Few maladies are as disconcerting and uncomfortable as the dreaded anal fissure. What is it? Simply a tear in the skin and mucosa of the anus. This area is highly innervated and the tear causes severe pain and often bleeding, especially with bowel movements.
Etiology: Constipation and passing hard stool, anal trauma (use your imagination)
Pathophysiology: Mechanical trauma which leads to sphincter spasm which leads to inability for the anoderm to heal, which leads to more sphincter spasm and pain, which leads to less healing, which leads to.... you get the idea. It's a vicious cycle that won't stop until you either control the pain or relieve the sphincter spasm.
Presentation: Horrendous, excruciating tearing sensation with BM's, often accompanied by bright red blood on the toilet paper. Patients adapt by trying to avoid the toilet, which leads to worsening comstipation and harder stools which leads to..... get it?
What the hell should I do? See your doctor. Don't screw around with expensive, useless over the counter products like Preparation H or laxatives, etc. You're just wasting time and money. 90% of anal fissures will heal on their own, without surgical intervention, but it isn't something you should self-treat. Often your PCP will refer early in the game to a surgeon.
Medical Treatment Options:
1. Sitz Baths- soothing soaks can relieve the itching and pain and relax the sphincter. Plan on sitting in a warm bath two or three times a day for twenty minutes at a time
2. Proctofoam- Some docs will rpescribe this; I haven't seen much efficacy though.
3. Nitroglycerin ointment (0.2%)- I've actually seen this work. It relaxes the internal sphincter and some studies have demonstrated healing rates of 60-80%, but the recurrence rate is rather high. Some patients develop headaches which can be quite severe. Also, patients will significant cardiac history need to be careful.
4. Diltiazem ointment (2%) - Essentially works by same mechanism. Efficacy similar to nitro.
5. Botox- Paralyzes the sphincter, but overall, outcomes are worse compared to nitro and diltiazem.
6. Stool softeners, high fiber diet- Soft and regular is the way to go. Hard pieces of coal dropping out your back end are not good for the ballclub.
7. Lidocaine jelly- I always prescribe this; seems to help.
The reason the pharmaceutical agents don't always work is that some fissures become chronic and form a triad of a deep ulcer, a sentinel pile, and a hypertrophic anal papilla. This situation often needs the attention of a surgeon
Defintive treatment involves doing a lateral internal sphincterotomy. This procedure will heal 97% of fissures. Often, a fissurectomy can be done at the same time, excising the chronic triad. I do these in the OR with the patient either asleep or anesthitized with a spinal block. Patient is placed in prone jack-knife position with the butt cheeks taped open. It's a cool, highly satisfying operation. I make a small incision right at the anal verge and dissect out the thickened internal anal sphincter. You can't miss it; it's like one of those Lance Armstrong Livestrong bracelets encircling your anus, deep to the skin. A quick cut and the tension in the anus almost immediately decompresses. If the fissure is nasty looking and edematous, I'll also sometimes excise the whole fissure complex as well. The case takes about five minutes usually. Relief comes a bit more slowly, hours to days (after all, the treatment does involve using knives on your ass). Sitz baths are resumed and stool softeners maintained for several weeks. Complications are rare but sometimes patients will note incontinence of flatus in the immediate post-op period. Incontinence of stool is an extremely rare and devastating complication.