An anal fissure or Fissure-in-ano is a tear or cut in the skin of the anal canal. The condition affects men and women equally and can occur at any age ( infants too ). Anal fissures are commonly found in the back part of your anus, in line with the cleft of your buttock.

A fissure which is present for less than 6 weeks is called an Acute fissure. That which is more than 6 weeks old is called a Chronic fissure. The Chronic fissure is usually hard to feel and may have a skin tag like growth called Sentinel Pile.

Anal Fissure treatment

Causes of Fissure

Usually trauma to the anal canal causes a fissure.
  • Hard stools especially associated with constipation - The increased pressure exerted in an effort to pass the hard stools causes tearing of the delicate perianal skin.
  • Diarrhoea - The frequent forceful bowel movement causes tearing of the anal skin.
  • Iatrogenic - A tear may occur during insertion of a rectal thermometer, USG probe, endoscope, enema tube.
  • Childbirth
  • Anal sex - Commonly encountered in homosexuals.
  • Rare causes - Crohns disease, leukaemia, tuberculosis, sexually transmitted diseases, viral infections etc




Symptoms Of Fissure

  • Painful defecation - This pain while passing stools may be so severe that patients are frightened of a bowel movement and avoid one.
    However this further causes constipation and hard stools, leading to a vicious cycle of trauma and hard stools. The pain during defecating may be severe, pricking or searing and the post defecation burning may last for a few hours.
  • Bleeding, sometimes seen as a streak of blood on stools or blood on the tissue.
  • Need to strain while passing stools - This is because the anal sphincter goes into a spasm.
  • Pruritus ani - Itching in the anal region.
  • Malodorous discharge
  • Sentinel pile - In long standing cases, a skin tag like growth can be felt at the edge of the fissure.

Diagnosis Of Fissure

A history of your symptoms followed by external inspection of the anus is enough to confirm the diagnosis.
On rare occasions your doctor may advice you other tests to rule out any suspected underlying cause for the fissure.

MEDICINES

Acute fissures ( < 6weeks old ) are usually treated non-surgically with medicines. Even Chronic fissures are first given a trial of medical management. The aim of the treatment is to break the vicious cycle of anal sphincter spasm and tearing of the anal skin.

I. MCDPA

At Healing Hands Clinic, Dr. Ashwin Porwal has devised a regimen called MCDPA as follows:

  • Medicines - Herbal medicines to reduce inflammation in the area
  • Constac -Taken before bedtime to add bulk and soften the stools.
  • Diet - A fibre rich diet to prevent constipation. An increase in the water and fluid intake also helps
  • Physiotherapy - Pelvic floor physiotherapy helps to reduce spasm of the anal sphincter.
  • Ayurveda therapy - Medicated herbal oils are used.

II. Sitz bath

Sitting in warm water that covers your hips and buttocks after a bowel movement helps to reduce the post defecation discomfort.

III. Nitroglycerin / Glyceryl trinitrate

Used in the form of an ointment, it helps to reduce spasm of the anal sphincter. However, it has side effects like headache, light-headedness which limit its role.

IV. Nifedipine ointment

It is also used to relax the anal sphincter.

SURGICAL TREATMENT

Acute fissures which do not heal with conservative therapy and most of the Chronic fissures need a surgical line of treatment.

I. Botulinum A toxin ( Botox ) injection

The Botox is injected into the internal anal sphincter to relax it. The effects of the Botox last for 3 months by which it is hoped that the fissure would heal. However, the high cost of therapy, and a major side effect in the form of varying degrees of incontinence limit the use of Botox.

II. Lords dilatation

This is an age old treatment which provides good sphincter relaxation and relief from pain. However, the forceful dilatation can lead to multiple abrasions on the anal skin and may need 6-12 weeks to heal. Also, the scarred tissue over the fissure could be a source of constant discomfort and needs to be removed separately.

III. PLIS ( Partial Lateral Internal Sphincterotomy )

Done under general anaesthesia, this is a minimally invasive procedure in which a small cut is made in the internal sphincter. Thus straining during defecation is considerably reduced and there is satisfactory relief from pain. This procedures requires a good amount of skill and expertise on the part of the surgeon as an inadvertent excessive cutting of the sphincter may lead to incontinence.

IV. Laser surgery

This is done with the Leonardo laser introduced for the first time in India at Healing Hands Clinic. The laser is used to perform internal sphincterotomy. This procedure is almost bloodless and the surgeon has good control over the operation site. Additionally, the chronic fibrosed scar is debrided with the laser. This prevents any long term discomfort and enables a quicker recovery.

V. BOTOX For Fissure

Botulinum Toxin A popularly known by brand name Botox is a neurotoxic protein that produces temporary, localized, flaccid paralysis of muscle. It is used commercially in medicine, cosmetics and research. It is often used to treat Anal Fissure, as an alternative to surgery, especially when medicines have been tried without success.

How does Botox work in fissure?

Many a times, an anal fissure is the result of an overactive sphincter muscle. This not only causes pain but also delays healing. The botulinum toxin is injected directly into the internal anal sphincter causing it to relax, thus reducing muscle tension. It also increases blood flow to the sphincter. All this aids in healing.

How is Botox given?

  • As the anal region is quite sensitive, you will be temporarily sedated during the procedure to reduce the pain. At times, local anaesthetic is used to numb in which case sedation is not required.
  • After cleaning the area, Botulinum Toxin is injected into the sphincter muscle that surrounds the anus
  • The entire process takes around 20-30 min out of which the actual injection time is around 5 min.
  • You can go home as soon as you are comfortable.

What happens after the procedure?

Painkillers may be used to relieve any pain from the injection. The effects of Botox start to become evident slowly over the next 72 hours, peak at 4 weeks and last for 3-6 months ( individual variation ). It is important to ensure that stools remain soft by taking a fiber-rich diet and stool softeners when prescribed.

Potential side effects ( seen in a minority of patients ) include bleeding, temporary loss of control over flatulence/bowel movement ( incontinence ), allergic reaction to Botox, muscle weakness and postural hypotension.

Final word on Botox for fissure

The popularity of Botox is because it offers a non-surgical option to treat chronic anal fissure. Most people have at least some relief in pain with it. It is effective in almost 60-70% cases. Another advantage is that it can be easily repeated after 6 months. There is a chance that in a small percentage of people it might not be effective and in that case other treatment options need to be considered.


Anal Fissure and Skin Tags Treated with Laser Sphincterotomy by Dr Ashwin Porwal



With the primary centre in heart of Pune city, Healing Hands Clinic now has satellite centres in Mumbai, Navi Mumbai, Chinchwad, Chakan and Jaipur. We will soon be extending services to people of Bangalore and Nasik too.