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Anal Fissure

An anal fissure is a vertical tear or crack of the anal skin that is usually found either posteriorly (closest to the sacrum) or interiorly (part of the anus adjacent to the vagina or base of the scrotum). The tear is vertically oriented (along the axis of the anus). The most common symptoms are pain with defecation and bleeding during and following BM’s. Patients commonly recall a difficult BM during which they felt a tearing sensation and pain. In many but not all cases anal fissures are associated with hard BM’s or constipation and the need to strain severely. In contrast and far less commonly, fissures may develop in the setting of diarrhea or frequent BM’s. Fissure-related pain often lingers after the BM and, in more severe cases, can last hours. Blood may be seen in the toilet water, on the stool, or on the toilet paper. There are a small percentage of fissure patients who report no symptoms.


Although some fissures may heal spontaneously with time, especially those associated with a traumatic BM, others do not. Unfortunately, some patients develop a chronic fissure problem. It is not uncommon for these patients to report that symptoms come and go over the course of weeks, months, or years. The treatments for anal fissures include: 1) dietary changes, 2) sitz baths, 3) fiber supplements and stool softeners, 4) muscle relaxing topical creams, 5) Botulin toxin anal injections, and 6) surgery. These treatments are briefly discussed below.


Dietary Changes


Since fissures most often develop in the setting of constipation and hard stool, the recommended dietary changes are geared toward making the stool softer, bulkier, and easier to pass. A high fiber and low starch diet (fruits, vegetables, and grains) combined with an increased intake of water (6-8 eight ounce glasses/day) is advised. It is better to have several bulkier BM’s each day than one hard BM every 1-2 days.


Pain may develop if a small fragment of stool gets lodged in the fissure. For this reason, it is advised that fissure patients take a shower, tub bath, or a sitz bath after BM’s. A sitz bath is a plastic basin that fits inside the rim of the toilet bowl. After a BM it is filled with warm water (no epsom salt or soap need be added) and placed over the toilet after which the patient sits in it and submerses the anal areal. This cleans and soothes the area. Sitz baths come with a plastic bag that is connected to the basin by plastic tubing. The bag can be filled with warm water and then elevated after the patient is sitting in the bath so that a stream of water irrigates the anal area directly. Regardless of which method is used, the goal is to keep the fissure empty and as clean as possible.


Fiber Supplements


Daily fiber supplements are also advised in an effort to increase the bulk of the stool. There are a wide variety of products on the market. Many contain psyllium husk whereas others are made up of methylcellulose. These products are helpful because they add bulk to the stool and act to prevent the development of hard stools. Fiber supplements do not directly stimulate the colon or rectum to contract and, thus are not laxatives in the true sense. It is important to avoid products that combine a true laxative with fiber. Whereas it is safe to take fiber supplements on a daily basis indefinitely, the same cannot be said for laxative containing fiber products. Although each patient needs to determine how much fiber supplement to take each day by testing a variety of doses, 1 tablespoon per day is the usual starting dose.


Muscle Relaxing Topical Creams


The last 2 decades has seen the development and introduction of several specialized topical creams that have dramatically changed the way that fissures are treated. It is believed that high pressures in the anus, generated by the sphincter muscles, constrict the blood vessels that supply the skin close to the fissure and prevent chronic fissures from healing. The fissure creams relax the anal muscles which leads to better blood flow in the area and, in many cases, if taken for several months, leads to healing. In many patients these creams also relieve or decrease BM related pain. The cream is placed around the rim of the anus with a finger but is not pushed all the way inside. Daily use of a topical fissure cream has been reported to result in healing in over 50 % of patients within 2 to 3 months. Fissure creams are now prescribed for practically all patients found to have an anal fissure and have become the first line of treatment. There are a number of topical creams in this category of treatment. Nitroglycerin (NTG) and several close cousins were the first treatment of this type to be used for fissures. Unfortunately, there is a small incidence of headaches associated with NTG. Mainly for this reason most Doctors are now recommending diltiazem or nifedipine cream which also relax the anal muscles but have fewer side effects. If complete healing and resolution of symptoms has not occurred after 2 to 3 months of diltiazem treatment then a different treatment approach should be considered.


Botulin Toxin Injections


The second line of treatment for anal fissures is botulin toxin injections (Botox) in the anus. The goal of the Botox injections is to temporarily paralyze the involuntary muscle of the anus known as the internal sphincter. The internal sphincter is the muscle that generates anal muscle tone between BM's. The injections are made directly into the internal sphincter. The botox decreases the pressure in the anal canal which usually relieves the pain and increases the blood flow to the fissure which should allow for healing. These injections do not affect the voluntary part of the anal sphincter and, therefore, should not prevent a person from contracting their anal sphincter to prevent or put off a BM. However, patients may experience occasional leakage of gas or staining of the underwear for about a month. Botox injections cause no permanent changes in anal sphincter function. Botox injections can be repeated once or twice at monthly or longer intervals. The anal injections are usually given in the office and are a little painful but take less than a minute to complete. A topical anesthetic can be applied to the skin before the injections to partially numb the skin. Although a local anesthetic could be injected into the skin prior to the Botox injections it is not logical to do this because the pain from the local injection is the same as for the Botox alone. This treatment has been reported to result in the healing of, at least, 50 % of fissures.


Surgical Treatment


Patients whose fissures do not heal and continue to cause pain and bleeding despite both diltiazem cream and botox treatments are best treated surgically. The necessary operation takes minutes to complete and is an outpatient or ambulatory procedure. The operation, called a “lateral sphincterotomy”, cuts the outermost 0.75 to 1 cm of the internal sphincter muscle on the left or right side of the anus. The majority of the internal sphincter muscle is left intact. The operation is done through a single small incision. If there is a skin tag or external hemorrhoid next to the fissure it is usually removed as well. There are 3 types of anesthesia that are used for this procedure: 1) local anesthesia and intravenous sedation, 2) a low spinal (saddle block) anesthetic, or 3) general anesthesia (breathing tube and full paralysis). The patient and anesthesiologist decide on the best approach on the day of surgery. The vast majority of patients opt for either the local or spinal approach. After the operation patients are kept in the ambulatory surgery area until they urinate. Patients are given several types of pain medications (toradol and percoset or equivalent narcotic containing pill) although the pain after this procedure is usually not severe or long lasting. Sitz baths and stool softeners and fiber are also recommended after surgery (see Post Anorectal Surgery instructions).


What are the possible side effects of cutting a piece of the internal sphincter muscle? Most patients do not experience or report any long lasting side effects. Incontinence of gas (flatus) has been reported in up to 15 % of patients. Similarly, a small percentage of patients experience occasional soiling or staining of their undergarments. Major loss of anal muscle control should not develop providing the operation is done properly and the patient had normal control before the surgery. The recurrence rate of anal fissures after sphincterotomy is between 3 and 6 %.

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Our family wishes to express our heartfelt appreciation for the kindness, excellent care and wisdom our mother, Jean Broussard, received during her hospitalization.

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