Anal fissure

Anal fissure

What is an anal Fissure?

Anal fissure in a painful condition of the anal region. The patient experiences excruciating pain while passing stools and after passing stools, so much so that most of them have a fear of passing stools.

Anal fissure is a cut in the anal skin, anal skin being a highly sensitive area, the patient will have severe pain on passing stools and also bleeding from the rectum.

What are the symptoms?

  • Pain on defecation – this is the most common symptom,
  • Bleeding while passing stools
  • Constipation, passing hard stools. Hard stools are a sequel to the pain and dehydration of the stools,
  • Fear of passing stools, as passing stools causes tremendous pain
  • Anal tag/ skin tag in the anal region- this is called the sentinel pile and is secondary to the chronic fissure (long standing fissure). This is often a painless thing but, in some patients, this is very large and causes pain and discomfort.

What is the vicious cycle of anal fissure?

Once there is a fissure, the sphincter muscle goes into spasm due to the pain. The stools get hard as the patient has the fear of passing stool due to pain.

Pain and spasm worsen the constipation. Passing the hard stool tears the anal fissure again and prevents healing.

Spasm decreases the blood supply to the fissured area and the fissure does not heal.

As long as the fissure does not heal, the pain, sphincter muscle spasm and the constipation do not improve and the fissure does not heal and the patient continues to have pain.

This interdependence, one leading to the other is called the Vicious cycle of anal fissure. It is imperative to break the vicious cycle of the anal fissure. The treatment is hence directed to break the vicious cycle.

Why is there so much pain?

Anal skin is a very sensitive area and this is very important for the anal function. This area has a very rich nerve supply.  Even a small cut or wound can cause severe pain and the internal anal sphincter muscle goes into spasm (becomes tight) and for these reasons, one has severe pain.,

What is the medical treatment for Anal fissure?

Medical treatment is recommended for all patients initially.  This includes:

  • Laxatives– bulk laxatives and liquid paraffin are best for ensuring a smooth and bulky stool. Laxatives like isabgol, Polyethylene glycol and liquid paraffin are recommended.
  • High fibre diet– this also helps to add bulk to stools and takes care of the constipation,
  • Ointment for local application- a internal muscle relaxing ointment like Nifedipine or Diltiazem containing ointments are advised for twice or thrice daily applications,
  • Sitz bath- Sitz bath is sitting in luke warm for 10-15 min each time, three to four times in a day. Sitz bath helps in relieving the pain and spasm and heling the wound.
  • Pain killers- some analgesics may be helpful initially to relieve pain.

What is the best diet for patients with anal fissure? Why diet is very important?

High fibre containing diet is recommended for patients with anal fissure.

Diets rich in fibre are-

  • Green leafy vegetables
  • vegetables like cucumber, ladies’ finger (Okra/ bhindi), carrots, cauliflower, broccoli etc are a very rich source of fibre
  • Brown rice– people used to a rice-based diet are recommended to have the unpolished, hand pound brown rice which is not only a rich source of fibre but also nutritionally good as it has vitamins and minerals intact.
  • Vegetable salads
  • Fruits
  • Oats

A fibre rich diet adds bulk to the stools, acts as a natural laxative and helps easy passage of stools. A fibre rich diet is a very important part of treatment for patients with anal fissures.

Can patients with fissure eat non vegetarian diet?

Patients with anal fissure are advised to reduce the non-vegetarian component of their diet & are recommended to have a fibre rich diet. Non vegetarian diet is known to worsen constipation and pain.

Can a fissure recur after medical treatment?

Yes, if preventive measures are not taken then the fissure can recur as many of the patients with fissure have an inherent tendency for the fissure to recur. One can prevent the recurrence by taking appropriate preventive measures.

What are the preventive measures to avoid the recurrence of anal fissure after medical treatment? 

Anal fissures can recur as some people have a tendency to develop an anal fissure. The following measures can help in preventing the fissure recurrence:

  • DietHigh fibre diet. Diet rich in green leafy vegetables, green salads, and oats should be consumed in good amounts to prevent constipation. Fibre adds bulk to the stool, prevents constipation and hard stools.
  • Plenty of water– at least consume 3 litres of water per day
  • Treat early – treat early when you develop symptoms, this avoids the pain and prolongation of the symptoms.

What is the surgical treatment for Anal fissure?

Most of the patients with anal fissure respond to medical treatment and can avoid surgery for the fissure.

Those patients who have “recurrent fissure, fissure not responding to medical treatment and if the symptoms are affecting the quality of life”, then surgery is advised.

What is the surgery performed for anal fissure?

“Lateral anal sphincterotomy” is the surgery of choice for anal fissure.

Is surgery mandatory for healing a fissure?

No, surgery is not mandatory. Surgery is not the first treatment option. Many patients do respond to medical line of treatment and may not need surgery.

What is laser surgery for Fissure?

The lateral anal sphincterotomy done with a Laser device is called Laser sphincterotomy. Laser surgery is less painful, the wound is smaller and many patients get discharged the same day.

Is surgery mandatory for healing a fissure?

No, surgery is not mandatory. Surgery is not the first treatment option. Many patients do respond to medical line of treatment and may not need surgery.

What is laser surgery for Fissure?

The lateral anal sphincterotomy done with a Laser device is called Laser sphincterotomy. Laser surgery is less painful, the wound is smaller and many patients get discharged the same day.

What is the recovery after surgery?

Be it open or Laser sphincterotomy, most of the patients are discharged the same day or the next day. Most of them can resume their routine work in once the pain subsides.  Bed rest is not recommended and the patient is encouraged to be physically active and resume their routine work as soon as possible.

What are the precautions and care to be taken after surgery?

Patients are advised to Take

  • Pain killers: Take some pain killers for few days,
  • Laxatives – bulk laxatives rich in fibre, like isabgol, PEG (poly ethylene glycol) etc
  • High fibre diet– like diets rich in green leafy vegetables, green salad, fruits and oats etc
  • Sitz bath– for a week or two weeks

How many days of Hospital stay is need for a Fissure surgery?

Most of the patients are discharged on the same day or the next day after surgery. Anal fissure surgery is a day care procedure.

Will the fissure recur after sphincterotomy surgery?

The recurrence of fissure after surgery is extremely rare.

What are the complications of surgery?

Surgery is safe. Bleeding, swelling and wound infection are some of the uncommon complications which are often self-limiting. Some patients may notice leakage of flatus or liquid stools unknowingly for few days after surgery which gets better in a few weeks.

Dr Datta Ram U
MBBS, MS, MRCS, DNB (Surgical Gastroenterology)

Senior Consultant Surgical Gastroenterologist
Laparoscopic & HPB surgeon
GI Cancer Surgeon
Sunshine Hospital, Gachibowli,
Hyderabad
Call/ Whats app: 9895437059

Email: gastrosurgeryhyd@gmail.com