What are anal fissures ?
An anal fissure is a cut or tear occurring in the anus that extends upwards into the anal canal. Fissures are a common condition of the anus and anal canal and are responsible for 6 – 15% of the visits to a colonic and rectal (colorectal) surgeon. They affect men and women equally and both the young and the old. Fissures usually cause pain during bowel movements that often is severe.
Causes of anal Fissure
Either extreme constipation or diarrhea, usually combined with nervous tension over a prolonged period of time, may produce anal abrasions, simple slit-like fissures, or acute ulcers at the anal verge. With constipation, this condition is usually caused by the passage of a hard dry stool that tears the anal lining upon defecation. With diarrhea, this condition is usually caused by an over use and over-wiping of an inflamed anal canal. In some patients, the anal fissure doesn’t heal and becomes a painful sore that is constantly re-injured or torn with each bowel movement.
What are the symptoms of anal fissures?
Patients with anal fissures almost always experience anal pain that worsens with bowel movements. The pain following a bowel movement may be brief or long lasting; however, the pain usually subsides between bowel movements. The pain can be so severe that patients are unwilling to have a bowel movement, resulting in constipation and even fecal impaction. Moreover, constipation can result in the passage of a larger, harder stool that causes further trauma and makes the fissure worse. Bleeding in small amounts, itching (pruritus ani), and a malodorous discharge may occur due to the discharge of pus from the fissure.
Diagnosis can be made by inspection. Closer inspection will frequently reveal a tag or sentinel pile. After gentle separation of the skin of the anal verge, the ulcer usually posterior can be seen. Frequently the fibers of the internal anal sphincter muscle can be seen at the base of this punched- out ulcer. A colonoscope or sigmoidoscope exam might be useful to out abscesses, colitis, and other causes of rectal bleeding.
How are anal fissures treated?
The purpose of the treatment for and fissures is to break the cycle of spasm of the anal sphincter and its repeated tearing of the anoderm.
General treatment. In acute fissures, medical (nonoperative) therapy is successful in the majority of patients. Of acute fissures, 80 – 90% will heal with conservative measures as compared with chronic (recurrent) fissures, which show only a 40% rate of healing. Initial treatment involves adding bulk to the stool and softening the stool with psyllium or methylcellulose preparations and a high fiber diet. Additionally, patients are advised to avoid “sharp” foods that may not be well-digested (i.e., nuts, popcorn, tortilla chips), increase their liquid intake, and, at times, take stool softeners (docusate or mineral oil preparations). Sitz baths (essentially soaking in a tub of warm water) are encouraged, particularly after bowel movements, to relax the spasm, to increase the flow of blood to the anus, and to clean the anus without rubbing the irritated anoderm.
Anesthetics and steroids. Topical anesthetics (e.g., Xylocaine, lidocaine, tetracaine, pramoxine) are recommended especially prior to a bowel movement to reduce the pain of defecation. Often, a small amount of a steroid is combined in the anesthetic cream to reduce inflammation. The use of steroids should be limited to two weeks because longer use will result in thinning of the anoderm (atrophy), which makes makes it more susceptible to trauma.
Nitroglycerine has been shown that a local application of topical nitrates reduces anal sphincter pressure and improves nitrates reduces anal sphincter pressure and improves anodermal blood flow. This dual effect results in fissure healing in more than 80% of patients. The principal side effect is headaches in 20% – 100% of cases.
Botilinum toxin has also been shown that local a local injection of botulinum toxin near the fissure. Fissure healing occurs in more than 60% of patients. The principal side effect is incomtinence of flatus and or feces, which last for up to two months in 2% to 21% of cases.
When surgical excision is required, the chronic fissure along with the sentinel pile, papilla, and adjacent crypts are dissected free from the underlying muscle. Associated internal and external hemorrhoids are removed. Usually the scar tissue in the posterior anal quadrant is completely denuded.
Lateral partial internal sphincterotomy has been utilized for uncomplicated fissures. This surgery consists of a small operation to cut a portion of the anal muscle. This helps the fissure to heal by preventing pain and spasm, which interferes with healing. Cutting this muscle rarely interferes with the ability to control bowel movements.
At least 90% of patients who require surgery for this problem have no further trouble from fissures. More than 95% of patients achieve prolonged symptomatic improvement. About 5% of patients with fissures are “chronic Fissure formers”, and for a variety of reasons (i.e., chronic constipation, failure to heal without scar tissue, etc.), will continue to develop new fissures despite all the efforts of medical and surgical treatment.
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