WHAT IS AN ANAL FISSURE?
An anal fissure (fissure-in-ano) is a small tear in skin that lines the opening of the anus. Fissures typically cause severe pain and bleeding with bowel movements. Fissures are quite common but are often confused with other causes of pain and bleeding, such as hemorrhoids.
Anal fissures can occur at any age and have equal gender distribution. Most (85-90%) fissures occur in the back of midline of the anus with about 10-15% occurring in the anterior (front) midline. A small number of patients may actually have fissures in both the front and back locations.
WHAT ARE THE SYMPTOMS OF AN ANAL FISSURE?
The typical symptoms of an anal fissure include pain and bleeding with bowel movements. Patients experience severe pain during, and especially after a bowel movement, lasting from several minutes to a few hours. Patients often notice bright red blood from the anus that can be seen on the toilet paper or on the stool. Between bowel movements, patients with anal fissures are often relatively symptom-free. Many patients are fearful of having a bowel movement and may try to avoid defecation secondary to the pain. Also, it is a common observation that patients restrict his or her food intake during an acute attack. This in fact leads to hard stool formation resulting in more injury to mucosa & causing mare pain & delayed recovery.
WHAT CAUSES AN ANAL FISSURE?
Fissures are usually caused by trauma to the inner lining of the anus. A hard, dry bowel movement is typically responsible, but loose stools and diarrhea can also be the cause. The inciting trauma to the anus produces severe anal pain, resulting in anal sphincter spasm and a subsequent increase in anal sphincter muscle pressure. The increase in anal sphincter muscle pressure results in a decrease in blood flow to the site of the injury, thus impairing healing of the wound. Ensuing bowel movements result in more pain, more anal spasm, diminished blood flow to the area, and the cycle is propagated. Treatment strategies are aimed at interrupting this cycle to promote healing of the fissure.
Anal fissures may be acute (recent onset) or chronic (typically lasting more than 8-12 weeks). Acute fissures may have the appearance of a simple tear in the anus, whereas chronic fissures may have swelling and scar tissue present. Chronic fissures may be more difficult to treat and may also have an external lump associated with the tear, called a sentinel pile or skin tag, as well as extra tissue just inside the anal canal, ( hypertrophied papilla.)
Quite commonly, anal fissures are misdiagnosed as hemorrhoids by the patient. This delay in diagnosis may lead to an acute fissure becoming a chronic one and, thus, more difficult to treat. Misdiagnosis of an anal fissure may also allow other conditions to go undetected and untreated, such as serious infections or even cancer. There are rare medical conditions that can cause fissure in ano which the surgeon can easily differentiate.
WHAT IS THE TREATMENT OF ANAL FISSURES?
The majority of anal fissures do not require surgery. The most common treatment for an acute anal fissure consists of making one’s stool more formed and bulky with a diet high in fiber as well as utilizing the fiber supplementation (totaling 25-35 grams of fiber/day). Stool softeners and increasing water intake may be necessary to promote soft bowel movements and aid in the healing process. Topical anesthetics, such as lidocaine, in combination with nifedipine/diltiazem, can be used for anal pain and warm tub baths (sitz baths) for 10-20 minutes several times a day (especially after bowel movements) are soothing and promote relaxation of the anal muscles, helping the healing process. Another medication depends on case to case basis determined by the surgeon.
Other medications may be prescribed, when a patient has a more chronic-type fissure, that promotes relaxation of the anal sphincter muscles. Your surgeon will go over the benefits and side-effects of each of these with you. Chronic fissures are generally more difficult to treat, and your surgeon may advise surgical treatment either as an initial treatment or following attempts at medical management.
WILL THE PROBLEM RECURE?
Fissures can recur easily, and it is quite common for a fully healed fissure to recur after a hard bowel movement or other trauma. Even when the pain and bleeding have subsided, it is very important to continue good bowel habits and a diet high in fiber as a lifestyle change. If the problem returns without an obvious cause, further assessment may be warranted
WHAT CAN BE DONE IF THE FISSURE DOES NOT HEAL?
A fissure that fails to respond to conservative measures should be re-examined. Persistent hard or loose bowel movements, scarring, or spasm of the internal anal muscle all contribute to delayed healing. Patients suffering from persistent anal pain should be examined to exclude other causes of the diseases. This may include a colonoscopy and an exam in the operating room under anesthesia with biopsies
WHAT DOES SURGERY FOR ANAL FISSURE INVOLVE?
Surgical options for treating anal fissure include Botulinum toxin injection into the anal (Not practiced widely in India.)
GOLD STANDARD SURGICAL TREATMENT FOR FISSURE IN ANO.
LATERAL INTERNAL SPHINCTEROTOMY
Precise and controlled division of the internal anal sphincter muscle is a highly effective and commonly used method to treat chronic and refractory anal fissures, with success rates reported to be over 90%. Recurrence rates after sphincterotomy are exceedingly low when properly performed by a surgeon. The surgery is performed as an outpatient, same-day procedure. The main risks of internal sphincterotomy are variable degrees of stool or gas incontinence. If any incontinence is present after surgery, it may resolve over a short time period. Patients undergoing sphincterotomy have a much-improved quality of life as compared to patients with persistent anal fissures.
We at our center will go over each of the potential risks and benefits of sphincterotomy and will decide if this procedure is right for you.
The lat sphincterotomy performed by LESER beams leads to precision apart from less or no pain
HOW LONG IS THE RECOVERY AFTER SURGERY?
It is important to note that complete healing with both medical and surgical treatments can take up to approximately 6-10 weeks. However, the severity of acute pain after surgery often disappears immediately after surgery. You may have some incontinence for stools or gases for 2 to 3 days.
IN THE NUTSHELL SURGERY FOR FISSURE IN ANO IS DAY CARE PROCEDURE WITH INSTANT RELIEF FROM SEVERE PAIN & WITH DISCOMFORT LASTING for 3 TO 4 DAYS ONLY.
CAN FISSURES LEAD TO COLON CANCER?
Absolutely not. Persistent symptoms, however, need careful evaluation since other conditions other than an anal fissure can cause similar symptoms. Your colon and rectal surgeon may request additional tests, even if your fissure has successfully healed. A colonoscopy may be required to exclude other causes of rectal bleeding.