Fissure in Ano: A Comprehensive Guide to Treatment

The prevalence of anorectal disorders has prompted increased awareness and understanding of conditions like the "fissure in ano." A fissure in ano, more commonly referred to as an anal fissure, is a small tear or crack in the lining of the anal canal, often resulting in considerable discomfort and pain for the affected individual. This condition, while common, is frequently misunderstood, leading to delays in seeking appropriate care. The Treatment for Fissure in Ano ranges from conservative measures such as dietary modifications and topical applications to more advanced surgical interventions. Effective treatment not only alleviates pain but also promotes the healing of the fissure, preventing potential complications and recurrence. Understanding the comprehensive options available for treating this condition is crucial for both healthcare professionals and patients. This guide aims to delve into the details of the various treatments, shedding light on their efficacy, benefits, and potential side effects, offering readers a holistic perspective on managing and overcoming anal fissures.

What is Fissure in Ano?

A fissure in ano, commonly referred to simply as an anal fissure, is a small tear or ulceration in the thin, delicate lining of the anal canal. It’s a common condition that affects many people worldwide. This article provides an in-depth understanding of the causes, symptoms, and treatments for this condition.

Causes for Anal fissures

There are several causes and predisposing factors associated with the development of anal fissures:

1. Straining during bowel movements: Passing hard or large stools can lead to trauma in the delicate lining of the anal canal, resulting in a fissure.
2. Chronic constipation: Persistent constipation increases the likelihood of straining during bowel movements and the subsequent risk of fissures.
3. Diarrhea: Repeated episodes of diarrhea can irritate and inflame the anal lining, increasing the risk of a tear.
4. Childbirth: The process of vaginal delivery, especially in the case of large babies or difficult deliveries, can lead to trauma in the anal region, causing fissures.
5. Anal intercourse: This can result in trauma to the anal canal.
6. Underlying medical conditions: Conditions such as Crohn’s disease and other inflammatory bowel diseases can predispose individuals to anal fissures due to inflammation and other related factors.
7. Decreased blood flow to the area: The posterior midline of the anus receives less blood flow compared to other parts, making it more susceptible to tearing and slower healing.
8. Overly tight or spastic anal sphincter muscles: Increased tension in these muscles can reduce blood flow to the anal canal, making it more prone to fissuring.
9. Previous anal surgeries or procedures: These can weaken the integrity of the anal canal or cause scar tissue, increasing the risk of fissures.
10. Aging: The skin and mucosal lining can become more fragile with age, making older adults potentially more susceptible to fissures.
11. Other infections or inflammatory conditions: Some infections or conditions can weaken the anal tissue or cause inflammation, leading to fissures.

It’s important to understand that while the above factors increase the risk, anyone can develop an anal fissure.

Symptoms of Fissure in Ano

Understanding the signs and symptoms can aid in early diagnosis and management. Here are the detailed signs and symptoms of an anal fissure:

1. Pain:
   • Intense, sharp, or burning pain during bowel movements is the most common symptom of an anal fissure.
   • This pain can persist for several hours after defecation.
   • Some people may avoid going to the toilet due to fear of the pain, which can exacerbate the condition by leading to constipation and harder stools.
2. Bleeding:
   • Bright red blood may be noticed on the toilet paper or in the stool after a bowel movement.
   • The blood is usually fresh and not mixed with stool, differentiating it from bleeding that originates higher up in the digestive tract.
3. Visible Tear or Crack:
   • On inspection, especially in acute fissures, a tear or crack might be visible in the lining of the anus, usually located in the posterior midline.
4. Anal Itching (Pruritus Ani):
   • The area around the fissure can become irritated and itchy.
5. Spasm of the Anal Sphincter:
   • The pain and irritation from the fissure can cause the surrounding anal sphincter muscles to go into spasm, further exacerbating the pain and potentially impairing blood flow to the area, which can delay healing.
6. Sentinel Pile:
   • Chronic fissures may be associated with the formation of a skin tag at the edge of the fissure, known as a sentinel pile. This tag can be mistaken for a hemorrhoid.
   • The sentinel pile can sometimes trap fecal matter, leading to further irritation and itching.
7. Discharge:
   • In some cases, there may be a small amount of mucous or pus discharge from the fissure, especially if there’s an associated infection or abscess.
8. Swelling and Redness:
   • The skin around the fissure may appear red and swollen due to inflammation.
9. Chronic Fissures:
   • If a fissure persists for more than eight weeks, it’s termed chronic. Chronic fissures may present with more pronounced symptoms like a sentinel pile and may have more irregular, scarred edges compared to acute fissures.

Diagnosis

A detailed clinical history and physical examination, including a gentle inspection of the anal region, often suffice to diagnose an anal fissure. In certain cases, a doctor might use an anoscope to view the fissure directly. If there’s a suspicion of underlying conditions like Crohn’s disease, further diagnostic procedures might be recommended.

Treatment for Fissure in Ano

The mainstay of treatment revolves around relieving the associated pain and promoting healing of the fissure. Both conservative and surgical treatment options are available. Here is a detailed overview:

Conservative Treatments

1. High-fiber Diet and Hydration:
   • Consuming a diet rich in fiber helps to soften stools, making them easier to pass and reducing the risk of further trauma to the fissure.
   • Drinking adequate water further aids stool consistency.
2. Stool Softeners:
   • Over-the-counter medications, such as docusate sodium, can help soften the stools, decreasing straining during defecation.
3. Sitz Baths:
   • Sitting in a tub of warm water for about 15-20 minutes, several times a day, can help soothe the area, relax the anal sphincter, and promote healing.
4. Topical Pain Relievers:
   • Over-the-counter ointments containing ingredients like lidocaine can help numb the area, reducing pain.
5. Topical Nitroglycerin:
   • Applied in ointment form, it helps to relax the anal sphincter, thereby reducing pain and improving blood flow to promote healing. However, headaches can be a common side effect.
6. Calcium Channel Blockers:
   • Ointments like nifedipine or diltiazem can also relax the anal sphincter and increase blood flow to the region, aiding in the healing process.
7. Botulinum toxin (Botox) Injections:
   • These can be administered into the anal sphincter. Botox paralyzes the muscle temporarily, reducing pain and allowing the fissure to heal.

Surgical Treatments

When conservative treatments are ineffective, or the fissure becomes chronic, surgical intervention might be considered:

1. Lateral Internal Sphincterotomy:
   • The most common surgical treatment, this procedure involves a small incision to cut a portion of the internal anal sphincter. By reducing the muscle’s spasm, there’s an improvement in blood flow, promoting healing of the fissure. It has a high success rate, but there’s a small risk of causing incontinence to gas or stool.
2. Fissurectomy:
   • The fissure is surgically removed, and if needed, the base of an associated sentinel pile might also be excised.
3. Advancement Flaps:
   • This procedure is usually reserved for more complex or recurrent fissures. It involves using adjacent healthy tissue to cover the fissure site, promoting healing.
4. Laser Therapy:
   • The use of lasers in treating anal fissures is emerging. It involves directing laser energy to the fissure site to promote healing. It’s less invasive than traditional surgery but may not be as widely available.

Aftercare and Prevention

Post-treatment, it’s essential to:

• Maintain soft stools through diet and hydration.
• Avoid straining during bowel movements.
• Ensure good anal hygiene to prevent infection or further irritation.
• Follow up with a physician to monitor healing and assess for potential complications.

Ayurvedic Treatment for Fissure in Ano

Fissure–in–ano can be correlated with a condition called Parikartika in Ayurveda. The word Parikartika is derived from two words – “pari” means all around and “karti” is ‘kartanavat vedana’ cutting or tearing kind of pain. It is one of the guda roga in which there is a cutting or tearing type of pain. In the classics, the description of Parikartika is not found independently. It is explained as one of the complications secondary to various diseases, as a complication of improper administration of panchakarma (purificatory procedures).

Etiology

• Consumption of food having excess lavana (salt), ushna (hot), teekshna (penetrating foods like very spicy), contaminated food, having very little food or starving, manadagni (poor digestion), malabaddhata (constipation)
• Occurs secondary to diseases like Atisara (diarrhea), Jwara (fever), Grahani (can be correlated with IBS), Udavarta, as a premonitory symptom in Arshas (haemrrhoids),  in Garbhavastha (pregnant women)
• Complication of Basti karma (enema therapy): when basti karma is done with ruksha (dry), teekshna (penetrating) drugs to patients who have poor functioning gastrointestinal tract, excess use of yapana basti karma
• Complication of basti netra (nozzle of the enema equipment): if the nozzle is bigger in size, has a rough surface, or has a defective hole on the sides of the nozzle
• Complications of virechana (purgation therapy): If strong medicines are administered to the patient it leads to excess purgation.

The etiology seen above leads to vata and pitta prakopa which cause pressure over guda pradesha (rectum and anal canal) and do the vitiation of raktha (blood and its components)and mamsa (muscle tissue) causing a cutting type of pain.

 Signs and symptoms of parikartika

The general symptoms seen in Parikartika are kartanavat vedana in guda pradesha (cutting type of pain in the rectum and anal canal), daha in guda-nabhi-medhra-basti pradesha (burning sensation in the anal region-umbilical region-penis-bladder region), vibandha (constipation), raktasraava (bleeding).

Types of parikartika

Three types of Parikartika are explained in the classics: 

1. Vataja parikartika: there is cutting type of pain
2. Pittaja parikartika: there is burning sensation
3. Kaphaja parikartika: dull aching pain

Treatment for Fissure in Ano in Ayurveda

The prognosis of the disease depends on the location of the ulcer that occurs. If it is deep-seated and the anal canal which is the vital structure with enough blood vessels, nerves, ligaments, etc. the treatment becomes difficult. If the ulcer is superficially located with less intensity of constipation and also if the patient is tolerable the treatment is easier.

Based on the dosha vitiated and clinical features management of Parikartika has to be done. As there is pain, vedana shamaka (pain relieving drugs) are used, vrana shodhaka (wound healing or cleansing drugs) to treat the wound or ulcer that has occurred, for malabaddhata or constipation vataanulomana or malanissaraka drugs are used. 

Parisheka (hot fomentation) or sitz bath, Anuvasana / Pichcha basti (oil enema) are some of the treatment modalities administered. These are followed by peya (a liquid diet with a red variety of rice and medicinal herbs) and yoosha (soup of pulses along with herbs) is also advisable. 

Diet and lifestyle

For the conditions where there is indigestion, easily digestible food is advised, ghee with juice of pomegranate is given in patients where there is vata prakopa (aggravated vata dosha), and emaciated conditions food rich in carbohydrates is given.

Devadaru (Cedrus deodara) with the paste of sesame and lukewarm water, medicated milk prepared from plants like Ashwattha (Ficus religiosa), Udumbara (Ficus racemosa), etc.

Plenty of fluids, whole grains, well-cooked brown or red variety of rice, fiber-rich diet, buttermilk, milk, lentils, pulses like green gram, and vegetables like carrot, beetroot, papaya, lemon water, ghee, turmeric, banana, and green leafy vegetables are advised.

Avoid excess indulgence in sexual activity, riding, driving, suppression of natural urges, and eating spicy and pungent food items. 

Home remedies for Fissure in Ano

1. Flax seeds: powder of flax seed to be taken in the dosage of one tablespoon with a glass of water at bedtime for one week
2. Apple cedar vinegar: Unfiltered apple cedar vinegar (one tablespoon), one tablespoon of honey mixed with a glass of water twice a day for one week to ten days
3. Coconut oil: application of coconut oil over the affected area 3-4 times a day till the symptoms are reduced
4. Aloe vera gel: Aloe vera gel application is done 3-4 times a day until the symptoms are reduced. 

Conclusion

Anal fissures, though painful, are treatable. Early diagnosis and intervention can prevent complications and ensure quick relief. If you suspect you have an anal fissure, it’s essential to see a medical professional to discuss the most appropriate treatment options.

Parikartika is a condition occurring as a complication secondary to diseases, and improper administration of purificatory procedures(panchakarma treatments). Cutting type of pain in the anal region is the predominant symptom along with a burning sensation, constipation, and bleeding from the wound site. Vedana shamaka, vrana shodhaka, vatanulomana drugs, enema therapy, and sitz bath are the Ayurvedic treatments.

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FAQ on Fissure in Ano

1. What is a fissure in ano (anal fissure)?
   • A fissure in ano is a small tear or crack in the delicate lining of the anal canal, leading to pain and potential bleeding during bowel movements.
2. What are the primary causes of anal fissures?
   • Common causes include straining during bowel movements, hard or large stools, chronic constipation, diarrhea, childbirth, and certain underlying medical conditions like Crohn’s disease.
3. How can I differentiate between hemorrhoids and an anal fissure?
   • While both conditions can cause pain and bleeding, an anal fissure often results in sharp or burning pain during bowel movements, whereas hemorrhoids typically cause aching pain and itching.
4. Are sitz baths effective for anal fissures?
   • Yes, warm sitz baths can help soothe the area, relax the anal sphincter, and promote healing. It’s recommended to take sitz baths for 15-20 minutes several times a day.
5. What dietary changes can assist in the treatment of an anal fissure?
   • Consuming a high-fiber diet, drinking plenty of water, and possibly using stool softeners can soften stools, reducing the risk of further trauma to the fissure.
6. Are there any over-the-counter treatments available?
   • Yes, over-the-counter ointments that contain ingredients like lidocaine can numb the area, providing pain relief. Stool softeners can also be purchased without a prescription.
7. When should I consider surgery for an anal fissure?
   • Surgery is usually considered when conservative treatments don’t provide relief or if the fissure becomes chronic (lasting more than eight weeks). A common surgical option is the lateral internal sphincterotomy.
8. Is surgery for an anal fissure safe?
   • Surgical treatment for anal fissures, particularly lateral internal sphincterotomy, has a high success rate. However, like all surgeries, there are risks, such as infection, bleeding, and, rarely, incontinence.
9. How long does it typically take for an anal fissure to heal with treatment?
   • Acute fissures (those present for six weeks or less) often heal within a few weeks with appropriate treatment. Chronic fissures may take longer or require surgical intervention.
10. Can anal fissures recur?
    • Yes, even after healing, anal fissures can recur, especially if the underlying causes, such as constipation or straining during bowel movements, are not addressed.

NOTE:
“This article does not provide medical advice. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Never ignore professional medical advice in seeking treatment because of something you have read on this WebSite. If you think you may have a medical emergency, immediately call or visit your doctor.”

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References

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4. https://www.aiirjournal.com/uploads/Articles/2022/10/5784_16.Dr%20Sanjaykumar%20Dhonde.pdf
5. https://www.onlymyhealth.com/health-slideshow/effective-natural-remedies-to-cure-anal-fissures-1461843873.html