Painful linear tears develop in the distal anal canal are called anal fissures. It involves both the epithelium and the full thickness of the anal mucosa. They can develop both in men and women. There are several non-traumatic diseases that can cause anal fissures but the predominant cause is considered to be trauma due to the passage of hard stools. It is a common occurrence and healing is rapid without any manifestations of long-term sequelae. Progress is acute in individuals with intrinsic internal sphincter abnormalities such as hypertonicity and hypertrophy. This leads to elevated resting pressures of the sphincter.
The main causes of anal fissures are associated with trauma due to bowel movement and repeated episodes of hard stool or diarrhoea.
Signs And Symptoms
- Anal pain that worsens bowel movements
- Brief or long-lasting pain after defecation
- Sometimes the pain is so severe that patients are unwilling to pass a bowel movement; this results in faecal impaction and constipation
- Pain affects urination and causes dysuria
- Small amounts of bleeding
- Pruritus ani or anal itching
- Malodourous discharge due to pus formation
Anal fissures are diagnosed by clinical examination.A rectal examination will show the fissure which is usually in the posterior aspect of the anal canal. Occassionally, anal fissures can be an indication to underlying illnesses such as Crohn s disease, AIDS squamous cell carcinoma etc. The ideal diagnostic tests that are ordered are stool and viral cultures, erythrocyte sedimentation rate, HIV test, biopsy of the fissure. Small intestinal x-rays are done to assess the presence of other diseases. A colonoscopy is done to examine the entire colon.
When medical therapy has failed to treat an acute fissure, surgical intervention is indicated. Initial prescriptive medical therapy would be fibre supplementation, stool softeners and stool bulking agents. Mineral oil may be prescribed for the smooth passage of stools without abrasions. It can also include second-line treatments with 0.4% nitroglycerine anal applicant applied directly into the internal anal sphincter. Definitive surgical therapy is indicated when acute fissures fail to heal for 3 4 weeks after initiation of medical therapy. Sphincter dilatation and lateral internal sphincterotomy are some of the curative procedures performed for fissures.
Sphincter dilatation: under general anaesthesia, an anal stretch is conducted to loosen a tight anal sphincter to correct the abnormality
Lateral internal sphincterotomy: performed under general and spinal anaesthesia the hypertrophied internal sphincter is cut to release the tension thus allowing the fissure to heal
Dr. Deepak Varma specializes in the treatment of digestive diseases and will advise the best course of action for each patient.