, while the nerves in the upper part can’t.

Haemorrhoids can be further classified, depending on their size and severity. They can be:

• first degree – small swellings that develop on the inside lining of the anus and aren’t visible from outside the anus
• second degree – larger swellings that may come out of your anus when you go to the toilet, before disappearing inside again
• third degree – one or more small soft lumps that hang down from the anus and can be pushed back inside (prolapsing and reducible)
• fourth degree – larger lumps that hang down from the anus and can’t be pushed back inside (irreducible)

It’s useful for doctors to know what type and size of haemorrhoid you have, as they can then decide on the best treatment

Symptoms

Signs and symptoms of hemorrhoids usually depend on the type of hemorrhoid.

External hemorrhoids

These are under the skin around your anus. Signs and symptoms might include:

• Itching or irritation in your anal region
• Pain or discomfort
• Swelling around your anus
• Bleeding

Internal hemorrhoids

Internal hemorrhoids lie inside the rectum. You usually can’t see or feel them, and they rarely cause discomfort. But straining or irritation when passing stool can cause:

• Painless bleeding during bowel movements. You might notice small amounts of bright red blood on your toilet tissue or in the toilet.
• A hemorrhoid to push through the anal opening (prolapsed or protruding hemorrhoid), resulting in pain and irritation.

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Thrombosed hemorrhoids

If blood pools in an external hemorrhoid and forms a clot (thrombus), it can result in:

• Severe pain
• Swelling
• Inflammation
• A hard lump near your anus

When to see a doctor

If you have bleeding during bowel movements or you have hemorrhoids that don’t improve after a week of home care, talk to your doctor.

Don’t assume rectal bleeding is due to hemorrhoids, especially if you have changes in bowel habits or if your stools change in color or consistency. Rectal bleeding can occur with other diseases, including colorectal cancer and anal cancer.

Seek emergency care if you have large amounts of rectal bleeding, lightheadedness, dizziness or faintness

Risk factors

As you age, your risk of hemorrhoids increases. That’s because the tissues that support the veins in your rectum and anus can weaken and stretch. This can also happen when you’re pregnant, because the baby’s weight puts pressure on the anal region.

Complications

Complications of hemorrhoids are rare but include:

• Anemia. Rarely, chronic blood loss from hemorrhoids may cause anemia, in which you don’t have enough healthy red blood cells to carry oxygen to your cells.
• Strangulated hemorrhoid. If the blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be “strangulated,” which can cause extreme pain.
• Blood clot. Occasionally, a clot can form in a hemorrhoid (thrombosed hemorrhoid). Although not dangerous, it can be extremely painful and sometimes needs to be lanced and drained.

Diagnosing haemorrhoids

Your GP can diagnose haemorrhoids (piles) by examining your back passage to check for swollen blood vessels.

Some people with haemorrhoids are reluctant to see their GP. However, there’s no need to be embarrassed – all GPs are used to diagnosing and treating piles.

It’s important to tell your GP about all of your symptoms – for example, tell them if you’ve recently lost a lot of weight, if your bowel movements have changed, or if your stools have become dark or sticky.

Rectal examination

Your GP may examine the outside of your anus to see if you have visible haemorrhoids, and they may also carry out an internal examination called a digital rectal examination (DRE).

During a DRE, your GP will wear gloves and use lubricant. Using their finger, they’ll feel for any abnormalities in your back passage. A DRE shouldn’t be painful, but you may feel some slight discomfort.

Proctoscopy

In some cases, further internal examination using a proctoscope may be needed. A proctoscope is a thin hollow tube with a light on the end that’s inserted into your anus.

This allows your doctor to see your entire anal canal (the last section of the large intestine).

GPs are sometimes able to carry out a proctoscopy. However, not all GPs have the correct training or access to the right equipment, so you may need to go to a hospital clinic to have the procedure.

prevent piles

Do

drink lots of fluid and eat plenty of fibre to keep your poo soft

wipe your bottom with damp toilet paper

take paracetamol if piles hurt

take a warm bath to ease itching and pain

use an ice pack wrapped in a towel to ease discomfort

gently push a pile back inside

keep your bottom clean and dry

exercise regularly

cut down on alcohol and caffeine (like tea, coffee and cola) to avoid constipation

Don’t

do not wipe your bottom too hard after you poo

do not ignore the urge to poo

do not push too hard when pooing

do not take painkillers that contain codeine, as they cause constipation

do not take ibuprofen if your piles are bleeding

do not spend more time than you need to on the toilet

treatment

Haemorrhoids (piles) often clear up by themselves after a few days. However, there are many treatments that can reduce itching and discomfort.

Making simple dietary changes and not straining on the toilet are often recommended first.

Creams, ointments and suppositories (which you insert into your bottom) are available from pharmacies without a prescription. They can be used to relieve any swelling and discomfort.

If more intensive treatment is needed, the type will depend on where your haemorrhoids are in your anal canal – the lower third (closest to your anus) or the upper two-thirds. The lower third contain nerves which can transmit pain, while the upper two-thirds do not.

Non-surgical treatments for haemorrhoids in the lower part of the canal are likely to be very painful, because the nerves in this area can detect pain. In these cases, haemorrhoid surgery will usually be recommended.

The various treatments for haemorrhoids are outlined below.

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Dietary changes and self care

If constipation is thought to be the cause of your haemorrhoids, you need to keep your stools soft and regular, so that you don’t strain when passing stools.

You can do this by increasing the amount of fibre in your diet. Good sources of fibre include wholegrain bread, cereal, fruit and vegetables.

You should also drink plenty of water and avoid caffeine (found in tea, coffee and cola).

When going to the toilet, you should:

• avoid straining to pass stools, because it may make your haemorrhoids worse
• use moist toilet paper, rather than dry toilet paper, or baby wipes to clean your bottom after passing a stool
• pat the area around your bottom, rather than rubbing it

Read more about preventing constipation.

Medication

Over-the-counter topical treatments

Various creams, ointments and suppositories (which are inserted into your bottom) are available from pharmacies without a prescription. They can be used to relieve any swelling and discomfort.

These medicines should only be used for five to seven days at a time. If you use them for longer, they may irritate the sensitive skin around your anus. Any medication should be combined with the diet and self-care advice discussed above.

There’s no evidence to suggest that one method is more effective than another. Ask your pharmacist for advice about which product is most suitable for you, and always read the patient information leaflet that comes with your medicine before using it.

Don’t use more than one product at once.

Corticosteroid cream

If you have severe inflammation in and around your back passage, your GP may prescribe corticosteroid cream, which contains steroids.

You shouldn’t use corticosteroid cream for more than a week at a time, because it can make the skin around your anus thinner and the irritation worse.

Painkillers

Common painkilling medication, such as paracetamol, can help relieve the pain of haemorrhoids.

However, if you have excessive bleeding, avoid using non-steroid anti-inflammatory drugs (NSAIDs), such as ibuprofen, because it can make rectal bleeding worse. You should also avoid using codeine painkillers, because they can cause constipation.

Your GP may prescribe products that contain local anaesthetic to treat painful haemorrhoids. Like over-the-counter topical treatments, these should only be used for a few days, because they can make the skin around your back passage more sensitive.

Laxatives

If you’re constipated, your GP may prescribe a laxative. Laxatives are a type of medicine that can help you empty your bowels.

Non-surgical treatments

If dietary changes and medication don’t improve your symptoms, your GP may refer you to a specialist. They can confirm whether you have haemorrhoids and recommend appropriate treatment.

If you have haemorrhoids in the upper part of your anal canal, non-surgical procedures such as banding and sclerotherapy may be recommended.

Banding

Banding involves placing a very tight elastic band around the base of your haemorrhoids to cut off their blood supply. The haemorrhoids should then fall off within about a week of having the treatment.

Banding is usually a day procedure that doesn’t need an anaesthetic, and most people can get back to their normal activities the next day. You may feel some pain or discomfort for a day or so afterwards. Normal painkillers are usually adequate, but your GP can prescribe something stronger, if needed.

You may not realise that your haemorrhoids have fallen off, as they should pass out of your body when you go to the toilet. If you notice some mucus discharge within a week of the procedure, it usually means that the haemorrhoids have fallen off.

Directly after the procedure, you may notice blood on the toilet paper after going to the toilet. This is normal, but there shouldn’t be a lot of bleeding. If you pass a lot of bright red blood or blood clots (solid lumps of blood), go to your nearest accident and emergency (A&E) department immediately.

Ulcers (open sores) can occur at the site of the banding, although these usually heal without needing further treatment.

Injections (sclerotherapy)

A treatment called sclerotherapy may be used as an alternative to banding.

During sclerotherapy, a chemical solution is injected into the blood vessels in your back passage. This relieves pain by numbing the nerve endings at the site of the injection. It also hardens the tissue of the haemorrhoid so that a scar is formed. After about 4 to 6 weeks, the haemorrhoid should decrease in size or shrivel up.

After the injection, you should avoid strenuous exercise for the rest of the day. You may experience minor pain for a while and may bleed a little. You should be able to resume normal activities, including work, the day after the procedure.

Electrotherapy

Electrotherapy, also known as electrocoagulation, is another alternative to banding for people with smaller haemorrhoids.

During the procedure, a device called a proctoscope is inserted into the anus to locate the haemorrhoid. An electric current is then passed through a small metal probe that’s placed at the base of the haemorrhoid, above the dentate line. The specialist can control the electric current using controls attached to the probe.

The aim of electrotherapy is to cause the blood supplying the haemorrhoid to coagulate (thicken), which causes the haemorrhoid to shrink. If necessary, more than one haemorrhoid can be treated during each session.

Electrotherapy can either be carried out on outpatient basis using a low electric current, or a higher dose can be given while the person is under a general anaesthetic or spinal anaesthetic.

You may experience some mild pain during or after electrotherapy, but in most cases this doesn’t last long. Rectal bleeding is another possible side effect of the procedure, but this is usually short-lived.  

Electrotherapy is recommended by the National Institute for Health and Care Excellence (NICE), and has been shown to be an effective method of treating smaller haemorrhoids. It can also be used as an alternative to surgery for treating larger haemorrhoids, but there’s less evidence of its effectiveness.

Surgery

Although most haemorrhoids can be treated using the methods described above, around 1 in every 10 people will eventually need surgery.

Surgery is particularly useful for haemorrhoids that have developed below the dentate line because, unlike non-surgical treatments, anaesthetic is used to ensure you don’t feel any pain.

There are many different types of surgery that can be used to treat haemorrhoids, but they all usually involve either removing the haemorrhoids or reducing their blood supply, causing them to shrink.

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A hernia of the abdominal wall is a protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall. Many hernias are asymptomatic, but some become incarcerated or strangulated, causing pain and requiring immediate surgery. Diagnosis is clinical. Treatment is elective surgical repair.

A hernia occurs when an organ protrudes through the wall of muscle that encircles it. There are several different types of hernias that can occur in the abdominal and surrounding areas. These include umbilical hernias, epigastric hernias, incisional hernias, and others. For more information on these specific types of hernias.

Types of Abdominal Wall Hernias

Epigastric Hernia

An epigastric hernia occurs when a weakened area in the abdominal wall allows a bit of fat to push through. Epigastric hernias are typically small. They occur in the middle of the belly, in the area between the belly button and the breastbone.

Some patients develop more than one epigastric hernia at a time. These hernias typically don’t cause symptoms, but you may experience pain in your upper belly.

Treatment of epigastric hernias typically involves surgery, but your doctor will discuss all your options with you in detail.

Incisional Hernia

A hernia that occurs in the area of a previous surgery is known as an incisional hernia. These hernias may occur when the abdominal wall has been weakened by surgery, or when a surgical incision becomes infected, further weakening the area.

Incisional hernias are relatively common because surgical incisions weaken the abdominal area. That weakness makes it easier for a part of the intestine or other tissue to protrude.

Incisional hernias can develop soon after surgery, or they can develop slowly, over months or even years. They typically occur alongside vertical incisions. Incisional hernias tend to be large and rather painful.

Incisional hernias will not heal on their own. Talk to your doctor for more details about your treatment options.

Spigelian Hernia

Spigelian hernias occur throughout the spigelian fascia. Unlike other types of hernias, which develop immediately below layers of fat, spigelian hernias occur in the midst of abdominal muscles. This means that spigelian hernias may not be immediately visible as a bulge or lump. They can go undetected for longer periods of time.

Because spigelian hernias tend to be small, the risk of developing a strangulated hernia is higher.

Spigelian hernias tend to occur more rarely than other types of hernias.

Umbilical Hernia

An umbilical hernia occurs when a weak spot in the belly allows a bit of fat, fluid, or intestine to push through, creating a lump or bulge near the belly button.

Umbilical hernias frequently occur in infants. In most cases, these hernias will heal on their own. Occasionally, however, surgery may be required.

Umbilical hernias also occur in adults, particularly those with health issues that cause increased pressure in the belly. Those issues may include obesity, pregnancy, chronic coughing or constipation, and difficulty urinating.

Because they tend to grow bigger over time, umbilical hernias require treatment. Treatment typically involves surgery, but your doctor will discuss all your options with you in detail. Without treatment, you are at risk of developing a strangulated hernia, which means that blood supply to the tissue has been cut off. Strangulation is life threatening and requires emergency surgery.

Causes 

Abdominal wall hernias can occur in people of any age, including infants. However, the risk of developing a hernia tends to increase as you age. Most abdominal wall hernias are caused by an area of weakness in the abdominal walls. A number of different factors can contribute to the development of that weakness. These factors include:

• Aging
• Chronic coughing
• Collagen vascular disease
• Frequent heavy lifting
• Genetic defects   
• History of previous hernias
• Infection (especially following surgery)
• Injuries to the abdominal area
• Obesity
• Pregnancy
• Straining during bowel movements or urination
• Surgical openings

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Diagnosis

In most cases, your doctor will be able to determine whether you are in fact suffering from a hernia simply by looking and by gently palpating the affected area.

If for some reason a diagnosis isn’t immediately apparent, your doctor may decide to order an imaging test, such as an abdominal ultrasound, CT scan, or MRI. These imaging tests can help to show the hole in the muscle wall, along with the tissue protruding from it.

Prognosis

Congenital umbilical hernias rarely strangulate and are not treated; most resolve spontaneously within several years. Very large defects may be repaired electively after age 2 years.

Umbilical hernias in adults cause cosmetic concerns and can be electively repaired; strangulation and incarceration are unusual but can happen and usually contain omentum rather than intestine.

Treatment

Abdominal wall hernias that have no associated symptoms may not require any treatment at all. Your doctor will discuss your options with you which may include surgery or watchful waiting.

Larger hernias, however, or hernias that are causing pain, may require surgical repair to relieve pain as well as to prevent complications.

There are two types of surgical hernia repair: open and minimally invasive surgery. The type of surgery chosen will depend on the severity and type of hernia you’ve developed, the anticipated recovery time, your past medical and surgical history, and your surgeon’s expertise.

Open Surgery: During this procedure, your surgeon will make a small incision into your groin, and then push the protruding tissue back into your abdomen. Your surgeon will then sew up the weakened area. In some cases, your surgeon will use a mesh  to reinforce that weakened area.

Open surgery can be performed either with general anesthesia or with sedation or local anesthesia.

After your surgery, it might be several weeks before you’re able to fully resume your normal activities. However, it’s still important that you begin moving about again as soon as possible for a healthier recovery.

Minimally Invasive Surgery: Minimally invasive surgery is typically performed under general anesthesia.

During this procedure, your surgeon will make a few small incisions in your abdomen. Your surgeon will then inflate your abdomen, using a special gas, in order to make your internal organs easier to see.

Your surgeon will then insert a small, narrow tube into one of the incisions in your abdomen. This tube has a tiny camera, or laparoscope, at the end of it. That camera serves as a kind of guide for your surgeon, who is then able to insert surgical instruments through the other incisions in your abdomen. Your surgeon will repair the hernia using  and may use mesh.

Patients who are candidates for minimally invasive surgery may experience less scarring and discomfort following surgery than those who undergo open surgery. Patients may also be able to return more quickly to their normal activities.

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A hydrocele is when fluid fills a male’s scrotum, causing it to swell. It is not a major health issue but it can be embarrassing and uncomfortable. Hydroceles are more common in male infants than adults, and there are treatments to solve the problem.

A hydrocele (HI-droe-seel) is a type of swelling in the scrotum that occurs when fluid collects in the thin sheath surrounding a testicle. Hydrocele is common in newborns and usually disappears without treatment by age 1. Older boys and adult men can develop a hydrocele due to inflammation or injury within the scrotum.

A hydrocele usually isn’t painful or harmful and might not need any treatment. But if you have scrotal swelling, see your doctor to rule out other causes.

Types of hydroceles

The two types of hydroceles are noncommunicating and communicating.

Noncommunicating

A noncommunicating hydrocele occurs when the sac closes, but your body doesn’t absorb the fluid. The remaining fluid is typically absorbed into the body within a year.

Communicating

A communicating hydrocele occurs when the sac surrounding your testicle doesn’t close all the way. This allows fluid to flow in and out.

Causes

Towards the end of pregnancy, a male child’s testicles descend from his abdomen into the scrotum. The scrotum is the sac of skin that holds the testicles once they descend.

During development, each testicle has a naturally occurring sac around it that contains fluid. Normally, this sac closes itself and the body absorbs the fluid inside during the baby’s first year. However, this doesn’t happen for babies with a hydrocele. Babies born prematurely are at a higher risk for hydrocele,

Hydroceles can also form later in life, mostly in men over 40. This usually occurs if the channel through which the testicles descend hadn’t closed all the way and fluid now enters, or the channel reopens. This can cause fluid to move from the abdomen into the scrotum. Hydroceles can also be caused by inflammation or injury in the scrotum or along the channel. The inflammation may be caused by an infection (epididymitis) or another condition.

Baby boys

A hydrocele can develop before birth. Normally, the testicles descend from the developing baby’s abdominal cavity into the scrotum. A sac accompanies each testicle, allowing fluid to surround the testicles. Usually, each sac closes and the fluid is absorbed.

Sometimes, the fluid remains after the sac closes (noncommunicating hydrocele). The fluid is usually absorbed gradually within the first year of life. But occasionally, the sac remains open (communicating hydrocele). The sac can change size or if the scrotal sac is compressed, fluid can flow back into the abdomen. Communicating hydroceles are often associated with inguinal hernia.

Older males

A hydrocele can develop as a result of injury or inflammation within the scrotum. Inflammation might be caused by an infection in the testicle or in the small, coiled tube at the back of each testicle (epididymitis).

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symptoms

Hydroceles usually don’t cause any pain. Usually, the only symptom is a swollen scrotum.

In adult men, there may be a feeling of heaviness in the scrotum. In some cases, the swelling might be worse in the morning than in the evening. It is not usually very painful.

Seek medical treatment if you or your child has sudden or severe pain in their scrotum. This could be the sign of another condition called testicular torsion. Testicular torsion occurs when the testicles become twisted, typically due to an injury or accident. Testicular torsion isn’t common, but it’s a medical emergency because it can lead to blocked blood supply to the testicle and ultimately infertility if untreated. If you think you or child has testicular torsion, go a hospital emergency room right away or call 911. It needs to be evaluated and treated immediately.

Diagnosis

ght passing through. However, if scrotal swelling is due to a solid mass (cancer), then the light will not shine through the scrotum. This test does not provide a definite diagnosis but can be very helpful.

Your doctor may also apply pressure to the abdomen to check for another condition called inguinal hernia; your doctor may also ask you to cough or bear down to check for this. This can occur when part of the small intestine protrudes through the groin due to a weak point in the abdominal wall. While it’s usually not life-threatening, a doctor may recommend surgery to repair it.

They may take a blood or urine sample to test for infections. Less commonly, your doctor may administer an ultrasound to check for hernias, tumors, or any other cause of scrotal swelling.

Risk factors

Most hydroceles are present at birth. At least 5 percent of newborn boys have a hydrocele. Babies who are born prematurely have a higher risk of having a hydrocele.

Risk factors for developing a hydrocele later in life include:

• Injury or inflammation to the scrotum
• Infection, including a sexually transmitted infection (STI)

Complications

A hydrocele typically isn’t dangerous and usually doesn’t affect fertility. But a hydrocele might be associated with an underlying testicular condition that can cause serious complications, including:

• Infection or tumor. Either might reduce sperm production or function.
• Inguinal hernia. The loop of intestine trapped in the abdominal wall can lead to life-threatening complications.

Treatment

A hydrocele usually goes away on its own before a boy’s first birthday. If it doesn’t, or if it gets bigger, their doctor will refer them to a specialist called a urologist. 

If your son has a communicating hydrocele, the pediatrician will usually recommend surgery without waiting for it to go away.

The doctor can remove a hydrocele in a brief operation called a hydrocelectomy.

Your  baby will get medicine to numb their body or to put them under completely. Then, a surgeon makes a cut in their scrotum or lower belly. The surgeon then drains the fluid and sews the sac closed. Once it’s finished, your son can go home the same day.

In the days after surgery, you’ll need to keep the area clean and dry. The doctor and team will show you how to care for your baby as they heal.

After a few days, you may need to take them back to the doctor to make sure they are healing well.

prevented

There is nothing you can do to prevent your baby from getting a hydrocele. For adolescent and adult men, the best protection against a hydrocele is to keep the testicles and scrotum free of injury. For example, if taking part in contact sports, use an athletic cup.

Although hydroceles are usually not a major health issue, you should tell your healthcare provider about any abnormality or swelling in the scrotum. Another disease or condition may be causing or mimicking the abnormality.

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Orchitis (or-KIE-tis) is an inflammation of one or both testicles. Bacterial or viral infections can cause orchitis, or the cause can be unknown. Orchitis is most often the result of a bacterial infection, such as a sexually transmitted infection (STI). In some cases, the mumps virus can cause orchitis.

Bacterial orchitis might be associated with epididymitis — an inflammation of the coiled tube (epididymis) at the back of the testicle that stores and carries sperm. In that case, it’s called epididymo-orchitis.

Orchitis causes pain and can affect fertility. Medication can treat the causes of bacterial orchitis and can ease some signs and symptoms of viral orchitis. But it can take several weeks for scrotal tenderness to disappear.

Acute epididymo-orchitis is a clinical syndrome consisting of pain, swelling and inflammation of the epididymis, with or without inflammation of the testes. The most common route of infection is local extension and is mainly due to infections spreading from the urethra (sexually transmitted infections (STIs)) or from the bladder^[1]. Orchitis (infection limited to the testis) is much less common. Chronic epididymitis refers to epididymal pain and inflammation (usually without scrotal swelling) that lasts for more than six months.

• Epididymitis means inflammation of the epididymis (the structure next to the testicle (testis) that is involved in making sperm).
• Orchitis means inflammation of a testicle.

As the epididymis and testis lie next to each other, it is often difficult to tell if the epididymis, the testis, or both are inflamed. Therefore, the term epididymo-orchitis is often used.

Causes

Orchitis can be caused by a bacterial or viral infection. Sometimes a cause of orchitis can’t be determined.

Bacterial orchitis

Most often, bacterial orchitis is associated with or the result of epididymitis. Epididymitis usually is caused by an infection of the urethra or bladder that spreads to the epididymis.

Often, the cause of the infection is an STI. Other causes of infection can be related to having been born with abnormalities in your urinary tract or having had a catheter or medical instruments inserted into your penis.

Viral orchitis

The mumps virus usually causes viral orchitis. Nearly one-third of males who contract the mumps after puberty develop orchitis, usually four to seven days after onset of the mumps.

Acute Epididymitis

An “acute” case is most often caused by an infection from bacteria. The e-coli bacteria are a common cause for infection.

• In children who haven’t reached puberty, the infection may start in the bladder or kidney. It then spreads to the testis. Some boys get more urinary tract infections, and may get this more often.
• In men, a STD ( sexually transmitted disease) is one of the causes. Mostly from chlamydia, mycoplasma or rarely gonorrhea. These infections start in the urethra. They can then move into the testis. Sometimes there is a discharge of fluid from the urethra.

Sometimes it is caused by something else:

• Enlarged prostate blocking the bladder
• Infection of the prostate gland (“bacterial prostatitis”)
• Partly blocked urethra
• Recent catheter use

Epididymitis is sometimes caused by other things:

• Chemical or inflammatory non-bacterial epididymitis may happen from urine flowing backwards to the epididymis. This is most often from heavy lifting. The urine causes swelling but no infection.
• The drug “Amidarone” can be a cause but this is rare
• An infection from the bloodstream (as with tuberculosis)
• Other unknown causes

In any of these cases, the first sign of a problem is often pain in the back of the testis.

Chronic Epididymitis

A “chronic” case may result after acute epididymitis. It doesn’t seem to go away. It can also happen without acute symptoms or known infection. In this case, the cause is unknown.

Orchitis

Orchitis alone is mostly from a mumps virus (or other virus) infection. “Mumps orchitis” appears in about 1/3 of males who get mumps after puberty. It only occurs in boys that have mumps AFTER puberty. In some cases of mumps, interferon can be given to prevent orchitis. This infection doesn’t spread to the epididymis.

Acute Epididymo-orchitis

Acute epididymo-orchitis is most often from a bacterial infection. It can also be caused by a tuberculous infection of the epididymis, but this is rare. Rarely, it can start in the testis and spread to the epididymis.

Symptoms

Orchitis signs and symptoms usually develop suddenly and can include:

• Swelling in one or both testicles
• Pain ranging from mild to severe
• Fever
• Nausea and vomiting
• General feeling of unwellness (malaise)

The terms “testicle pain” and “groin pain” are sometimes used interchangeably. But groin pain occurs in the fold of skin between the thigh and abdomen — not in the testicle. The causes of groin pain are different from the causes of testicle pain.

When to see a doctor

If you have pain or swelling in your scrotum, especially if the pain occurs suddenly, see your doctor right away.

A number of conditions can cause testicle pain, and some require immediate treatment. One such condition involves twisting of the spermatic cord (testicular torsion), which might cause pain similar to that caused by orchitis. Your doctor can perform tests to determine which condition is causing your pain.

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Epidemiology

• A study of UK general practices during the years 2003-2008 reported a highest incidence of 25/10,000 in 2004-2005. The incidence declined during the latter part of the study.
• Acute epididymitis most commonly occurs in patients aged 15-30 years and patients older than 60 years. In the UK GP study, the incidence declined in younger age groups throughout the study period but that of males aged over 45 years was stable. Prepubertal epididymitis is rare (and testicular torsion is much more common in this age group).
• Mumps orchitis occurs in up to 40% of postpubertal boys with mumps; it is rare in prepubertal boys. An outbreak starting in 2004 and lasting for some three years was seen in England and Wales and was attributed to a reduction in the uptake of measles-mumps-rubella (MMR) vaccine during the early to mid-1990s in children who subsequently matured.
• Prepubertal epididymitis is thought to be more common than was once believed. It is thought to be a postviral infectious phenomenon.

Risk factors

Risk factors for nonsexually transmitted orchitis include:

• Not being immunized against mumps
• Having recurring urinary tract infections
• Having surgery that involves the genitals or urinary tract
• Being born with an abnormality in the urinary tract 

Sexual behaviors that can lead to STIs put you at risk of sexually transmitted orchitis. Those behaviors include having:

• Multiple sexual partners
• Sex with a partner who has an STI
• Sex without a condom
• A personal history of an STI

Complications

Complications of orchitis may include:

• Testicular atrophy. Orchitis can eventually cause the affected testicle to shrink.
• Scrotal abscess. The infected tissue fills with pus.
• Infertility. Occasionally, orchitis can cause infertility or inadequate testosterone production (hypogonadism). But these are less likely if orchitis affects only one testicle.

Prevention

To prevent orchitis:

• Get immunized against mumps, the most common cause of viral orchitis
• Practice safe sex, to help protect against STIs that can cause bacterial orchitis

Treatment

Acute Epididymitis and Acute Epididymo-orchitis

Treatment often starts with a 1-2 week course of antibiotics. Most cases can be treated out of the hospital with pills. The best medicine for you will depend on the type of bacteria found. The most common antibiotics used are:

• Doxycycline
• Ciprofloxacin
• Levofloxacin
• Trimethoprim-sulfamethoxazole

For bad cases of infection, you may need to stay in the hospital for treatment. These are cases with pain that’s hard to control with vomiting, high fever and if you are not getting better with antibiotics given by mouth. Occasionally, for bad cases, narcotics are needed for a few days.

Tuberculosis epididymitis is more serious but is very rare. It is treated with anti-tuberculous drugs. If damage is bad, surgery may be needed to take out the testis and the epididymis (“orchiectomy”).

Epididymitis caused by amidarone is treated by limiting or stopping the drug. Your health care provider will tell you what to do.

For other types of non-infectious epididymitis, there’s no set treatment.

Epididymitis care involves rest for 1 – 2 days with the scrotum raised if possible. The aim is to get the inflamed area above the level of the heart. This helps blood flow, which lowers swelling and pain, and helps with healing. Putting ice on the scrotum now and then can also help. In cases due to infection, it helps to drink fluids.

Anti-inflammatory pills like ibuprofen or naproxen help ease pain. They also ease the swelling that causes the pain. If the pain is severe, a short-term narcotic pain medicine may help but is only used for a short period of time at best in most situations.

Chronic Epididymitis

Chronic epididymitis is mainly treated with drugs and comfort to ease pain. Pain medicine and applying heat are the standard treatments.

If symptoms don’t go away, your health care provider may suggest other pain medicine. Or, recommend a pain management specialist. If all else fails, the epididymis can be surgically removed (“epididymectomy”). The testis can be left in place.

Acute Orchitis

Antibiotics are often the best treatment for bacterial infections. Pain medicine may help reduce symptoms.

There’s no set care for acute mumps orchitis and this will usually resolve in time.

After Treatment

Acute Epididymitis and Acute Epididymo-orchitis

For infectious cases, it takes two to three days to start feeling better. If you don’t, and if the redness doesn’t begin to fade, call your provider. Discomfort can last for weeks to months after the full course of antibiotics is taken in some cases. It can take months for the swelling to ease. Rest with the scrotum raised for a day or two helps speed healing.

Cases of tuberculous epididymitis (without surgery) may need months to heal with medicine. The testis may shrink after treatment.

Amidarone epididymitis simply gets better after cutting the dose or stopping the drug.

Chemical epididymitis heals fully with treatment.

Please follow-up with your health care provider to make sure the problem doesn’t return.

Chronic Epididymitis

Symptoms for chronic epididymitis go away eventually or may come and go. Anti- inflammatory medicine may be needed on and off for a months or years. Symptoms are sometimes better and sometimes worse.

If surgery is done, symptoms ease in most men after a few weeks of healing. If surgery hasn’t helped, your health care provider will try drugs again. In certain cases, he/she may suggest microsurgery to block nerves on the spermatic cord.

Acute Orchitis

Pain often goes away after the acute phase. The testis often shrinks.

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Benign prostatic hyperplasia—also called BPH—is a condition in men in which the prostate gland is enlarged and not cancerous. Benign prostatic hyperplasia is also called benign prostatic hypertrophy or benign prostatic obstruction.

The prostate goes through two main growth periods as a man ages. The first occurs early in puberty, when the prostate doubles in size. The second phase of growth begins around age 25 and continues during most of a man’s life. Benign prostatic hyperplasia often occurs with the second growth phase.

As the prostate enlarges, the gland presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder. The narrowing of the urethra and urinary retention—the inability to empty the bladder completely—cause many of the problems associated with benign prostatic hyperplasia.

BPH is an enlarged prostate. The prostate goes through two main growth cycles during a man’s life. The first occurs early in puberty, when the prostate doubles in size. The second phase of growth starts around age 25 and goes on for most of the rest of a man’s life. BPH most often occurs during this second growth phase.

As the prostate enlarges, it presses against the urethra. The bladder wall becomes thicker. One day, the bladder may weaken and lose the ability to empty fully, leaving some urine in the bladder. Narrowing of the urethra and urinary retention – being unable to empty the bladder fully – cause many of the problems of BPH.

BPH is benign. This means it is not cancer. It does not cause or lead to cancer. However, BPH and cancer can happen at the same time.

BPH is common. About half of all men between ages 51 and 60 have BPH. Up to 90% of men over age 80 have it.

causes

The prostate gland is located beneath your bladder. The tube that transports urine from the bladder out of your penis (urethra) passes through the center of the prostate. When the prostate enlarges, it begins to block urine flow.

Most men have continued prostate growth throughout life. In many men, this continued growth enlarges the prostate enough to cause urinary symptoms or to significantly block urine flow.

It isn’t entirely clear what causes the prostate to enlarge. However, it might be due to changes in the balance of sex hormones as men grow older.

The causes of BPH are not well-understood. Some researchers believe that factors related to aging and the testicles may cause BPH. This is because BPH does not develop in men whose testicles were removed before puberty.

Throughout their lives, men produce both testosterone, a male hormone, and small amounts of estrogen, a female hormone. As men age, the amount of active testosterone in the blood lowers, leaving a higher share of estrogen. Studies have suggested that BPH may happen because the higher share of estrogen in the prostate adds to the activity of substances that start prostate cells to grow.

Another theory points to dihydrotestosterone (DHT), a male hormone that plays a role in prostate development and growth. Some research has shown that, even when testosterone levels in the blood start to fall, high levels of DHT still build up in the prostate. This may push prostate cells to continue to grow. Scientists have noted that men who do not produce DHT do not develop BPH.

Symptoms

The severity of symptoms in people who have prostate gland enlargement varies, but symptoms tend to gradually worsen over time. Common signs and symptoms of BPH include:

• Frequent or urgent need to urinate
• Increased frequency of urination at night (nocturia)
• Difficulty starting urination
• Weak urine stream or a stream that stops and starts
• Dribbling at the end of urination
• Inability to completely empty the bladder

Less common signs and symptoms include:

• Urinary tract infection
• Inability to urinate
• Blood in the urine

The size of your prostate doesn’t necessarily determine the severity of your symptoms. Some men with only slightly enlarged prostates can have significant symptoms, while other men with very enlarged prostates can have only minor urinary symptoms.

In some men, symptoms eventually stabilize and might even improve over time.

Other possible causes of urinary symptoms

Conditions that can lead to symptoms similar to those caused by enlarged prostate include:

• Urinary tract infection
• Inflammation of the prostate (prostatitis)
• Narrowing of the urethra (urethral stricture)
• Scarring in the bladder neck as a result of previous surgery
• Bladder or kidney stones
• Problems with nerves that control the bladder
• Cancer of the prostate or bladder

How common is benign prostatic hyperplasia?

Benign prostatic hyperplasia is the most common prostate problem for men older than age 50. In 2010, as many as 14 million men in the United States had lower urinary tract symptoms suggestive of benign prostatic hyperplasia.¹ Although benign prostatic hyperplasia rarely causes symptoms before age 40, the occurrence and symptoms increase with age. Benign prostatic hyperplasia affects about 50 percent of men between the ages of 51 and 60 and up to 90 percent of men older than 80.

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Risk factors

Risk factors for prostate gland enlargement include:

• Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than age 40. About one-third of men experience moderate to severe symptoms by age 60, and about half do so by age 80.
• Family history. Having a blood relative, such as a father or a brother, with prostate problems means you’re more likely to have problems.
• Diabetes and heart disease. Studies show that diabetes, as well as heart disease and use of beta blockers, might increase the risk of BPH.
• Lifestyle. Obesity increases the risk of BPH, while exercise can lower your risk.

Complications

Complications of an enlarged prostate can include:

• Sudden inability to urinate (urinary retention). You might need to have a tube (catheter) inserted into your bladder to drain the urine. Some men with an enlarged prostate need surgery to relieve urinary retention.
• Urinary tract infections (UTIs). Inability to fully empty the bladder can increase the risk of infection in your urinary tract. If UTIs occur frequently, you might need surgery to remove part of the prostate.
• Bladder stones. These are generally caused by an inability to completely empty the bladder. Bladder stones can cause infection, bladder irritation, blood in the urine and obstruction of urine flow.
• Bladder damage. A bladder that hasn’t emptied completely can stretch and weaken over time. As a result, the muscular wall of the bladder no longer contracts properly, making it harder to fully empty your bladder.
• Kidney damage. Pressure in the bladder from urinary retention can directly damage the kidneys or allow bladder infections to reach the kidneys.

Most men with an enlarged prostate don’t develop these complications. However, acute urinary retention and kidney damage can be serious health threats.

Having an enlarged prostate is not believed to increase your risk of developing prostate cancer.

diagnosis

When checking you for BPH, your doctor will usually begin by doing a physical exam and asking you about your medical history. The physical exam includes a rectal examination that allows the doctor to estimate the size and shape of your prostate. Other tests can include:

• Urinalysis: Your urine is checked for blood and bacteria.
• Prostatic biopsy: A small amount of prostate tissue is removed and examined for abnormalities.
• Urodynamic test: Your bladder is filled with liquid via a catheter to measure the pressure of your bladder during urination.
• Prostate-specific antigen (PSA) test: This blood test checks for cancer of the prostate.
• Post-void residual: This tests the amount of urine left in your bladder after urination.
• Cystoscopy: This is the examination of your urethra and bladder with a tiny lighted scope that is inserted into your urethra
• Intravenous pyelography or urography: This is an X-ray exam or CT scan that is done after a dye is injected into your body. The dye highlights your entire urinary system on the images produced by the X-ray or CT.

Your doctor may also ask about medications you’re taking that might be affecting your urinary system, such as:

• antidepressants
• diuretics
• antihistamines
• sedatives

Your doctor can make any necessary medication adjustments. Don’t attempt to adjust your medications or doses yourself. Let your doctor know if you’ve taken self-care measures for your symptoms for at least two months without noticing any improvement.

treatment-

Treatment options for benign prostatic hyperplasia may include

• lifestyle changes
• medications
• minimally invasive procedures
• surgery

A health care provider treats benign prostatic hyperplasia based on the severity of symptoms, how much the symptoms affect a man’s daily life, and a man’s preferences.

Men may not need treatment for a mildly enlarged prostate unless their symptoms are bothersome and affecting their quality of life. In these cases, instead of treatment, a urologist may recommend regular checkups. If benign prostatic hyperplasia symptoms become bothersome or present a health risk, a urologist most often recommends treatment.

Lifestyle Changes

A health care provider may recommend lifestyle changes for men whose symptoms are mild or slightly bothersome. Lifestyle changes can include

• reducing intake of liquids, particularly before going out in public or before periods of sleep
• avoiding or reducing intake of caffeinated beverages and alcohol
• avoiding or monitoring the use of medications such as decongestants, antihistamines, antidepressants, and diuretics
• training the bladder to hold more urine for longer periods
• exercising pelvic floor muscles
• preventing or treating constipation

Medications

A health care provider or urologist may prescribe medications that stop the growth of or shrink the prostate or reduce symptoms associated with benign prostatic hyperplasia:

• alpha blockers
• phosphodiesterase-5 inhibitors
• 5-alpha reductase inhibitors
• combination medications

Alpha blockers. These medications relax the smooth muscles of the prostate and bladder neck to improve urine flow and reduce bladder blockage:

• terazosin (Hytrin)
• doxazosin (Cardura)
• tamsulosin (Flomax)
• alfuzosin (Uroxatral)
• silodosin (Rapaflo)

Phosphodiesterase-5 inhibitors. Urologists prescribe these medications mainly for erectile dysfunction. Tadalafil (Cialis) belongs to this class of medications and can reduce lower urinary tract symptoms by relaxing smooth muscles in the lower urinary tract. Researchers are working to determine the role of erectile dysfunction drugs in the long-term treatment of benign prostatic hyperplasia.

5-alpha reductase inhibitors. These medications block the production of DHT, which accumulates in the prostate and may cause prostate growth:

• finasteride (Proscar)
• dutasteride (Avodart)

These medications can prevent progression of prostate growth or actually shrink the prostate in some men. Finasteride and dutasteride act more slowly than alpha blockers and are useful for only moderately enlarged prostates.

Combination medications. Several studies, such as the Medical Therapy of Prostatic Symptoms (MTOPS) study, have shown that combining two classes of medications, instead of using just one, can more effectively improve symptoms, urinary flow, and quality of life. The combinations include

• finasteride and doxazosin
• dutasteride and tamsulosin (Jalyn), a combination of both medications that is available in a single tablet
• alpha blockers and antimuscarinics

A urologist may prescribe a combination of alpha blockers and antimuscarinics for patients with overactive bladder symptoms. Overactive bladder is a condition in which the bladder muscles contract uncontrollably and cause urinary frequency, urinary urgency, and urinary incontinence. Antimuscarinics are a class of medications that relax the bladder muscles.

Minimally Invasive Procedures

Researchers have developed a number of minimally invasive procedures that relieve benign prostatic hyperplasia symptoms when medications prove ineffective. These procedures include

• transurethral needle ablation
• transurethral microwave thermotherapy
• high-intensity focused ultrasound
• transurethral electrovaporization
• water-induced thermotherapy
• prostatic stent insertion

Minimally invasive procedures can destroy enlarged prostate tissue or widen the urethra, which can help relieve blockage and urinary retention caused by benign prostatic hyperplasia.

Urologists perform minimally invasive procedures using the transurethral method, which involves inserting a catheter—a thin, flexible tube—or cystoscope through the urethra to reach the prostate. These procedures may require local, regional, or general anesthesia. Although destroying troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue destruction does not cure benign prostatic hyperplasia. A urologist will decide which procedure to perform based on the man’s symptoms and overall health.

Transurethral needle ablation. This procedure uses heat generated by radiofrequency energy to destroy prostate tissue. A urologist inserts a cystoscope through the urethra to the prostate. A urologist then inserts small needles through the end of the cystoscope into the prostate. The needles send radiofrequency energy that heats and destroys selected portions of prostate tissue. Shields protect the urethra from heat damage.

Transurethral microwave thermotherapy. This procedure uses microwaves to destroy prostate tissue. A urologist inserts a catheter through the urethra to the prostate, and a device called an antenna sends microwaves through the catheter to heat selected portions of the prostate. The temperature becomes high enough inside the prostate to destroy enlarged tissue. A cooling system protects the urinary tract from heat damage during the procedure.

High-intensity focused ultrasound. For this procedure, a urologist inserts a special ultrasound probe into the rectum, near the prostate. Ultrasound waves from the probe heat and destroy enlarged prostate tissue.

Transurethral electrovaporization. For this procedure, a urologist inserts a tubelike instrument called a resectoscope through the urethra to reach the prostate. An electrode attached to the resectoscope moves across the surface of the prostate and transmits an electric current that vaporizes prostate tissue. The vaporizing effect penetrates below the surface area being treated and seals blood vessels, which reduces the risk of bleeding.

Water-induced thermotherapy. This procedure uses heated water to destroy prostate tissue. A urologist inserts a catheter into the urethra so that a treatment balloon rests in the middle of the prostate. Heated water flows through the catheter into the treatment balloon, which heats and destroys the surrounding prostate tissue. The treatment balloon can target a specific region of the prostate, while surrounding tissues in the urethra and bladder remain protected.

Prostatic stent insertion. This procedure involves a urologist inserting a small device called a prostatic stent through the urethra to the area narrowed by the enlarged prostate. Once in place, the stent expands like a spring, and it pushes back the prostate tissue, widening the urethra. Prostatic stents may be temporary or permanent. Urologists generally use prostatic stents in men who may not tolerate or be suitable for other procedures.

Surgery

For long-term treatment of benign prostatic hyperplasia, a urologist may recommend removing enlarged prostate tissue or making cuts in the prostate to widen the urethra. Urologists recommend surgery when

• medications and minimally invasive procedures are ineffective
• symptoms are particularly bothersome or severe
• complications arise

Although removing troublesome prostate tissue relieves many benign prostatic hyperplasia symptoms, tissue removal does not cure benign prostatic hyperplasia.

Surgery to remove enlarged prostate tissue includes

• transurethral resection of the prostate (TURP)
• laser surgery
• open prostatectomy
• transurethral incision of the prostate (TUIP)

A urologist performs these surgeries, except for open prostatectomy, using the transurethral method. Men who have these surgical procedures require local, regional, or general anesthesia and may need to stay in the hospital.

The urologist may prescribe antibiotics before or soon after surgery to prevent infection. Some urologists prescribe antibiotics only when an infection occurs.

Immediately after benign prostatic hyperplasia surgery, a urologist may insert a special catheter, called a Foley catheter, through the opening of the penis to drain urine from the bladder into a drainage pouch.

TURP. With TURP, a urologist inserts a resectoscope through the urethra to reach the prostate and cuts pieces of enlarged prostate tissue with a wire loop. Special fluid carries the tissue pieces into the bladder, and the urologist flushes them out at the end of the procedure. TURP is the most common surgery for benign prostatic hyperplasia and considered the gold standard for treating blockage of the urethra due to benign prostatic hyperplasia.

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School Health is:

• a healthful environment,
• nursing and other health services that students need to stay in school,
• nutritious and appealing school meals,
• opportunities for physical activity that include physical education,
• health education that covers a range of developmentally appropriate topics taught by knowledgeable teachers,
• programs that promote the health of school faculty and staff, and
• counseling, psychological and social services that promote healthy social and emotional development and remove barriers to students’ learning.

Over 2.3 billion school age children spend one third of their time in schools. Schools therefore constitute a unique setting to help children and adolescents to develop a positive outlook on life and help them establish healthy lifestyles. Yet global mortality and morbidity estimates in children and adolescents suggest that school aged children have significant needs for health promotion, prevention and health care services.

For many school age children school health services are the first and the most accessible point of contact with health services, with a potential to regularly reach most school-age children with preventive, curative and supportive health interventions. School health services are a very common model of service provision in both high- and middle and low-income countries – at least 102 countries have either school-based or school-linked service provision.

School health services are part of the whole school approach that is promoted by WHO through the Global School Health Initiative launched in 1995. The initiative supports countries to implement the four pillars for Health Promoting Schools: 1) Health promoting school policies 2) Safe and healthy learning environment, 3) Skills-based health education, and 4) School-based health and nutrition services.

Recent guidance from WHO and other UN partners – the Global accelerated action for the health of adolescents (AA-HA!): guidance to support country implementation – gave a new impetus to school health by recommending that “every school should be a health promoting school”.

WHO is working to support Member States in strengthening school health services. This work will support the implementation of the WHO’s 13th General Programme of Work, and more specifically its targets of “1 billion more people benefitting from universal health coverage” and “1 billion lives made healthier” by 2023.

What are best practices in school health?

The American Cancer Society identified the basics of a high-quality school health program in a brochure Elements of Excellence. Those basic elements are:

1. Active leadership from school administrators, a school and community health council, and a school employee with responsibility for coordination.
2. A coordinated and collaborative approach overseen by a school health council, that sets priorities based on community needs and values, and that links with community resources.
3. A safe and nurturing learning environment with supportive policies and practices, facilities that are hazard free, and consistent health-enhancing messages.
4. A commitment of time, personnel, and resources.

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Committees & Initiatives

The American School Health Association values member volunteers and their contributions to our committees and initiatives. ASHA encourages engagement from a diverse group of volunteers who represent various roles, settings, student populations, and health issues.

Committees

Advocacy and Coalitions Committee

Purpose: To build partnerships with national level coalitions and other partners to influence public policy on issues of importance to ASHA’s mission. This committee also works to educate and empower the ASHA membership to act on school health policy issues at the local, state, and federal levels.

Leadership and Recognition Committee

Purpose: To help support ASHA’s efforts in building a community to support the whole child, and to activate champions of school health by recognizing leaders in school health, developing their skills, and to support academic pursuits of young school health professionals through scholarships.

Professional Development Committee

Purpose: To work in collaboration with ASHA staff to plan and implement year-round professional development opportunities for school health professionals including the annual ASHA conference, monthly webinars, self-studies, and any new opportunities that may emerge.

Research and Publications Committee

Purpose: To solicit, curate, disseminate, and promote research I the field of school health. These activities help the ASHA leadership better understand how to lead change efforts and provided the bases of how best to build communities to support school health.

Actions for country impact

WHO provides technical assistance to governments and partners to strengthen school health services as part of national school health programmes and initiatives.

The Pan American Health Organization supported Member States to conduct assessments of school health programmes, including school health services. The assessments informed the regional meeting “Improving the health and wellbeing of school-aged children and adolescents in the Americas” that took place on 11-13 June, 2019, in Washington, DC. The purpose of the meeting was to engage stakeholders from 18 LAC and Caribbean countries in a regional dialogue on the current status of school health based on the results of the regional assessment and country experiences, and to jointly identify actions to strengthen school health in the region.

The WHO Regional Office for Africa supported 29 Member States to take stock of progress made in school health in the African Region. Country teams reviewed progress and planned action to strengthen school health programmes during a regional consultation involving government officials, representatives of United Nations agencies, international NGOs, bilateral agencies, civil society organizations and young people’s organizations operating at the global, regional and national level.

Evaluation of school health services and school health programmes

WHO and partners are working towards a monitoring and evaluation framework for the Global Standards for Health Promoting Schools. A web-platform will be developed to facilitate students’ and parents’ engagement in monitoring and evaluation of the performance of their school against Global Standards. Key indicators will be aligned with existing global monitoring systems for input, process, outcome and impact indicators, such as the Global School-based Student Health Survey (GSHS), the Health Behaviour in School-aged Children (HBSC) survey, and other surveys.

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Disaster, as defined by the United Nations, is a serious disruption of the functioning of a community or society, which involve widespread human, material, economic or environmental impacts that exceed the ability of the affected community or society to cope using its own resources . Disaster management is how we deal with the human, material, economic or environmental impacts of said disaster, it is the process of how we “prepare for, respond to and learn from the effects of major failures”. Though often caused by nature, disasters can have human origins. According to the International Federation of Red Cross & Red Crescent Societies a disaster occurs when a hazard impacts on vulnerable people. The combination of hazards, vulnerability and inability to reduce the potential negative consequences of risk results in disaster.

The impact of disasters on the environment has become more severe over the last decades. Moreover, the reported number of disasters has dramatically increased, as well as the costs to the global economy and the number of people affected . The reasons for these disasters are manifold, and the impact can be found in the increasing vulnerability of societies, infrastructure, and population. Furthermore, extreme weather events have become more common and severe.

The increasing occurrences of natural and man-made disasters lead to a growing demand for up-to-date geographic information, especially timely material on rapidly evolving events. This includes comprehensive, near-real-time Earth observation data, which offer independent coverage of wide areas for a broad spectrum of civilian crisis situations . Satellite imagery can serve as a source of information in disaster situation. Accordingly, remote sensing can provide information on various domains of the disaster management, from risk modelling and vulnerability analysis to early warning and damage assessment

Types of Disaster-

A disaster is a more serious event, defined as “A serious disruption of the functioning of a community or a society involving widespread human, material, economic or environmental losses and impacts, which exceeds the ability of the affected community or society to cope using its own resources” (United Nations Office for Disaster Risk Reduction, UNISDR Terminology and Disaster Risk Reduction, Geneva 2009).  The exceedance of the affected community’s ability to cope is a critical differential point compared to an emergency, and external help will be required to restore functioning. 

Whether an emergency results in disaster is context specific – disasters are often described as a result of the combination of: the exposure to a hazard; the conditions of vulnerability that are present; and insufficient capacity or measures to reduce or cope with the potential negative consequences (UNISDR 2009).   Resilience and response of the community can prevent an emergency becoming a full-scale disaster.

Types of emergencies:

• ‘Man-made’ e.g. transport-related, terrorism
• Natural e.g. flooding, earthquake
• Can also be defined by speed of onset e.g. ‘big bang’ – sudden events such as bombings or earthquakes; ‘rising tide’ gradual events such as famine, infectious disease pandemics.

Natural Disasters

According to the International Federation of Red Cross & Red Crescent Societies Natural Disasters are naturally occurring physical phenomena caused either by rapid or slow onset events that have immediate impacts on human health and secondary impacts causing further death and suffering. These disasters can be:

• Geophysical (e.g. Earthquakes, Landslides, Tsunamis and Volcanic Activity)
• Hydrological (e.g. Avalanches and Floods)
• Climatological (e.g. Extreme Temperatures, Drought and Wildfires)
• Meteorological (e.g. Cyclones and Storms/Wave Surges)
• Biological (e.g. Disease Epidemics and Insect/Animal Plagues)

The United Nations Office for Disaster Risk Reduction characterises Natural Disasters in relation to their magnitude or intensity, speed of onset, duration and area of extent e.g. earthquakes are of short duration and usually affect a relatively small region whereas droughts are slow to develop and fade away and often affect large regions.

Man-Made Disasters-

Man-Made Disasters as viewed by the International Federation of Red Cross & Red Crescent Societies are events that are caused by humans which occur in or close to human settlements often caused as a results of Environmental or Technological Emergencies. This can include ^[3]:

• Environmental Degradation
• Pollution
• Accidents (e.g. Industrial, Technological and Transport usually involving the production, use or transport of hazardous materials) 

Complex Emergencies

Some disasters can result from multiple hazards, or, more often, to a complex combination of both natural and man-made causes which involve a break-down of authority, looting and attacks on strategic installations, including conflict situations and war. These can include ^[6]:

• Food Insecurity
• Epidemics
• Armed Conflicts
• Displaced Populations

According to ICRC these Complex Emergencies are typically characterized by ^[6]:

• Extensive Violence
• Displacements of Populations
• Loss of Life
• Widespread Damage to both Societies and Economies
• Need for Large-scale, Humanitarian Assistance across Multiple Agencies
• Political and Military Constraints which impact or prevent Humanitarian Assistance
• Increased Security Risks for Humanitarian Relief Workers

Pandemic Emergencies

Pandemic (from Greek πᾶν pan “all” and δῆμος demos “people”) is an epidemic of infectious disease that has spread across a large region, which can occur to the human population or animal population and may affect health and disrupt services leading to economic and social costs. It may be an unusual or unexpected increase in the number of cases of an infectious disease which already exists in a certain region or population or can also refer to the appearance of a significant number of cases of an infectious disease in a region or population that is usually free from that disease. Pandemic Emergencies may occur as a consequence of natural or man-made disasters. These have included the following epidemics:

• Ebola
• Zika
• Avian Flu
• Cholera
• Dengue Fever
• Malaria
• Yellow Fever
• Coronavirus Disease (COVID-19)

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Preparedness

is the step beyond planning, implies a plan is in place, and has been tested: organisations and individuals are clear about their roles and responsibilities.

Types of responders:

In the UK, the Civil Contingencies Act 2004 (CCA) defines two categories or responders, with different roles and responsibilities when planning for and responding to emergencies:

• Category 1 responders are agencies core to civil protection – emergency services, local government, acute hospitals and emergency departments, health service managers, public health agency, the environment agency, maritime and coastguard agency, port health authority
• Category 2 responders have a role to co-operate to support the main effort – utility companies, highway authorities, railway, harbour and airport operators, health and safety executive, primary care organisations
• The military are not categorised here because the Act governs responses to civil emergencies
• Category 1 & 2 responders have a duty to cooperate and share information for the purpose of civil protection.  Category 1 responders have additional duties to put in place emergency plans, business continuity arrangements, arrangements to keep the public informed during emergencies, and to provide advice and assistance to local business and voluntary agencies about business continuity.

National organisational response to emergencies 

(Scientific advice and evidence in emergencies – UK Science and Technology Committee http://www.publications.parliament.uk/pa/cm201011/cmselect/cmsctech/498/49806.htm)

Where there are (or there is the potential to be) more than one emergency response over several regions, a further level of strategic oversight exists in the UK.  The Cabinet Office Briefing Rooms (COBR) takes the strategic lead and is a forum of Ministers and senior officials from relevant Departments and agencies, brought together to make decisions on an emergency response. External representatives and experts are invited to attend COBR meetings as appropriate; discussions are confidential.  COBR should facilitate rapid coordination of the Central Government response and effective decision-making.   In an emergency where a central response is required, a Lead Government Department (LGD) is appointed. The LGD is responsible for ensuring that appropriate plans exist to manage the emergency, for ensuring that adequate resources are available and for leading on public and parliamentary handling. LGDs are also responsible for ensuring they have effective arrangements to access scientific and technical advice in a timely fashion in an emergency.  This may involve establishing a Science Advisory Group for Emergencies (SAGE).

Acronym

M – Major Incident Declared?

E – Exact Location

T – Type of Incident

H – Hazards present or suspected

A – Access – routes that are safe to use

N – Number, type and severity of casualties

E – Emergency services present, and those required

Disaster Response / Relief-

“The provision of emergency services and public assistance during or immediately after a disaster in order to save lives, reduce health impacts, ensure public safety and meet the basic subsistence needs of the people affected”.

Focused predominantly on immediate and short-term needs, the division between this response/relief stage and the subsequent recovery stage is not clear-cut. Some response actions, such as the supply of temporary housing and water supplies, may extend well into the recovery stage. Rescue from immediate danger and stabilization of the physical and emotional condition of survivors is the primary aims of disaster response/relief, which go hand in hand with the recovery of the dead and the restoration of essential services such as water and power . 

Coordinated multi-agency response is vital to this stage of Disaster Management in order to reduce the impact of a disaster and its long-term results with relief activities including :

• Rescue
• Relocation
• Provision Food and Water
• Provision Emergency Health Care
• Prevention of Disease and Disability
• Repairing Vital Services e.g. Telecommunications, Transport
• Provision Temporary Shelter

Disaster Recovery-

Vulnerability of communities often continues for long after the initial crisis is over. Disaster Recovery refers to those programmes which go beyond the provision of immediate relief to assist those who have suffered the full impact of a disaster and include the following activities:

• Rebuilding Infrastructure e.g. Homes, Schools, Hospitals, Roads
• Health Care and Rehabilitation
• Development Activities e.g. building human resources for health
• Development Policies and Practices to avoid or mitigate similar situations in future

How Physiotherapists Can Contribute

The roots of physiotherapy can be traced back to the early 20th century when physiotherapists were involved in the rehabilitation of people affected by war and illness.

Physiotherapists continue to be involved in these situations and are often called on to be part of a humanitarian response. This could include providing support to people in conflict-affected parts of the world, being part of humanitarian response to a natural disaster, or working with people affected by pandemics.

We can advocate to make sure physiotherapists have access to appropriate equipment to work safely and effectively.

Equipment donation

Many World Physiotherapy member organisations and their individual members are involved in programmes as donors or recipients of physiotherapy equipment in different countries.

We have developed an information note, with input from a range of stakeholders (including ADAPT, ICRC, WHO), to help donors and recipients find the best possible solution for the donation of physiotherapy equipment.

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Most kidneys work well to clean the blood and keep the body’s fluids and electrolytes in balance. But sometimes, the arteries of the kidneys can get smaller or become blocked. This can seriously damage this important filtering system. It can limit the blood supply going to and from the kidneys.

Renovascular diseases are diseases of the arteries to the kidneys. High blood pressure and/or kidney failure can result from these diseases.

Renal vascular disease affects the blood flow into and out of the kidneys. It may cause kidney damage, kidney failure, and high blood pressure.

Vascular conditions include:

• Renal artery stenosis (RAS). This is a narrowing or blockage of an artery to the kidneys. It may cause kidney failure and high blood pressure. Smokers have a greater risk of getting RAS. It’s most common in men between the ages of 50 and 70. High cholesterol, diabetes, being overweight, and having a family history of heart disease are also risk factors for RAS. High blood pressure is both a cause and a result of RAS.
• Renal artery thrombosis. This is a blood clot in an artery that supplies the kidney. It may block blood flow and cause kidney failure.
• Renal vein thrombosis. This is the formation of a clot in a vein to the kidney.
• Renal artery aneurysm. This is a bulging, weak area in the wall of an artery to the kidney. Most are small and don’t cause symptoms. Renal artery aneurysms are rare and are often found during tests for other conditions.
• Atheroembolic renal disease. This happens when a piece of plaque from a larger artery breaks off and travels through the blood. This blocks small renal arteries. This disease is becoming a common cause of kidney problems in the older adults.

Renin is a strong hormone that raises blood pressure. Decreased blood flow to the kidney(s) from renal vascular disease may cause too much renin to be made. This can lead to high blood pressure.

types of renovascular diseases

There are two main diseases of the renal (kidney) arteries:

• Atherosclerotic renal artery stenosis (AS-RAS), and
• Fibromuscular dysplasia (FMD)

Atherosclerosis is better known as hardening of the arteries. It is a common disease. Atherosclerosis is the cause of 9 out of 10 renovascular disease cases. It can involve the large and/or small branches of the renal artery. People with diabetes, aortoiliac occlusive disease, coronary artery disease or other forms of high blood pressure are at risk.

The main risk factors for AS-RAS are:

• High blood pressure
• High cholesterol
• Older age
• Smoking
• Diabetes
• Heavy alcohol use or drug abuse

If you have AS-RAS you may have ongoing narrowing of the renal artery. This means that the arteries continue to narrow for many years, even after treatment. Many arteries can become totally blocked. For some people, their kidney shrinks. AS-RAS is seen if you have diabetes or similar problems. This disease can be missed if hypertension or kidney dysfunction doesn’t occur.

Fibromuscular dysplasia (FMD) is a group of vascular diseases that affect the linings of the renal artery. About 10% of AS-RAS cases also have FMD. It is more common in women and people between age 25 and 50. FMD involves the main renal artery and its branches. It looks like beads in the arteries with imaging tests (angiograms). It rarely leads to total artery block, but it is still a problem.

The cause of FMD is not known, though some experts think genetics play a role. Smoking, hormones and disorders of the blood supply to the renal artery may also play a role.

causes

The most common cause of renal artery stenosis is a buildup of fatty deposits called plaque. It can happen in either or both renal arteries. This is often called “hardening of the arteries,” or atherosclerosis. The buildup can narrow the artery and reduce blood flow to the kidneys.

Renal artery stenosis can also be caused by fibromuscular dysplasia. This is a condition in which some of the cells that line the renal arteries grow or don’t develop the right way. This growth can cause the arteries to narrow.

The cause of renal vascular disease will depend on the specific condition involved. The main causes are:

• Atherosclerosis
• Injury
• Infection
• Inflammatory or other underlying disease
• Surgery
• Tumor
• Aneurysm
• Pregnancy
• Certain medicines
• Birth defect

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symptoms

Symptoms of renal vascular disease vary depending on the type of disease and degree of involvement present.

Renal Artery Stenosis

• High blood pressure that doesn’t get better with 3 or more medicines.
• Increased urea (a waste product made by the kidneys) in the blood.
• Unexplained kidney failure.
• Sudden kidney failure when first taking an angiotensin-converting enzyme (ACE) inhibitor for blood pressure and/or heart treatment      

Renal Artery Thrombosis

• Sudden onset of side pain between the ribs and the upper border of the hip bone (flank pain), pain and tenderness
• Fever
• Blood in the urine
• Nausea and vomiting
• Sudden decrease in kidney function
• High blood pressure

A gradual or incomplete clot may not cause symptoms and go undetected

Renal Artery Aneurysm

• There are often no symptoms·     
• High blood pressure
• Tear in aneurysms may cause flank pain and blood in the urine

Atheroembolic Renal Disease

• Skin lesions or red or purple color of the skin.
• Discolored areas of the toes and feet
• Kidney failure
• Belly pain
• Diarrhea
• Confusion
• Weight loss
• Fever
• Muscle aches

Renal Vein Thrombosis

Slow Onset

• Most often causes no symptoms

Sudden Onset

• On-going severe flank pain with spasms at times
• Soreness over the kidney, between the ribs and the backbone
• Decreased kidney function
• Blood in urine    

diagnosis

Duplex Doppler ultrasound.

This test uses sound waves to show how blood flows through a blood vessel. It can show reduced flow of blood through narrow areas in the renal arteries. Computed tomography (CT) angiogram.

This test uses X-rays to provide pictures of the renal arteries. The test uses a special dye that is put into a vein (IV) to make very detailed pictures of the arteries. It can show if the artery is narrowed or blocked. Magnetic resonance angiogram.

This test uses a magnetic field and pulses of radio wave energy to make pictures of the renal arteries. It can show narrowing in the renal arteries that may be causing reduced blood flow. This test allows the doctor to see both the blood flow and the condition of the artery walls. A catheter angiogram of the kidney.

This is an X-ray test that provides pictures of the blood flow in a blood vessel, such as the renal arteries. During an angiogram, the doctor will put a thin, flexible tube into a blood vessel in your groin or arm. This tube is called a catheter. The doctor guides the tube to the blood vessel that will be studied. Then a dye is injected through the tube to make the area easier to see. X-rays or pictures are taken of the area. An angiogram can also show narrowing or a blockage in a blood vessel that affects blood flow. Sometimes a problem can be treated during this test. For example, a catheter can be used to open a narrowed renal artery.

risk factors

Many of the risk factors for renal artery disease are the same as those for atherosclerosis in other parts of the body, such as coronary artery disease and peripheral arterial disease. Risk factors for renal artery disease include:

• age over 50
• diabetes
• high cholesterol
• smoking
• high blood pressure
• a family history of coronary artery disease
• a family hisotry of peripheral arterial disease
• a family history of renal artery disease
• neurofibromatosis.

treatment choices for renal artery disease

In nearly half of patients, untreated renal artery disease gets progressively worse and can lead to kidney failure. In one large study at Cleveland Clinic, obstruction of the arteries progressed in 44 percent of untreated patients; in 16 percent of those, total occlusion occurred. For unknown reasons, women are at higher risk for disease progression than men.

Like treatment for heart disease, there are many treatments available for renal artery disease. The right treatment for an individual depends on the severity of the disease and the person’s medical history.

Medical Therapy

All patients with renal artery disease require treatment for cardiovascular risk factors (such as high blood pressure, high cholesterol, diabetes) and lifestyle changes such as weight reduction, smoking cessation, exercise and a low-salt and low-fat diet. Medication to lower blood pressure is an important part of treatment, along with careful monitoring of the response to the blood pressure medications to be sure the blood pressure is lowered to the treatment goal. Regular follow-up every 4 to 6 months will be part of the treatment plan so your physician can monitor your condition.

Procedures

For some patients with significant narrowing of the renal arteries, particularly patients with narrowed areas in the renal arteries on both sides of the body, or those with severe symptoms, a procedure may be recommended to open up the blocked arteries to restore circulation. In some cases, opening the blocked arteries may improve kidney function and may improve control of high blood pressure. Not surprisingly, the techniques used to open blocked renal arteries are very similar to those used to treat blocked coronary arteries.

Renal angioplasty: A small catheter – a long, thin tube – carrying a tiny balloon is inserted through a small puncture in the groin and guided by X-ray to the kidney artery. When the catheter is guided to the narrowed part of the artery, the balloon is inflated. As it expands, it compresses the plaque against the artery walls, re-opening the vessel for blood to flow through. Once the artery is open, the physician may insert a stent at the site to keep the artery open and support the arterial wall.

In carefully selected patients, renal angioplasty improves blood pressure and kidney function with minimal risk. It can be done as an outpatient procedure or with only an overnight stay, does not require general anesthesia and has a short recovery time.

Surgical treatment: With the development of new and improved types of stents, angioplasty with stenting is the preferred treatment for renal artery disease. But, in certain cases, surgical treatment may be necessary to restore blood flow to the kidney and preserve kidney function.

Surgical treatments for renal artery disease include:

Endarterectomy, during which a vascular surgeon removes the diseased inner lining of the artery and the plaque deposits.

Bypass procedure, which involves using a segment from another artery or vein to construct a detour around the blocked area of the renal artery. The most commonly used technique creates a bypass from the abdominal aorta (the large artery in the abdomen) to the kidney using a segment from the saphenous vein in the leg or the hypogastric artery from the abdomen.

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