What is an anal fissure?
An anal fissure is a tear in the lining of the anus. Fissures typically cause severe pain and bleeding with bowel movements. Fissure is often confused with other causes of pain and bleeding, such as hemorrhoids.
Who is at risk for anal fissures?
Anal fissures can occur in anyone at any age. However, people with fissures are more likely to have them in the future.
What causes an anal fissure?
Fissures are usually caused by trauma to the inner lining of the anus. A hard, dry bowel movement is typically responsible, but loose stools and diarrhea can also be the cause. The injury to the tissue creates severe anal pain, resulting in anal sphincter spasms and a subsequent increase in anal sphincter muscle pressure. The increase in anal sphincter muscle pressure decreases blood flow to the injury site, thus impairing wound healing.
The trauma can be caused by one or more of the following:
- Chronic (long-term) constipation
- Straining during bowel movement, especially if the motions are hard and dry.
- Prolonged diarrhea
- Anal sex.
- Insertion of foreign objects into the anus.
- excessive tissue wiping of the anus after a motion
- Crohn’s disease
- Scratching (as a reaction to pinworm infection, for example)
- Anal injury
What are the signs and symptoms of an anal fissure?
Signs and symptoms of an anal fissure include:
- Pain during, and even hours after, a bowel movement
- Blood on the outside surface of the stool
- Blood on toilet tissue or wipes
- A visible crack or tear in the anus or anal canal
- Burning and itching.
- Discomfort when urinating, frequent urination, or inability to urinate
- Foul-smelling discharge
What are the Complications of anal fissure?
Some of the possible complications of an anal fissure include the following:
- Chronic anal fissure – the tear fails to heal. Over time, this can cause extensive scar tissue at the fissure site (sentinel pile).
- Anal fistulas: An abnormal ‘tunnel’ joins the anal canal to the surrounding skin.
- Anal stenosis – the anal canal becomes abnormally narrowed due to a spasm of the anal sphincter or contraction of the resultant scar tissue.
How is an anal fissure diagnosed?
Usually, your doctor can diagnose an anal fissure by visually inspecting the anus or by gentle exam with the fingertip or an anoscope.
How are anal fissures treated?
Most fissures heal on their own and do not need treatment.
The goal of anal fissure treatment is to lower the pressure on the anal canal by making stools soft and to ease discomfort and bleeding
Clinical guidelines on anal fissure management:
- Acute anal fissure: Non-operative treatment includes a high-fiber diet, stool softeners, and sitz baths.
- Chronic anal fissure: Topical agents like nitrates or calcium channel blockers
- A chronic anal fissure that fails to respond to medical therapy may be treated with botox or internal anal sphincterotomy.
Nonsurgical treatment of anal fissure?
Your doctor will discuss the benefits and side effects of treatments.
- A high-fiber diet and over-the-counter fiber supplements (25-35 grams of fiber/day) make stools soft, formed, and bulky.
- Drinking more water helps prevent hard stools and aid in healing.
- Warm sitz baths for 10 to 20 minutes, a few times daily (especially after bowel movements to soothe the area and help relax anal sphincter muscles).
- Medications like lidocaine can be applied to the skin around the anus for pain relief.
- Medications such as diltiazem, nifedipine, or nitroglycerin ointment to relax the anal sphincter muscles help heal.
- Narcotic pain medications are avoided because they can cause constipation which could make the situation worse.
What does surgery for an anal fissure involve
Lateral internal sphincterotomy
Precise and controlled division of the internal anal sphincter muscle is highly effective and commonly used to treat chronic and refractory anal fissures. Success rates are reported to be over 90%. Recurrence rates after sphincterotomy are exceedingly low when adequately performed by a surgeon. Now a days this procedure is done with laser. In this technique there is no open wound and so no suturing is required. The surgery is performed as an outpatient, same-day procedure. The principal risks of internal sphincterotomy are variable degrees of stool or gas incontinence.
How long is the recovery after surgery?
It is important to note that complete healing with medical and surgical treatments can take approximately 1-2 weeks. However, acute pain after surgery often disappears after a few days. Therefore, most patients can return to work and resume daily activities a few days after the surgery.
Can fissure occur again?
Fissures can recur easily, and it is pretty typical for a fully healed fissure to recur after a strenuous bowel movement or other injuries. Therefore, even when the pain and bleeding have subsided, it is crucial to continue good bowel habits and a diet high in fiber as a sustained lifestyle change.
Pilonidal Cyst or Sinus
What is a Pilonidal sinus or cyst?
Pilonidal means a ‘nest of hairs.’
A sinus tract is a narrow tunnel (a small abnormal channel) in your body. A sinus tract typically goes between a focus of infection in deeper tissues to your skin surface. This means that the tract may discharge pus from time to time onto your skin.
A pilonidal sinus is a sinus tract that commonly contains hairs. It occurs under your skin between your buttocks (the natal cleft) Rarely a pilonidal sinus occurs in other sites of your body.
Who is at risk for Pilonidal sinus or cyst?
Certain factors increase the risk of developing the condition and include:
- A job involving much sitting (a sedentary occupation).
- Being overweight or obese.
- A previous persistent irritation or injury to the affected area.
- Having a hairy, deep natal cleft.
- A family history of the condition.
- Being male
- Practicing poor hygiene habits
- Sitting for long periods at a time.
- Having thick, stiff body hair.
What causes Pilonidal sinus or cyst?
Pilonidal disease is considered an acquired disease resulting from three main factors- the hair or foreign body, a force causing hair deposition into the sinus, and skin vulnerability.
The exact cause is not clear. There are various theories.
A similar condition can occur between the fingers of hairdressers, caused by customers’ hairs entering moist, damaged skin.
What are the signs and symptoms of Pilonidal sinus or cyst?
A pilonidal sinus affects the natal cleft.
Symptoms vary from mild to severe, depending on the presence or absence of infection
- Small dimples in the skin
- Irritation or discomfort
- Painful mass, which may be an abscess.
- Drainage from the area, which may be a clear, cloudy, or bloody fluid
- Red, tender area
- Foul-smelling pus
How is Pilonidal sinus or cyst treated?
- No symptoms:
- If you have no symptoms, you will normally be advised to clear the affected area of hair (by shaving, etc.) and keep the area clean with good personal hygiene.
- Rapid-onset (acute) symptoms
- If you have an infection, you may need some antibiotics and painkillers. You may need an emergency operation. This procedure punctures and drains the pus with the surrounding skin infection. This is usually done in a hospital.
- Persistent (chronic) symptoms
- In most cases, an operation will be advised. Various operations are done to cure this problem. Your surgeon will be able to give the details and the pros and cons of each operation.
What are the surgical options for pilonidal sinus?
- Wide excision and healing by secondary intention.
- This operation involves cutting out the sinus and a wide margin of skin surrounding the sinus. The wound is not closed but left to heal by natural healing processes. This usually requires several weeks of regular dressing changes until it heals fully. Recurrence is low with this procedure.
- Excision and primary closure.
- This means taking out the section of skin which contains the sinus and stiching the wound. The advantage of this is that, if successful, the wound heals quite quickly. However, the risk of a recurrence or of developing a wound infection after the operation is higher than with the above procedure.
- A plastic surgery technique
- When the sinus recurs or is extensive, plastic surgery may be advised.
What should be done after your operation?
You need to keep the wound clean and the surrounding hairy area to be shave regularly to prevent recurrence.
Hair removal techniques
In some cases, hair removal may be the first step in treating a pilonidal sinus if an infection is not present.
Hair removal options may include:
- laser removal
- depilation creams