Fissure in Ano

What is an anal fissure?

This is a very common Ano rectal disease causing a lot of suffering to the patient. It consist of a tear or a crack in the skin lined part of the anal canal. It usually found in young and middle age people but some times even in children. Though a small crack, the pain and suffering inflicted by it is of great magnitude. Beside, more often than note, it dose not heal permanently and keeps on showing its effects continually or intermittently.

Site

The crack is usually in the midline posterior i.e. in line with the cleft of the buttocks. Occasionally it may be in the front or sides. Some times a little tag, swelling of the skin develops at the edge of the anus. This is could the sentinel tag or Sentinel Piles. This stays even after the fissure heals unless excised.

Very long standing fissure develops hard fibroid tissue. Later on perennial abscess or a anal fistula may form as a complication. Fissure in Ano is also a common cause of anal stenosis / spasmodic anus.

Causes

The causes of fissure are not very clear. Rarely fissure are cause due to some bigger under line problem like chrons, Ulcerative colitis, Tuberculosis, Growths etc. The other main possible region could be trauma to the area due to passage of unusually hard stool. Patients often tend to take laxatives for getting soft watery stool, thinking that this will not cause them pain and will solve the problem. It is true that such patients will note face the problems (Pain, temporarily) avoiding the necessity to expand or starch anal canal / anal orifice, but ultimately this leads to more contractions of the canal. Hence, after some times this patients face difficulty in passing even normally formed stool.

Spasm in the anal sphincter (Valve of the anal canal) and ischemia (insufficient blood supply to the area may be the helping factors in the development of fissure and also in preventing the healing process.

The internal sphincter plays an important role in the development of a fissure. These mussels, controlling the opening of the anus, can not be control voluntarily. Pain due to the fissure will cause spasm of the internal sphincter and not allowed it to relax.

Symptoms:

•  Pain : This is the most predominant symptom of fissure in Ano. It is often describe by the patient as of sharp, cutting searing and tearing nature & is of great severity. The pain is usually during defecation and may last up to three to four hours after defecation. The Pain is so agonizing that the patient dreads his visits to the toilet and tends to avoid passing stool, as a result in some cases remains constipated for several days. This further aggravates the symptoms when he eventually has to pass stool.

Some patient s discover that by passing soft watery stool, the pain can be avoided and develop a habit of tacking laxative / purgatives regularly instead of getting proper medical advise. These patents unknowingly are actually aggravating the problem by worsening the condition of the sphincter.

•  Bleeding : There may be fissures without bleeding but usually the pain is accompanied by bleeding during defecation it is bright red appears as a speak along with the passage of stool. Occasionally it may be profuse-heavy.

•  Swelling : Most patients develop a skin tag ( a lump) due to the swelling of the skin at the site of the fissure

•  Discharge & Purities- Anal itch : Occur usually in chronic cases and leaves the patient very uncomfortable.

•  Urinary problems : Some long standing cases of painful fissure develop disturbances in passage of urine, some times the frequency to urinate is increased whereas in some cases there is retention.

Condition of the Anal Fissure

Fissure can be categories as acute and chronic.

Acute anal fissures are those which have develop recently ( Less than about 5 weeks) these may heal spontaneously .

Chronic anal fissure are comparatively long standing fissure more than 5 to 6 weeks these fissures will usually not heal without professional care.

When to see a Doctor?

When the symptoms persist for more than five weeks or if the pain is sever or the bleeding profuse one should seek medical advice.

Treatment

Self help

Correcting Constipation : Correcting constipation is very essential. It is necessary to setup a regular pattern of passing stools. This can be done by adopting a high fiber diet, not only till the fissure heals bur permanently to avoid recurrence. A high fiber diet may be supplemented by taking bulk forming agent when & where required. (Proctobulk)

Local Anesthetics are effective to reduce patient should not be used over prolong periods.

Sitzs Bath : The best way to reduce pain is a sites bath in simple warm water or warm medicated water (Proctobath)

Conservative treatment of Anal Fissure:

Ayurveda offer conservative treatment for acute anal fissure, for some not so chronic fissures where operative procedure has to be temporarily avoided or prolonged due to various region, for infants and aged patient or where there is risk of surgery / anesthesia.

Classical texts of Ayurveda like Sushruta & Charak etc advocate the use of many herbal combinations both oral & topical for the treatment of Fissure in Ano. In our experience of over 20 years we have taken clinical trials of a number of these combinations and have developed a few very effective combinations to treat this condition.

•  Proctobulk powder - A unique combination of bulk forming herbal agents & other precious herbs that help to establish regular bowel movement. These herbs are also store houses of natural anti oxidants and have Rasayana (rejuvenation & longevity promoting) property

•  Solution Proctorelax (Topical) : This unique Ayurveda formula ( Medicated ghritam) is introduce in to the anal canal ( 15 to 20 ml) daily for 7 to 10 days before going to bed. It helps to heal the anal fissure and significantly reduces the pain & spasm.

•  Proctobath powder / tab (Topical) : This is a time tested Ayurveda - herbal combination slightly modified to suite our specific needs. Added to the warm water for the sits bath it provides quick and significant relief from Pain, burning & swelling in the anal - perennial region. It also helps to check infections, controls discharge and Anal itch -pruritus.

•  Anal dilators : use of anal dilators of varying size is helpful. The dilator is lubricated and gently inserted in to the anal canal ones a day after defalcation & sits bath for 7 to 15 days.

Surgical and Para Surgical Procedures

Anal Dilation : Dilation of the anal canal under anesthesia. This is a short procedure where by anal canal is manually dilated after giving a short acting deep general anesthesia. This is also called Lord's anal dilatation.

Spginchterotomy: This involves cutting the anal sphincter. In some cases the patient may develop partial incontinence (Inability to control wind or stool after surgery. However, in most cases this is a temporary condition and improves with time. Methods of spginchterotomy may vary (internal spginchterotomy, Posterior internal spginchterotomy, Lateral spginchterotomy).

Fissurectomy - Surgical removal of anal fissure

Fissurectomy if done in the conventional way may need hospitalization for a couple of days. Laser Fissurectomy is becoming more popular because of its less sever postoperative problems like pain, bleeding etc. It requires fewer days of hospitalization.