| The anal fissure is the most painful of the peri-anal conditions; it is a lesion present right at the opening of the anus. It usually starts as a small split in the skin of the anus, after a hard bowel movement or an episode of diarrhea and subsequently progresses becoming a rather large open sore.
The symptoms of a fissure are very similar to the symptoms of hemorrhoids, and to complicate things even further, a fissure is also often associated with a variable degree of hemorrhoids as well.
The cardinal symptom of an anal fissure is pain in the anal area, which starts during the bowel movements and lasts a variable amount of time afterwards. This pain is usually described as sharp, cutting and tearingduring the actual passage of stool and subsequently it may turn into a burning discomfort that may persist for a few minutes to several hours after the bowel movement.
Because of the anticipated pain, the patient may put off his bowel movements when the natural urge occurs, and this leads to harder stools and subsequently even more painful bowel movements.
Bleeding is also very common with fissure, usually bright red and of variable amounts.
Constipation is frequent cause as well as a consequence of an anal fissure.
Patients with painful fissures sometimes develop disturbances with urination as well.
An ulceration in the anus could also represent:
a infective ulcer,
a tuberculous ulcer,
a cancer of the anus,
a lesion associated with inflammatory bowel disease and
a lesion associated with HIV infecton.
Treatment of an acute fissure consists of medical management with stool softeners, bulking agents (Konsyl, Perdiem, Citrucel, etc.), warm sitz baths, and the application of anesthetic ointments. In the last several years we had good success with the use of Nitroglycerin ointment, applied directly in the perianal area 3 times a day. The course of treatment lasts 4-8 weeks and can be repeated in case of incomplete healing. The main side effect of the treatment is headache. The combination of Nifedipine/Lidocaine ointment is slightly less effective but much better tolerated. The efficacy of intrasphincteric injection of Botulin Toxin has been proven by several studies, however it has not achieved widespread use so far, mostly because of the high cost of the medication.
If the fissure becomes chronic or fails to respond to medical management, then surgical treatment is indicated; a LATERAL SPHINCTEROTOMY is the standard surgical treatment, and consists of the division of a small part of the internal sphincter muscle. A FISSURECTOMY, which consist of the excision of the fissure itself is also an option.
These procedures are usually performed as outpatient under local anesthesia. |
