Proctology Blog

Anal fissure is the most common cause of severe anal pain. It is seen in all age groups and may affect infants and children too. The pain of anal ulcer is intolerable. It may be so severe that patients may avoid defecation for days together until it becomes inevitable. This leads to hardening of the stools, which further tear the anoderm during defecation, setting a vicious cycle. The fissures can be classified into
1] Acute or superficial
2] Chronic fissure in ano
An anal fissure (fissure-in-ano) is a small, elliptical tear in skin that lines the opening of the anus. Fissures typically cause severe pain and bleeding with bowel movements. Fissures are quite common in the general population, but are often confused with other causes of pain and bleeding, such as haemorrhoids.

chronic-anal-fissure

Most (85-90%) fissures occur in the posterior (back) 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 the back locations
CAUSES OF ANAL FISSURE
It has been proved that constipation is the primary and sole cause of initiation of a fissure. Passage of hard stool, low fibre diet, consumption of spicy and pungent food, faulty bowel habits such as sitting on the commode for a long time, and lack of local hygiene can contribute for initiation of the pathology. In females, the ailment is usually triggered during pregnancy and following childbirth. It occurs as a superficial split in the anoderm that may heal by itself or may progress to a chronic fissure
TREATMENT OF SUPERFICIAL FISSURES:
It has long been recognized that superficial fissures can be cured conservatively.
1. Warm water sitz bath with or without addition of Betadine and rock salt. This treatment soothes the pain and relaxes the spasm of the internal sphincter for some time. This should be carried out several times a day and after each bowel movement.
2. Stool softening is essential as soft and formed stools negotiate the rectum and anal canal in non-traumatic physiologic way. Plenty of oral fluids also help in keeping the stools soft.
3. High-fibre-diet and bulk-forming agents such as Isaphgula; green leafy vegetables and fibrous fruits go a long way in increasing the bulk of stool leading to a smooth and swift act of defecation.
4. Reassurance and encouragement for not resisting the urge for defecation help prevent hard stools. Later the patient could be encouraged to acquire and maintain a regular bowel habit of once or twice a day.
5. Application of local anesthetic cream or gel may help avoid the torture experienced in passage of stools in the patients with acute fissures. Ointments containing xylocaine, and soothing agents can help in relieving pain. These mixtures are introduced on the finger instead of using as suppositories.

TREATMENT OF CHRONIC OR COMPLICATED FISSURES:
The above mentioned approaches do not prove effective in the chronic variety of fissures. These chronic or complicated fissures are not amicable to the simple conservative line of treatment. A definitive therapy is needed to tackle this stubborn problem. The fissure is labelled as chronic or complicated if it does not respond to conservative treatment, if it has associated sentinel skin tag, if the fissure is indurated and associated with fibrous polyp and if internal sphincter fibres are visible in the base of fissure.
Treatment of chronic fissures could be operative or non-operative.
Non-operative techniques
1] Injection of Botulin Toxin: Botulin toxin (Botox) is known to cause paresis of the sphincter. This causes sphincter relaxation for about 3 months, a period which is sufficient for healing of a chronic uncomplicated anal fissure. It is well tolerated and can be administered on an outpatient basis. The healing rate reported is about 79%.
2] Local application of vasodilators: Voasodilator creams such as nitro-glycerine and Diltiazem cause internal anal sphincter relaxation and thereby improving blood flow to the ulcer and promoting healing. It has been proved that chronic anal fissure is ischemic in origin due to poor blood supply and spasm of internal anal sphincter. Headaches during the treatment is major drawback.

OPERATIVE TECHNIQUES
1] Stretching of anal sphincter [Lord’s anal dilatation]:
This was one of the most favoured and accepted methods of treating the anal fissures. The primary cause of attraction for the procedure is its extreme simplicity. Anal dilatation helps in healing of the fissure by reducing the anal canal pressure. If performed with due care by avoiding excessive manipulation, it does not cause any damage to the external anal sphincter as feared. In experienced hands, incontinence of stools or flatus is seldom seen.
2] Division of internal anal sphincter:
Division of internal sphincter fibres to relieve the sphincter spasm is presently considered the preferred therapy for chronic, recurrent and non-healing fissures. Division of internal sphincter could be open sphincterotomy or closed sphincterotomy.
Lateral internal sphincterotomy is the most favoured procedure due to the simplicity of the procedure, minimal anaesthesia requirement and good results.
RECENT ADVANCES:
Recently with advent of surgical Lasers, the CO2 or Diode Lasers are used to vaporize the base of fissure and carry out the sphincterotomy together offer promising results, quick recovery and minimal post-operative pain.

CONCLUSION:
Revisiting the trends of treatment of anal fissures, it can be concluded that conservative treatments with nitro-glycerine, and botulin toxin are effective methods that may reduce the need for anaesthesia and surgery in many of the patients. These could always be offered to the patients who are not willing for operative procedure. Surgical manipulation should be sought in case of recurrence or failure of conservative treatment. However Laser fissurectomy with sphincterotomy should remain the treatment of choice when available.

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