ENTreatment of rectal diseases in Germany starts by establishing which structure is damaged: the lining, the sphincter (the ring of muscle that holds stool in), the pelvic floor muscles or the nerves controlling them. Many people take years to get there: blood in the stool, pain, incomplete emptying and leakage are awkward to talk about, so the visit to a doctor comes late.
This page explains which conditions belong here, how German assessment differs from a quick look and a prescription, what responds without surgery and which operations preserve continence. The specialty as a whole is described under proctology in Germany. A rectal tumour has its own page and is only touched on here.
The conditions people come with
Most patients come with haemorrhoids, covered under haemorrhoid treatment in Germany, or with an anal fissure or fistula. A fissure is a tear in the delicate skin at the edge of the anus; rich in nerve endings, it hurts with every bowel movement, and the resulting sphincter spasm keeps it from healing. An acute fissure often heals once the stool is soft; a chronic one lasts weeks or months, with hardened edges. A fistula is a narrow tunnel from an anal gland to the skin, usually left by an abscess; it almost never closes by itself and keeps flaring up with pain and discharge.
Rectal prolapse means the bowel slips out through the anus on straining. It often comes with descent of the pelvic floor and is a disorder of support, not of the bowel alone: pelvic floor muscles and ligaments hold the rectum, the bladder and, in women, the uterus like a hammock. When it sags, several organs drop, so German teams work on it with gynaecologists and urologists.
The third group is what patients rarely say out loud: a weak sphincter that cannot hold wind or stool, and disordered emptying, when the urge is there but the bowel will not empty. Causes include childbirth, operations, age or pelvic floor muscles that tighten instead of relaxing. Inflammatory bowel disease involving the rectum is managed by a gastroenterologist on its own terms.
How the assessment is done
Assessment moves from simple to complex: a conversation, an examination including one with a gloved finger, a rectoscopy and, as a rule, a full colonoscopy, even when the complaint is low down, because bleeding may come from a polyp or tumour higher up. How colonoscopy in Germany works is described separately.
The second part answers the question of function rather than appearance. Endoanal ultrasound shows whether the sphincter is intact and where a fistula runs; manometry measures how strongly it squeezes and whether it relaxes on straining; defecography or pelvic floor MRI records emptying itself. These tests separate “the bowel prolapses” from “the sphincter does not hold”, which are treated differently.
The written report you take home must give the diagnosis, the state of the sphincter, the plan and the alternatives with their risks for continence. The German guideline on anal fistulas, for example, recommends assessing the sphincter with endoanal ultrasound and allows MRI before surgery for complex and recurrent fistulas.
What responds without surgery
Fissures, disordered emptying and mild incontinence can often be managed without surgery, so German teams do not skip this conservative stage. It starts with stool and diet: fluid, fibre, psyllium if needed, no prolonged straining. In a fissure, sphincter spasm is relieved with relaxing ointments or a botulinum toxin injection. Weak continence calls for a course of biofeedback therapy, where patients watch their muscles on a screen and learn to control them, and pelvic floor training.
This stage is prescribed seriously and for a set period, not as a trial. In fissure and disordered emptying it often removes the need for surgery; if it fails, its result still tells the surgeon what worked and which operation to offer.
Operations: what is done and what is preserved
German proctological surgery is governed by one principle: preserve the sphincter, so techniques that do not cut muscle are preferred. A fistula is laid open only when superficial, because the more muscle is divided, the higher the risk to continence. A high fistula is treated and its inner opening closed with a flap of bowel wall; if inflamed or complex, it first gets a drainage thread and is treated in stages.
Prolapse is operated on in one of two ways. Through the abdomen, usually by keyhole surgery, the rectum is lifted and fixed, sometimes with a mesh. Through the anus, the prolapsed segment is removed or gathered into folds: easier to tolerate, but the prolapse returns more often. The choice depends on age, other illnesses and fitness for abdominal surgery, and on the state of the pelvic floor.
Operations are done in visceral surgery and coloproctology departments, while assessment and conservative care are often led by gastroenterologists trained in proctology. At München Klinik Harlaching, visceral surgery and coloproctology is led by Professor Mia Kim, whose focus includes prolapse surgery, chronic constipation, incontinence, fissures and fistulas. At ISAR Klinikum in Munich the gastroenterology department is headed by PD Dr Holger Seidl, a specialist in gastroenterology and proctology. In Berlin, proctology is one focus of the Department of General, Visceral and Oncological Surgery at Helios Hospital Berlin-Buch, headed by Professor Roger Wahba.
If a tumour is found
If a malignant tumour is suspected, the plan changes to biopsy, staging and a tumour board, and in Germany the decision is not left to one surgeon. Pelvic MRI and CT determine the stage, which decides whether radiotherapy and chemotherapy come before surgery. The patient’s main question, whether the sphincter can be preserved, is answered by the tumour board from the images and biopsy, not by one doctor at the first visit.
How rectal cancer treatment in Germany works and in what order the steps follow is set out on a separate page. Tumour treatment is costed separately; the cost of rectal cancer treatment is explained on its own page.
Frequently asked questions
How are rectal diseases treated?
Rectal diseases are treated by cause, not symptom: the same bleeding can come from haemorrhoids, a fissure, a polyp or a tumour. Haemorrhoids and fissures usually get non-surgical treatment first, then banding, removal or excision if needed. Polyps are removed at colonoscopy, fistulas and marked prolapse are operated on, and tumours follow the tumour board’s plan.
Can an anal fissure heal without surgery?
Often, yes, especially when it is fresh. Treatment rests on soft, regular stools and ointments or suppositories that ease pain and relax the sphincter; persistent spasm may be treated with botulinum toxin. A chronic fissure heals more slowly, so the course runs for a set period under supervision. If it fails, surgery is discussed.
What should you do about bleeding from the rectum?
See a doctor rather than blaming haemorrhoids unexamined. The cause is usually benign, a haemorrhoid or fissure, but a polyp, inflammation or tumour can bleed the same way, so a proctologist examines the rectum and usually arranges a colonoscopy. Do not delay if the bleeding is heavy, you feel weak or dizzy, or your bowel habits change.
How AlenMed arranges treatment
AlenMed reviews your records, colonoscopy results and images remotely, matches a department and sends the request to the hospital. The hospital issues the official cost estimate (Kostenvoranschlag), then the visa invitation follows. A medical interpreter attends consultations, which matters especially here: continence is hard to discuss even in your own language, and diagnosis depends on precise wording.
You take home a written plan, the procedure report, diet and exercise instructions and follow-up dates, so your doctor at home can continue the care.
This material is for information only and is not an offer. The approach is decided by a doctor in person.