Anorectal conditions(Anal fissure treatment) are very common in general surgical practice. Most patients think almost all conditions are piles. (Haemorrhoids) Numbers of other conditions are also very common among the patients. These include fissures, perianal haematomas and fistulae.
What is an Anal fissure condition
An Anal fissure is a tear in the inner lining of the anal region. Since this area is very sensitive the condition is very painful. Usual presentation is severe pain following defaecation and associated bleeding during defaecation. The pain may even last for an hour after the bowel movement. Patients may sometimes try to postpone bowel movements due to the fear of the pain.
When the condition is new it is called an acute fissure. If the fissure does not heal and persists beyond six weeks then it is called a chronic fissure. Sometimes a small lump occurs at the outermost end of the fissure called the sentinel tag.
Majority of acute fissures will heal with simple measures and laxatives. Some persists and become chronic. Chronic fissures are a separate entity due to the associated increased tone of the anal sphincter. Anal sphincter is the muscle surrounding the anal canal which controls the continence.
The sphincter consists of an inner involuntary muscle component and an outer voluntary muscle component. It is thought the higher tone of the muscle prevents the fissure from healing.
Currently available medical therapies are all working with the principal of reducing the sphincter tone to encourage healing of the fissure.
Three categories of drugs are available for treating fissures.
- Topical GTN (Glyceryl Trinitrate) -0.2 % paste
- Calcium Channel Blocker (Diltiazem 2% Cream)
- Botulinum Toxin injection
Local application of above drugs is effective but takes few weeks for the healing to complete.
Headache is the commonest side effect of GTN. Botulinum toxin injection can cause transient incontinence and may result in infection at the injection site.
Some fissures are resistant to the medical management. Despite giving laxative to soften stools, analgesia to reduce the pain and drugs to lower the sphincter tone a significant number of fissures will not heal
Surgery is the next available options for the treatment of these fissures.
The procedure is called lateral anal sphincterotomy. This procedure involved division of the inner muscle layer of the sphincter to reduce the tone. Usually the muscle is divided in a length equal to the length of the fissure. Generally the muscle is divided away from the fissure to encourage rapid healing of the fissure. Rapid resolution of the pain following the procedure is most promising to the patient.
Multiple studies have clearly established the efficacy of this procedure in fissure healing with a healing rate above 90%. Minor degree of incontinence can occur in some patients but it is less than 10% according to the literature.
Rarely fissures may be a feature of another disease. When a fissure does not heal for a long duration with optimal medical and surgical management we need to think about a secondary pathology such as Crohn’s disease, Tuberculosis etc.
Dr Udaya Samarajeewa MBBS, MD- Surgery, MRCS (Eng.)
Consultant General Surgeon