An anal fissure is a tear in the skin around the opening of the anus (the last part of the digestive tract that controls the removal of stools). An anal fissure is associated with pain and bleeding during bowel movements. The condition is more common in young infants but it can happen at any age. Anal fissures are usually caused by trauma or injury to the anal canal while passing hard or large stools, constipation, diarrhoea or childbirth.
Most anal fissures can be diagnosed by a physical examination which involves viewing the anal region and reviewing your medical history. In some cases, diagnosis is done by digital rectal examination or using an instrument called an anoscope. The anoscope is a short instrument with a lighted tube which can help the doctor view and examine the fissure.
Anal fissures usually heal on their own in a few days or weeks (acute), but in cases when it doesn’t heal even after 6 weeks (chronic), medical treatment or surgery is recommended.
Treatment usually involves adopting simple measures to keep your stool soft such as by increasing fibre and fluid intake. Soaking in warm water for 10 – 20 minutes as often as possible, particularly after bowel movements, also helps with healing and reducing discomfort. If symptoms still persist, further treatment is required which involves initially using special cream based on Diltiazem and in case of no success injection of botulin toxin into internal anal sphincter. Topical anesthetics and pain medication may also be prescribed to control pain.
Historically surgery is recommended if the symptoms do not respond to conservative treatment. A procedure called Lateral internal sphincterotomy as been the mostly used intervention for this type of problem although the results in the immediate and long-term were not very good especially because the procedure is associated to a degree of new onset of anal incontinence caused by the fact that the sphincter muscle is divided for a certain amount of its length. For the above-mentioned reason sphincterotomy has been completely abandoned by this practice. Fissurectomy , which involves surgically removing the anal fissure leaving an open wound to heal naturally, may be a times utilized to promote and more rapid healing of the fistula associated to the injection of botulin toxin
The most common treatment option adopted by this practice is definitely the injection of botulin toxin into the internal anal sphincter. This procedure is either done under deep sedation or general anesthesia. It is a fully day cases procedure which does not require overnight stay. The procedure is always associated to a local anesthetic injection called pudendal block, which is performed after completing the injection of the bottoming toxin into the internal anal sphincter. The entire procedure does not last more than 5 minutes but deep sedation or general anesthesia are required in order to control the pain codes by the injection interval and area which is a radiates very sensitive to the spasm of the anal sphincter.
Pre/post Operative Instruction
Anal Fissure Surgery
The aim of this information sheet is to provide an answer the most frequently asked question about Anal Fissure Surgery. Additional and detailed information on the technique of this procedure can be found in the Educational Video and Presentation in the website www.colorectalclinic.ae.
Anal Fissure surgery is aimed to re-establish the conditions which lead to healing of the small mucosa tear, called fissure. Some of the procedures can be planned and done in stages and your doctor will explain how the entire sequence of surgery works and more detailed explanation can be found on the website in the Educational Video section.
The principle of Anal Fissure surgery is to re-establish the condition which favors the healing of the fissure and the resolution of the anal pain which is the main symptoms associated to Fissure. As we now know very well the main cause of primary Anal Fissure is the increase tone or spasm of the Internal Anal Sphincter, which is normally responsible for the so called resting tone responsible for one of the most important functions of anal continence. The main treatment for anal fissure is to restore a normal anal tone, decreasing the tightness of this muscle. Once this happens the fissure heals naturally. This is achieved with the injection of Botulin Toxin solution in the area of Internal Sphincter in order to decrease the tone of the muscle itself with a partial relaxation of it. An additional procedure called fissurectomy may be done in order to refresh the fissure edges in order to speed up the healing time.
What to expect after the procedure?
Anal Fissure surgeries are performed under general anesthesia as a day case procedure. There is no need for the patient to undertake bowel preparation before surgery. The duration of surgery is usually between 10 to 15 minutes. Once the procedure is completed your doctor will inject local anesthetic in the area blocking the inferior hemorrhoid nerve, which is very effective in controlling post-procedural pain. Patients are generally able to go home within 3 hour after surgery is completed. Medications to control postoperative pain are prescribed by the doctor and postoperative follow-up is generally scheduled after few days from the procedure. The patient at the time of discharge will receive Operation note, Discharge summary and Sick note when required.
What activity would I be able to perform immediately after surgery?
Light physical activity can be sustained immediately after surgery and full physical activity can generally be resumed after one day. The effects of injection usually become apparent in few days’ time. Patients are generally able to resume work after couple of days although a longer resenting may be granted by your doctor based on the clinical conditions.
What are the complications of this surgery?
Anal fissure surgery we offer to our patients is generally very well tolerated with low complication rate. The most common symptoms that the patients are complaining after surgery is mild perianal discomfort. Incontinence to feces in any form is not a described complication. Your doctor will be able to assess the condition after surgery on a regular basis and he will also keep you updated on how the condition is progressing. Dr Cristaldi as colorectal surgeon has performed more than 1000 surgeries for Anal Fissure mainly using Botulin Toxin injection and Fissurectomy.
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Miss Hannah Giron