ANAL FISSURE

Why do anal fissures occur?

Fissures can occur at any age, but most commonly occur in young children and adults. Many fissures occur for no particular reason. However, direct trauma to the area may be a factor in many cases. Anything that can cut or irritate the inner lining of the anus can cause a fissure. Most commonly constipation leading to a hard, dry bowel movement may cause a fissure.
Other causes of a fissure include diarrhoea or inflammatory conditions of the anal area. Fissures may also develop after delivery of a baby (post partum). Anal fissures may be acute (recent onset) or chronic (present for a long time or recurring frequently). Chronic fissures often have a small external lump associated with the tear called a sentinel pile or skin tag. This is commonly mistaken for standard piles or haemorrhoids.

What are the symptoms of an anal fissure?

The symptoms of a fissure are pain, especially when passing a bowel motion, and some bleeding. Occasionally, people experience discharge of an abscess in association with a fissure. Fissures are quite common, but are often confused with other causes of pain and bleeding, such as piles or haemorrhoids. Patients may try to avoid defecation because of the pain.

How is an anal fissure treated?

Often treating the constipation or diarrhoea can cure a fissure. An acute fissure is usually man-aged with dietary changes and local creams (non-operative treatments) which heals more than 90% of acute fissures. At least 50% of fissures heal either by themselves or with simple measures. A high fibre diet, bulking agents (fibre supplements), stool soften¬ers, and plenty of fluids help relieve constipation, promote soft bowel movements, and aide in the healing process. Increased dietary fibre may also help to improve diarrhoea. Warm baths for 10-20 minutes several times each day are soothing and promote relaxation of the anal muscles, which can also help healing. Occasionally, special medications may be recommended. A chronic fissure may require additional treatment.

A number of specific creams have come on the market over the last few years. These have been designed to reduce the spasm within the anal sphincter and can heal up to 80% of fissures. Some fissures, if they do not respond to these methods, may require an operation. The most commonly used ointments are:

• Rectogesic: (0.4 per cent GTN -(glyceryl tri-nitrate)). This may cause headaches if not used according to instructions. An information sheet on using GTN ointment for anal fissure is available here. Additional information is available on NHS choices website
•   Anoheal (2% diltiazem cream). This is better tolerated although some patients develop skin irritation with the cream. An information sheet on using diltiazem cream for anal fissure is available here.

How successful is non-operative treatment for anal fissure?

Fissures can recur easily, and it is quite common for a healed fissure to recur after a hard bowel movement. Even after the pain and bleeding has disappeared one should continue to aim for good bowel habits and adhere to a high fibre diet or fibre supplement regimen. If the problem returns without an obvious cause, further assessment may be needed.

What can be done if a fissure doesn’t heal?

A fissure that fails to respond to treatment should be re-examined. Persistent hard or loose bowel movements, scarring, or spasm of the internal anal sphincter muscle all contribute to delayed healing. Other medical problems such as inflammatory bowel disease, infections, or anal growths (skin tumours) can cause fissure like symptoms and patients suffering from persistent anal pain should be examined to exclude these conditions.

What types of operation are performed for anal fissure?

An operation may be necessary in order to get a more detailed look at the fissure and possible take a biopsy. This is called an Examination under Anaesthesia (EUA). Your colorectal surgeon may also recommend additional measures including injection of the anal sphincter with Botox. This relaxes the anal sphincter muscle and may heal up to 85% of fissures. The effect is transient (8-12 weeks) and of course, the patient may get a recurrent fissure once the drug has worn off. It is therefore important to keep the stools soft and avoid constipation, even after a fissure has healed.

Persistent fissures may require a lateral internal anal sphincterotomy. This is a highly effective treatment for a fissure and recurrence rates after this type of surgery are low. Surgery usually consists of a small operation to cut a portion of the internal anal sphincter muscle (a lateral internal sphincterotomy). This is a fairly minor operation and most cases can be performed as a day case without the need to stay overnight. This sphincterotomy operation helps the fissure heal by decreasing pain and spasm which improves the blood supply to the skin.

A small percentage of patients who undergo a sphincterotomy may find impaired control of the bowel motions after operation (minor faecal incontinence). Surgery is not therefore usually performed without first trying non-operative measures. Your colorectal specialist may also wish to perform specialised ultrasound scan and pressure test on the muscles of the anus (back passage) first before considering sphincterotomy. These are performed in order to be certain that the muscles are functioning normally prior to considering a sphincterotomy.

Other operations, less frequently performed, include anal stretch or anoplasty. If a sentinel pile is present, it too may be removed to promote healing of the fissure. This may be combined with either injection with Botox or sphincterotomy.

What are the complications of surgery for anal fissure?

A small number of patients who undergo injection of the anus with Botox may experience transient weakness in the sphincter muscle and some incontinence of stool.

As discussed above, sphincterotomy also infrequently may interfere with one’s ability to control bowel movements. Patients who have had previous anorectal surgery or women who have sustained a preceding injury to the anal sphincter during childbirth may be at increased risk of these problems.

Surgery is generally very safe. However, all surgical treatments do have other risks, and your colorectal specialist will address these with you.

How long does the healing process take after surgery for anal fissure?

Complete healing occurs in a few weeks, although pain often disappears after a few days.

What an Ayurveda surgeon does?

Taking only oral medications may helps in some patients if fissure is of recent orogin. Final and permanent remedy for this is again kshara karma. Under local anesthesia application of kshara to fissure bed. This burns the part mildly without damaging much tissue. So that fresh wound is created which heals faster. Agni karma follows this, senile pile excised and sphincterotomy is adopted to prevent recurrence. Intermittent anal dilatation to be done after the procedure in further follows up.

How this is advantageous?

This is advantageous than conventional surgery because – instead of excision of tissue (is done during fissurectomy) kshara is applied. Post operative pain is less. Recovery is fast. Less chance of recurrence, less cost.