Another thought: hemorrhoids can often manifest as lumps.

"lumps" and skin tags ? there is a big difference I think? lumps I think of well...lumps. but a skintag is like a fleshy growth. I have one near my anus too, I thought it was a hemorrhoid too but it never swells its just there. but when I do wipe a lot it tends to leave a few specs of blood on paper. My GI never said anything about it after the last few scopes. I am going to ask Dr Shen about mine during my next pouchoscopy in July. If it not actually in the anus I wonder why the GI cant just handle it? why the need for a surgeon?

Yes to be clear the dermatologist used the term "tags" but she was uncertain what they were and they feel like bumps.

Scott F, I have never had hemorrhoids but I would think they would hurt? These lumps or "tags" or bumps don't hurt at all. One of them, the bigger of the two, is very slightly sensitive to the touch but when I shower I can vigorously soap and scrub the area with no pain.

i am sure you guys know what I mean when I say that this area just external to my anus in the butt crack has been a HIGH TRAFFIC area for many years, I am 53 years old and have had IBD since age 9 so we are talking major traffic on that skin for 44 years. Never had roids, warts or anything beyond some butt burn mostly right after takedown.

Poucho, mine is not actually in the anus it's just outside of it like on the outer cusp. I never noticed it until very recently when I had the nocturnal seepage. My dermatologist speculated that it's been there for longer than I have noticed. Obviously I am concerned and would be more concerned if it was in the rectum that I felt such bumps but it's outside that area. Although not sure that necessarily is a good sign.

poucho, she said it was too close to the anal sphincter to be messed with by anyone other than a surgeon. And that it should be treated surgically and will not get better although not necessarily bothering me right now. I was given the name of a colorectal surgeon at Yale.

Thanks for your replies.

Hemorrhoids can be completely painless. In any case, a physical exam by an expert generally beats internet diagnosis. I hope no treatment is necessary. 

Well it was examined by a dermatologist and she never once mentioned the possibility of hemerrhoids. She called them "tags" but didn't seem to know what they were. A buddy of mine who has had multiple bouts of roids told me they always hurt and especially when one flexes the anal sphincter. However I feel like I can do about 1,000 anal sphincter kegel exercises right now and be none the worse for the wear. My buddy also mentioned the possibility of internal hemerrhoids that do not hurt. But the dermatologist who examined me didn't mention these possibilities.

I have something just like pouchomarx says, it is fleshy and like a little cluster of skin which my dermatologist has confirmed as skin tag, at the moment I am not so sure as occasionally bleeds when my hemorroids are irritated by being slightly constipated and I feel that underneath this tag is connected to the anus and possibly internal hemorroids. My gastro specialist has had it biopsy and apparently I should not worry about as they told me it is some form of warts but I feel it is getting a bit bigger and more on the way of wiping and washing!! I will have to check it out again as I am not happy about!! Please post more news on this, thank you

Patrizia,

Like you, I have a feeling that whatever they are, they have gotten bigger and more noticeable in the last 4 weeks. Although they are not causing me any discomfort at the moment,either at rest, moving my bowels, wiping, showering or flexing the anal sphincter, my intention is to be very proactive, have a colorectal surgeon look at it ASAP as I was recommended to do, and treat it. I hope it's a benign "tag", but given my dysplasia and thyroid cancer histories, it would be foolish to not have it biopsied and confirmed one way or the other. This is what I am working on doing right now.

Hello, CTBarrister.

Google "anal sentinel piles" or "anal sentinel tags". You might find more information on this, and pictures if you search images. I had one after my takedown last year. It was irritated because of frequent burning BMs in those early days, and it worried me too because of my cancer. But it settle down to nothing, it doesn't ever hurt or bother me. My surgeon examined and said if it doesn't bother me then just leave it because surgically removing it could cause permanent incontinence. Each case is different, and my situation was not troubling me. It only pops up (or out) if I have pouchitis or hard BM.

I am confused on this, if it is on the outer rim of the anus, how could removing it cause incontinence? I could see removing from inside anus.

Poucho,

Its external to but very close to the anal sphincter.

Winterberry, thanks for your information. However the dermatologist told me it will not go away, shrink or reduce in size. I don't want it getting bigger.

I have an appointment with a colorectal surgeon at Yale for consultation on this issue Tuesday April 4 at 9:30 am thankfully. I will have answers soon!

Winterberry,

I did the Google search you mentioned and it took me to a page on fissures - which might be another name for anal skin tag. I should note that I have had a J pouch for 25 years now (my takedown was in July 1992) and in those 25 years never once had any anal skin or bump issues, other than a short period of butt burn after takedown. The other thing I should mention is that the 2 week or so bout of nocturnal seepage I had in February was the longest stretch of nocturnal seepage I have ever had in those 25 years. That being said, my J pouch function has been pretty good since I have been taking Remicade (the past 1.5 years). 

I should also note that today when wiping after BM noticed some bleeding and the area is getting a little tender. So I am now concerned not just with possible cancer but the worsening of this situation into one that produces discomfort and/or pain.

I will post an update Tuesday after I see the colorectal surgeon. A fissure is what I could be dealing with. I just want it treated at this point. 

Here is a link I found with information on anal tags, or sentinel tags. I hope it is useful. Hopefully your tag is only a result of internal fissure or hemorrhoid.

http://www.hemorrhoid.net/fissure.php

Winterberry- thanks for the link! A word that is used to describe a anal fissure is "painful", and that is the one thing that doesn't fit with what I have. I can't feel it all except when I touch the two lumps. One is slightly tender to the touch but less than a not so bad pimple. It's really not giving me a discomfort problem- so far. 

So I saw a colorectal surgeon at Yale this morning and he thinks I am dealing with an anal fistula. He told me it's not a good idea to surgically treat it because of the area in which it's located and possible incontinence resulting from surgery. He has referred me back to my gastroenterologist to further treat it.

Have any of you had anal fistulas? How are they treated? Will it go away with treatment or possibly on its own?

CT, you said you had two lumps?, does he think you have two fistulas? Do you have Crohns? Fistulas don't typically resolve on their own. Sometimes biologics can help but you are already on Remicaide you said? You should probably get an MRI or CT scan to get a better grasp on where this fistula is coming from. So did he say that the drainage/leakage you had that this is the actual fistula draining? I am confused why he referred you to a GI since I don't think a GI could do anything for a fistula. keep us posted my friend

Poucho,

To answer your questions he said one of the lumps looks like a tag and the other one which is bigger looks like an anal fistula. He asked me about whether there was drainage. I have no idea. I had nocturnal seepage right around when I first noticed these which I assumed was stool in my underwear. I did not conduct a chemical analysis of it, just assumed it was stool so I don't know if it was stool or stool and drainage from the fistula.

i am in fact on Remicade and antibiotics and I am being referred back to my GI to evaluate that treatment plan and perhaps to scope me as well to assess how the Pouch looks. If I am getting fistulas then we may re-evaluate and re-assess the treatment plan but I am sure he will want to scope me and I am seeing him April 17 or possibly sooner if he resolves some personal issue he is having which is causing him to be away right now.

The colorectal surgeon I was sent to is a general colorectal surgeon and he indicated if surgery is ultimately necessary (1) there is a J Pouch surgeon at Yale more specialized in these issues than he is, (2) it's a highly complicated surgery, and (3) there is a risk of incontinence from any surgery due to the location of the fistula and the pre-existing weakness of the anal sphincter due to the J Pouch surgery. So for all of the above reasons he wants my GI to see me and determine the next step.

I would have seen my GI already except as I noted earlier  I was certain it was a wart issue based on my history. My self diagnosis was proven incorrect. Obviously because it's near my anus I can only feel it and not see it, and because it wasn't hurting me I deduced it was a wart caused by moisture from the bout with nocturnal seepage. I never had any issues like this before in the Perianal area so I didn't know what I was dealing with.

So I will post after my GI sees me but looks like I am headed for a scope which I am due for anyway, and possibly a new biological drug (he had mentioned Entyvio as being a "pinch hitter" for Remicade, if it ever proved Remicade wasn't working, so we shall see if that happens).

The colon rectal surgeon I go to at Yale is Dr.  Reddy.  I believe   that one of the guys my husband works with may have gone to him for this very issue.  My experiences with him so far have been very good.

CTB23,

Dr. Reddy is in fact the specialist that was referred to above by the general colorectal surgeon. Reddy is "the J Pouch guy." J Pouch guys and regular colorectal surgeons are two different species of surgical animal. I guess sort of like cheetahs and Jaguars, both big cats but different. I have heard good things about Dr. Reddy too, but hopefully his involvement will not be necessary because the location of this fistula and my prior history make any surgery in this area possibly dicy.

I now worry a bit cuz I also have a little tag above the anus, its been there for awhile and I am sure Remzi and Shen have seen it before I think. when I wipe a lot it gets irritated and I get a dot of bright red blood on toilet paper from it. As far as I know its never drained anything but hard to know 100% because I in fact have had some very minor leakage since I have had this second jpouch hooked up.I was told this could be a complication from the second pouch and also the mucosectomy. I was having leakage with my ileostomy as well before I was connected again a year ago. But In May I had a pouchoscopy and nothing was noted and I had a MRI this past September for some lower back pain that has been on and off since my new pouch was made. The MRI was clean as well.  I am scheduled for my annual scope with Shen in July so I will verify it with him.

CTBarrister,

Hope all goes well and surgery is not necessary.  

Sorry to hear this news, CT. I am a jooucher who developed an anal fistula. A general surgeon operated with a traditional "lay open" procedure, and I was rendered incontinent. Do tread carefully. It sounds like you are in good hands-I wish you the best-

I feel a bit like  Pouchomarx! Good to see all the comments, thank you. I understand it might be a good idea to see my original Jpouch surgeon as he is still at it!! Maybe I should send him a picture of my so called tag/wart???Best wishes to all. 

Thanks for all the replies. Your collective responses have been very helpful to me.

I have an appointment with my GI doctor on April 17. He is away from his practice at the moment dealing with a personal issue but may be back next week and if so my appointment will be moved up. I will report back after I see him.

I just want to add that in retrospect and thinking about the timeline of events and how I feel right now I strongly believe that the Remicade is wearing off at the 6 week mark and then I am deteriorating and it was the late cycle deterioration that led to this fistula. My last Remicade infusion was February 20 and I am on a 8 week cycle. It was just before that infusion that I had the 2 straight weeks of nocturnal seepage and then after the infusion I was fine again. Now it's April 5 and I feel like I am deteriorating again. I am trying to get an infusion scheduled this week.

i reported all of this to my GI in November - that Remicade was losing its effectiveness in the last 2 weeks of each infusion cycle - but he said stick with it until spring and we will scope you. I think it's on me for not calling and complaining in February when I had the 2 straight weeks of nocturnal seepage which was for me unprecedented. If it continued I would have, but then I got infused and felt better and boom, the seepage stopped. However the appearance of this fistula perhaps indicates the extent of the deterioration I had at the end of the last Remicade cycle.

so CT, do you have Crohns? and what is the cause of the seepage to begin with and was that the reason you started Remicaide to begin with?

Yes I have Crohns. The cause of the stool seepage is inflammation of the J Pouch. Inflammation of the J Pouch (and of the ileum above the J Pouch) which was not being controlled by antibiotics was the reason for starting Remicade November 2015. I should note I periodically had nocturnal seepage when I flared for years, but never anything as consistent as that two week stretch in February.

Since 1994/1995 antiobiotocs have controlled my symptoms but I have always had chronic inflammation of the pouch. Whether we call it pouchitis or Crohn's IMHO is irrelevant. Either way It has to be treated and the treatments are the same, so diagnosis is not really significant except to insurance companies who pay for the treatment and want to latch on to something they understand.

MRIs are used to detect fistulas. Fistulas do not close on their own. They often require placement of a seton drain because if the fistula doesn't drain properly, an abscess will form. This too might be what your feeling, the beginning of an abscess. And because you are on antibiotics, you might not feel the discomfort just yet. Perhaps while you are waiting to see your GI doc, you ask the on call doc if you can schedule an MRI bc you suspect a fistula. Good luck

My appointment was moved up to April 12 next week so not long now. I will ask my doctor if an MRI is indicated after he examines me. I would prefer he examine me before anything gets ordered or changed. The other two specialists I have seen were uncertain what I am dealing with and a fistula was the speculation of the colorectal surgeon but he said have the GI examine and go from there.

brewbirds thanks for your info I will keep this in mind to discuss with him.

I  also discovered a tag a few months after J-pouch surgery due to UC.  I asked my surgeon he said it was a tag not worry about it,  that was 6 years ago.  The only time it bothers me is when I have a problem with pouchitis or but burn from something that I ate.  It hasn't gotten any bigger.  You still should check it out.

Fistula owner since 12/12/12. Seton owner since 3/2013. 

If you have questions, feel free to message me. 

GraceB posted:

I  also discovered a tag a few months after J-pouch surgery due to UC.  I asked my surgeon he said it was a tag not worry about it,  that was 6 years ago.  The only time it bothers me is when I have a problem with pouchitis or but burn from something that I ate.  It hasn't gotten any bigger.  You still should check it out.

where exactly is your tag? does it bleed when irritated? mine is small right above my anus. whenever I wipe a lot it leaves a dot of blood on paper and gets a little sore. I don't ever notice it gets any larger and I think its been there for awhile but surgeon or GI never mentioned it ever?? I will ask again when I have my annual pouchoscopy in July

Hi all,

Just going to throw in my experience with skin tags and fistulas. Soon after my j pouch surgery for UC, I got a skin tag. The surgeon didn't care about it at all until it got bigger and then I started having problems with fissures. I had surgery to remove the skin tag and it was horribly painful (not sure how something that little caused so much pain) only to have it just come back again. Later in the life of my pouch, I had what looked like a possible fistula so the surgeon re-did the bottom of my pouch and removed the skin tags (by this time they multiplied!) and the skin tags came back again. A few years later, I developed 2 perianal fistulas which led to abscesses all within the same week. The abscesses had to be drained and setons had to be placed. The discomfort of a skin tag was way different than the PAIN from the abscesses caused by the fistulas. My diagnosis was then changed to Crohn's b/c of all this drama! I realize we are all somewhat different but I would make sure any skin tag HAD to be removed before getting that baby chopped off. 

LORI726 posted:

Hi all,

Just going to throw in my experience with skin tags and fistulas. Soon after my j pouch surgery for UC, I got a skin tag. The surgeon didn't care about it at all until it got bigger and then I started having problems with fissures. I had surgery to remove the skin tag and it was horribly painful (not sure how something that little caused so much pain) only to have it just come back again. Later in the life of my pouch, I had what looked like a possible fistula so the surgeon re-did the bottom of my pouch and removed the skin tags (by this time they multiplied!) and the skin tags came back again. A few years later, I developed 2 perianal fistulas which led to abscesses all within the same week. The abscesses had to be drained and setons had to be placed. The discomfort of a skin tag was way different than the PAIN from the abscesses caused by the fistulas. My diagnosis was then changed to Crohn's b/c of all this drama! I realize we are all somewhat different but I would make sure any skin tag HAD to be removed before getting that baby chopped off. 

how did you find the fistula? was it internally and you were having issues and it was found on an MRI? And what do you mean the surgeon redid the "bottom" of the pouch? did he do a pouch advancement surgery because of the fistulas? were they from the pouch to the perianal area?  so was the skin tag a totally separate issue from the fistulas? or are you saying the complications from removing the skin tag causes the abcesses that in turn caused the fistulas? sorry I am just trying to understand what you are saying..

Sorry to confuse you! They were 2 completely separate issues. The skin tags were not related to the fistulas at all! I had my pouch formed in 1992 so it had gone through many years of usage until I had a temp (99 percent sure he will become permanent ileo) formed Oct 2015. I saw people were talking about tags and fistulas so I commented on both since I had experiences with both. I will break them up.

1. Skin tags. I commented on making sure removal is necessary b/c it was PAINFUL (and yes this is still my opinion after having multiple surgeries cutting open my abdomen) and each time my skin tag(s) returned so that procedure now seems that it was unnecessary to me. The first time I had the skin tag removed, it was because my surgeon thought it might be contributing to a fissure that I had. That skin tag came back and multiplied and no fissure ever occurred again b/c of those skin tags. The second time was because of a presumed fistula when he re-did the bottom of my pouch and wanted to "clean everything up". Skin tags returned again and are probably still there. Onto #2....

2. Fistulas. In about 2010, I started having problems with urgency/frequency and iron deficiency anemia. My surgeon diagnosed me with a fistula during an office exam-he could see drainage from a tract. He did a fisulotomy which involved re-doing the bottom of my pouch but I didn't lose any sphincter control. I don't think that this was a "pouch advancement" surgery. He literally cut out the fistula and re-stapled my pouch. I was so desperate to feel better that I would have done anything at that point. My diagnosis was soon changed from UC to Crohns and I started the biologics (remicade, humira, cimzia) with remicade working the best but I had to stop b/c of the antibodies/lupus like reaction after about 2 years. Uggghhh. While on cimzia in 2015, I developed an abscess on a Monday as a result of an unknown fistula, had it drained, and developed another or an extension of 1st fistula by Friday with another painful abscess. I had that abscess drained and setons placed. 

Looking back, I guess 2010 was the start of the end for my J pouch when my UC diagnosis was changed to Crohns. Should I have questioned things more-absolutely! I really trusted my surgeon and have only stopped going to him b/c of insurance coverage. Ugggghh to that too. I don't want to sound like the voice of doom. I would still repeat my surgery to get my J pouch in a heartbeat b/c it gave me a more normal way of living while I was younger. The majority of my problems have been peri-anal so this may just be the result of how my disease progressed. In comparing skin tag "bumps" and fistula "bumps" there was no comparison in the end for me. The skin tags were a minor irritation every now and then while those fistula abscesses were a whole elevated level of discomfort. Some fistulas drain and don't cause abscesses so I think a diagnostic procedure (MRI?/CT enterography?) would be needed to diagnose them. I don't think a surgeon would be able to say 100 percent that a fistula won't lead to an abscess so I think that is where the need for setons come in.

Sorry this is sooooo long. Please let me know if anything else doesn't make sense. Ironically my husband (who is older than me) had his first colonoscopy today so I am beat from having to get up so early!!

Best of luck to you all and rock on J pouchers����

Hi everyone,

I saw my gastroenterologist this morning who examined the two lumps and he said one looks like a fistula and one looks like a skin tag. He ordered an MRI on my pelvis, changed my Remicade dosage, changed my antibiotic treatment, and gave me a kit to give the blood laboratory to examine my  Remicade level one week before the next infusion which is May 25, in order to determine that I am maintaining a therapeutic Remicade level from infusion to infusion.

He said that if the MRI confirms the fistula, no other treatment would be necessary and it's a "non issue" because it's not precancerous or cancerous, it's closed and not actively draining, and is not fluculent and is not causing me any pain or discomfort. He also said it's small. So I guess it is sort of like an inactive volcano. But one wonders whether over time it will erupt again. He thinks it's fully drained and I will not need a seton because it appears to be closed but he will get an MRI to know for sure.

Thanks to Lori for explaining clearly the two issues and thank you Barrister. I am glad the problem is less serious though as you say a possible volcano!! Will the specialist let you know what best to do and/or avoid eating in order to prevent any more similar problems??  I feel that certain type of food specially the ones which are a bit more difficult to digest, seems to cause me more constipation which inflames the area of the anus, hemorroids and tags get swollen and bleeding but recently I discovered that using a daily spoon of olive oil after breakfast has been  helping  a lot.

Best regards

Patrizia,

My GI Doctor did not mention diet at all. He thinks the treatment regimen needed to be fine tuned.  We both suspect that I am lagging with the 8 week infusion schedule so my Remicade schedule was increased from every 8 weeks to every 6 weeks and he also rotated me onto old friend Xifaxin and wrote the scrip for IBS/diarrhea so that insurance company will authorize. Anyway this all seems to be a byproduct of IBD and I just have to deal with it going forward. I should stress that I don't have any seepage or incontinence issues and no physical discomfort although I notice these lumps when I shower. It could be worse.

I finally had the MRI on my pelvis at Yale on May 3, 2017. It was negative for an anal fistula or abcess. So it turns out that these two lumps are just benign skin tags which are not bothering me, even though I can feel them. I think it's weird that I just noticed them appear out of nowhere. The GI doc said they could be related to the skin being irritated in the anal area, which makes sense as I only noticed them after the 2 week episode of nocturnal fecal incontinence in February.

Yay! Awesome new!!