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Fissure

A linear tear or crack develops in the distal anal canal involving first the epithelium and then the full thickness of the anal mucosa leading to fissures. Anal fissures prominently develop in both males and females. They usually occur in middle-aged and younger individuals. A tear in the anal mucosa persists over an elongated period of time causing acute anal fissures. They affect the anterior midline, posterior midline and in some cases, both. Midline fissures are indicative of IBD, AIDS or cancer.

Causes and risk factors

  • Trauma due to painful and strenuous bowel movement

  • Low-fibre diets that lack in fruits and vegetables

  • Scarring from prior anal surgery

  • Hypertrophy and hypertonicity of the internal anal sphincter

  • Elevated sphincter resting pressures

  • Compromised blood supply to the posterior midline and anal fissure

  • Chronic diarrhoea

  • Pregnancy and childbirth

  • Anorectal area inflammation due to IBD

  • Anal cancer

  • HIV / AIDS

  • Herpes

  • Syphilis

  • Aging – decreased blood flow and slowed circulation

Signs and symptoms

  • Pain with each bowel movement due to stretching of raw area

  • Poor healing

  • Unwillingness towards a bowel movement due to fear of pain

  • Bright red blood with stool

  • Irritation and itching in and around the anus

  • Visible crack or tear in the anal mucosa

  • Noticeable lump or skin tag

Diagnosis

  • Physical examination indicates tearing of the anal mucosa with visibility of fibres of the internal anal sphincter at the base of the fissure.

  • Lab studies will include erythrocyte sedimentation rate, stool and viral cultures, biopsy of the lesion, testing for HIV

  • Digital rectal examination is recommended though painful

  • Anoscopy to visualize the full fissure

  • Rigid proctosigmoidoscopy

Treatment and Medication

Acute anal fissures require surgical therapy. Medical therapy includes stool-bulking agents, stool softeners and fibre supplementations. Laxatives are prescribed to maintain regular bowel movements. Mineral oil facilitates passage of stool without stretching and abrasion of the anal mucosa. Sitz baths for symptomatic relief and relief of painful internal sphincter muscle spasms. Intra-anal application of 0.4% nitroglycerin rectal ointment is recommended directly on to the internal sphincter. Chemical sphincterotomy is performed by directly injecting Botulinum toxin or BOTOX into the internal anal sphincter, till nerve findings are regenerated.

Generally medical and alternative therapies fail indicating the need for surgical intervention. Dr. Deepak and his team surgically treat anal fissures successfully by performing a fissurectomy with a lateral sphincterotomy.

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