In routine practise as a surgeon, we come across these very common complaints.

  • There is Severe pain on passing stools
  • There is blood in my stools
  • I nearly fainted with pain while passing stools

The first thing that comes to mind is Anal Fissure

Patients have a barrage of queries regarding the symptoms some of which I have addressed here.

What Is Anal Fissure?

This is a tear in the Anal Mucosa or the lining.

Why does it cause so much pain?

Fissure is just like any cut in the skin. This one happens to be in the sensitive part of anal canal.

Just like any other cut it hurts and causes pain, especially when passing stools.

Pain can be there all day long, spasmodic coming in waves.

Does it cause only Pain?

It is a cut so it can bleed also. Bleeding usually is with passage of stools and is bright red in color.

How did the anal fissure happen to me?

Think of the anus as a muscular ring which controls the passage of stools. It is covered by soft mucosa.

1. Passing Hard Stools –

  • on passage of hard stools it stretches the mucosa too much and mucosa being softer tears itself causing pain.
  • When repeatedly this happens the tear extends to the muscle causing throbbing pain throughout the day

2. Constant Straining To pass stools.

When you sit for long periods of time trying to pass stools it can result in injury.

3. Childbirth – In case of prolonged labor the anal opening is stretched and cause injury.

4. Inflammatory disease – Crohn’s disease.

5. Anal intercourse.

 

I am Scared to pass stools as it hurts so much? What do I do?

The pain typically described is so severe that out of fear of pain patients do not pass stools for days.

The texts describe it as a patient having a bottle of whiskey before going to the toilet.

Need to see your physician and surgeon for diagnosis and treatment.

What am I going to ask my doctor?

Do Not hesitate to ask your surgeon any doubts that you have. Anal Fissure is a lifestyle changing disease.

It forces you to change your routine, food habits, etc.

So few helpful queries are

  • Am I going to undergo surgery?
  • Could I have prevented this problem?
  • Do Medicine work effectively in this disease?
  • How long will the treatment take?
  • What precautions do I need to take?
  • For How long these precautions are to be taken?
  • How do I Know I am improving?
  • Can it happen again? If so how do I prevent that?

The list is long one but these will give you a fair idea of the treatment, recurrence and prevention of Anal fissure.

DIAGNOSIS

The surgeon usually does a per-rectal examination.

The finding are of a cut in the rectal mucosa along with a anal tag at times.

The condition if very painful dictates that proctoscopy will be avoided by the surgeon.

In case of suspicion of any co-morbid disease the surgeon can ask for further tests.

1. Colonoscopy

2. Sigmoidoscopy

TREATMENT

Anal fissures usually heal within few weeks if proper treatment and precautions are taken.

  1. HOME REMEDIES

The aim is to relax the anal sphincter muscle

  • Stool Softeners
  • High Fibre Diet
  • Exercise regularly
  • Drink adequate fluids
  • Sitz Bath
  • AVOID

– Straining when passing stools

– Stimulants like coffee, tea.

– Spicy food.

– Sitting for prolonged periods of time.

2. MEDICINES

i. Externally applied nitroglycerin

It is generally considered the medical treatment of choice when other conservative measures fail

To increase blood flow to the fissure and promote healing.

To help relax the anal sphincter.

Applied externally

ii. Topical anesthetic creams such as lidocaine hydrochloride.

iii. Botulinum toxin type A (Botox) injection, to paralyze the anal sphincter muscle and relax spasms.

iv. Blood pressure medications – can help relax the anal sphincter

oral nifedipine

diltiazem

How Do I Know That I Am Improving?

The effectiveness of the treatment can be gauged by,

  • Pain subsiding within a few days.
  • Bleeding stops.
  • Throbbing pain is gone.

3. SURGERY

When Is surgery recommended?

If you have

  • Severe Disease
  • Chronic Anal Fissure
  • Resistant to other Treatment

What Surgery is Done?

Lateral Internal Sphincterotomy (LIS).

How Do I Prevent Anal Fissures?

  • Keep the ano-rectal area dry.
  • Wipe the area with soft materials, a moistened cloth.
  • Promptly treat all occurrences of constipation.
  • Avoid irritating the rectum.

How Long Do I Need To Take The Precautions?

Anal Fissures can recur so it is said to be a lifestyle changing disease. The changes have to be done for as long as possible so as to give the injury time to heal.

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