Anal Fissure

An anal fissure is no more than a tear or cut of the anal skin below the dentate line in the anal canal, usually very small. This injury can cause severe and disabling pain to the patient. Symptoms include rectal bleeding, pain, and burning after defecation that could last from minutes to hours.

Fissures are mainly caused by trauma to the anal canal, such as, with the passage of hard stool. Other theories, such as ischemia to the posterior midline of the anus, have been entertained. Fissures are usually located in the posterior midline of the anus, but can also be seen in the anterior midline, and in both locations at the same time. When a fissure is located off the midline of the anus, the clinician should investigate for other potentially complicated disease processes, such as, Crohn’s disease, trauma, tuberculosis, syphilis, HIV/AIDS or anal carcinoma. The diagnosis of the fissure is usually suggested by the description of the patient’s symptoms, and is easily confirmed by physical examination. Usually, other means of examination such as a digital rectal examination and anoscopy are not required and actually could be very painful for the patient.

The treatment of an anal fissure usually goes directed towards relieving the hypertony of the internal sphincter muscle that is associated with the condition. Fiber supplements, stool softeners and laxatives are also prescribed as needed. The treatment is also divided into medical or surgical. With the medical therapy, the aim is to chemically induce a relaxation of the internal sphincter muscle, while the aim of the surgical therapy is to mechanically cause that same effect.

The medications more widely used for the treatment of anal fissures are topical anti-inflammatory agents, such as, hydrocortisone. In addition, sphincter relaxants such as, nitrate formulations, oral and topical calcium channel blockers, adrenergic antagonists, topical muscarinic agonists, phosphodiesterase inhibitors and the use of botulinum toxin with success cure rates that range from 50 to 80% are implemented.

 

Historically, surgical techniques, have had a high success rate to treat this condition. Techniques such as, anal dilatation and posterior sphincterotomy, have been largely abandoned due to their side effects in particular, fecal incontinence. The American Society of Colon and Rectal Surgeon’s practice parameters for the management of anal fissures recommends, Lateral Internal Sphincterotomy as the surgical treatment of choice in medically refractory anal fissures, in which a small portion of the left aspect of the internal sphincter muscle is divided to achieve the desired mechanical relaxation needed to help the fissure heal.

 

Despite the mixed results with medical therapy, it is our practice to step up treatment options. From the use of topical anti-inflammatories to sphincter relaxants to surgical therapies, treatment options depend on the patient’s potential risk for fecal incontinence.

Treating Hemorrhoids

Hemorrhoids are a normal part of the human anorectal anatomy. They do not constitute a disease unless they become symptomatic. The prevalence of symptomatic hemorrhoids in the United States is reported to be 4.4%, affecting men and women equally. Hemorrhoid disease accounts for 3.2 million ambulatory care visits, 306,000 hospitalizations and the issue of over 2 million prescriptions a year. Hemorrhoids, when symptomatic, can be treated successfully. Treatment can be divided into four different steps:

Step 1: Dietary and Lifestyle Modification

Constipation is one of the most common causes of symptomatic hemorrhoid disease. Dietary management with increased fiber and water intake is the primary noninvasive mean to treat constipation.

– Psyllium is the principal fiber supplement used in concert with water to add moisture to the stool, ameliorating constipation.

-Other alternative medications include witch hazel, horse chestnut, ginger root, butchers broom, rutin, hesperidin and diosmin – all mainly used in homeopathic medicine.

Step 2: Topical Agents

Most of the creams, ointments and suppositories prescribed for the treatment of symptomatic hemorrhoids contain corticosteroids. They are good for the short-term treatment of the hemorrhoid flare, but its chronic use is discouraged do to the possibility of permanent damage to the perianal skin. They could also promote opportunistic infections such as fungal dermatitis. Some creams are mixed with local anesthetics such as lidocaine and pramoxine, which could give short-term relief. Other alternative medications that are used locally are astringents such as Witch Hazel (Hammamelisvirginiana), Aloe Vera and phenylephrine.

Step 3: In-Office Procedures

The goal of in-office procedures is to ablate the vessels involved and fix the sliding hemorrhoidal tissue back onto the muscle wall of the anal canal with minimal pain. These procedures include:

Sclerotherapy: indicated for grade 1 and 2 internal hemorrhoids. It involves a submucosal injection of a sclerosant at the apex of the hemorrhoid and usually causes thrombosis of the vessels with shrinkage and fixation.

Rubber Band Ligation: the most commonly used in-office procedure, indicated for internal hemorrhoids grades 1, 2 and 3. Ligators deploy a rubber band around a hemorrhoid pedicle. The procedure is usually painless and takes only a few minutes to perform. The ligated tissue usually necroses and sloughs in 3-4 days, causing elimination of the redundant tissue and fixation.

Infrared Coagulation (IRC):  produces an infrared light which penetrates the tissue and converts to heat, promoting coagulation of the vessels and fixation. It is usually indicated for small bleeding internal hemorrhoids, grade 1.

Electrocoagulation and Bipolar Coagulation: indicated for small bleeding internal hemorrhoids, relies on coagulation and fixation as other techniques. It is somehow less effective and more painful than RBL and IRC.

Direct-Current Electrotherapy (Ultroid):  is similarly applied through a probe placed via an anoscope into the mucosa at the apex of the hemorrhoid. It is a lengthy procedure and reapplications to the same site are sometimes required.

Thrombectomy: usually indicated for the therapy of small thrombosed external hemorrhoids. The procedure usually does not excise the involved hemorrhoid complex, but rather evacuates the blood clot beneath the anal skin, relieving the tension and pain immediately.

Step 4: Surgical treatment

Several options and techniques are available for the surgical treatment of symptomatic hemorrhoids. They include:

Doppler Guided Hemorrhoidal Artery Ligation: using a Doppler transducer, the hemorrhoidal arteries are identified and ligated. It causes less pain than a traditional surgical hemorrhoidectomy, but sometimes, the large prolapse of grade 4 internal hemorrhoids or the prolapsing of large external hemorrhoids are difficult to address.

Excisional Hemorrhoidectomy: several techniques exist to excise the hemorrhoid tissue, including: the closed or Ferguson, the open or Milligan-Morgan, the Nd-YAG laser, and the use of energy instruments such as the Harmonic Scalpel and Ligasure. Postoperative pain and prolonged healing time are some main disadvantage. Long-term results are usually excellent.

Stapled Hemorrhoidectomy:  also known as PPH (procedure for prolapsed hemorrhoids), thought to decrease the amount of postoperative pain. A portion of the rectal mucosa and submucosa close to the apex of the hemorrhoid pedicle is excised and stapled again. The hemorrhoids are re-suspended and brought back into the anal canal. A major drawback of this technique is that the procedure does not treat the large external hemorrhoids and associated tags sometimes present. The use of PPH is limited to patients with large grade 3 and 4 internal hemorrhoids.