Anal Fissures: Symptoms, General Measures, and Treatment Options

Anal fissures are small tears in the lining of the anal canal, often causing significant discomfort. Below is a detailed overview of symptoms, general management strategies, and treatment options, including medications and their available brands.

Symptoms of Anal Fissures

• Constipation: Difficulty passing stools, often leading to straining.
• Perianal Pain and Itching: Persistent discomfort and itching around the anal area.
• Perianal Irritation: Redness and soreness in the anal region.
• Bleeding: Small amounts of bright red blood, typically seen as streaks on the side of stools.
• Visible Tear: A longitudinal tear in the midline posteriorly, sometimes covered by a skin tag, with localized inflammation and hardening.

General Management Strategies

1. Hydration: Drink 6-8 glasses of water or other fluids daily to soften stools.
2. Dietary Fiber: Include fiber-rich foods like vegetables, fruits, and whole grains (e.g., brown rice) to prevent constipation.
3. Sitz Baths: Soak the perineal area in lukewarm water for 15-20 minutes to relieve pain and muscle spasms. Adding antiseptics or potassium permanganate (KMnO4) can enhance healing.

Pharmacological Treatments

Here are the medications commonly used for anal fissures, along with their available brands:

1. Metronidazole (400mg)
   • Brands: Flagyl, Metrozine
   • Dosage: 1 tablet three times daily (TDS).
2. Cephalexin (250mg or 500mg)
   • Brands: Ceporex, Keflex
   • Dosage: 1 capsule two to three times daily (BD/TDS).
   • Alternative: Cefixime (400mg)
     • Brand: Cefiget
     • Dosage: 1 capsule once daily (OD).
3. Esomeprazole (40mg)
   • Brands: Esso, Nexum
   • Dosage: 1 capsule once daily at night.
4. Glyceryl Trinitrate (GTN) Ointment (2%)
   • Use: Applied topically to relax the anal sphincter.
   • Side Effect: May cause severe headaches.
5. Lidocaine Jelly (2%)
   • Brands: Xyloaid, Lignocaine
   • Use: Applied as a local anesthetic to numb the area and reduce pain.
6. Laxatives
   • Syrups:
     • Duphalac or Cremaffin
     • Dosage: 2 teaspoons three times daily (TDS).
   • Ispaghula Husk:
     • Dosage: 2 or 3 TSF in 1 glass water, leave it for 2-3 hours, twice daily.

The Role of Sitz Baths

Sitz baths are highly effective for relieving pain and promoting healing after perineal surgeries or conditions like hemorrhoids, fissures, or fistulas. The process involves sitting in a shallow tub of warm water with the perineal area submerged. Warm water acts as a vasodilator, relaxing muscles and reducing swelling. Adding antiseptics or potassium permanganate (KMnO4) can further aid in healing and prevent infection. A typical session lasts 15-20 minutes and can be repeated multiple times a day for optimal results.

Surgical Options for Anal Fissures

When conservative and pharmacological treatments fail to heal chronic anal fissures, surgical intervention may be required. Surgery aims to reduce anal sphincter hypertonicity, improve blood flow to the fissure, and promote healing. Below are the primary surgical options:

1. Lateral Internal Sphincterotomy (LIS)

• Procedure: This is the most commonly performed surgical procedure for anal fissures. The internal anal sphincter is divided laterally (away from the fissure) to reduce spasm and improve blood flow to the fissure.
• Techniques:
  • Closed Method: A small incision is made over the intersphincteric groove, and the internal sphincter is divided under direct vision.
  • Open Method: The anoderm is incised to expose the internal sphincter, which is then divided under direct vision.
• Advantages:
  • High success rate (90-95%).
  • Immediate relief from pain.
  • Faster healing compared to non-surgical treatments.
• Risks:
  • Risk of incontinence (up to 30% in some studies), particularly in women or those with pre-existing sphincter weakness.
  • Other complications include hemorrhage, hematoma, perianal abscess, and fistula formation.

2. Anal Advancement Flap

• Procedure: This technique is particularly useful in patients with normal or low resting anal pressures or those at high risk of incontinence (e.g., women with prior obstetric trauma). The fissure edges are excised, and a mobilized skin flap is advanced to cover the fissure base.
• Advantages:
  • Preserves sphincter integrity.
  • Effective for chronic fissures with poor healing potential.
• Risks:
  • Minor breakdown of the flap edges may occur but does not necessarily lead to failure.
  • Longer healing time compared to LIS.

3. Posterior Sphincterotomy

• Procedure: The internal sphincter is divided in the posterior midline, directly at the fissure site. This method is less commonly used today due to the risk of a “keyhole deformity,” which can lead to passive fecal leakage.
• Indications: May be considered if there is an associated intersphincteric fistula.
• Risks:
  • Prolonged healing time.
  • Higher risk of incontinence compared to lateral sphincterotomy.

4. Manual Dilatation of the Anus (MDA)

• Procedure: The anal sphincter is manually stretched under anesthesia to reduce sphincter tone. This method is now less popular due to the uncontrolled nature of the stretching and the high risk of incontinence.
• Advantages:
  • Simple and quick procedure.
• Risks:
  • High risk of incontinence due to potential damage to both internal and external sphincters.
  • Less predictable outcomes compared to LIS.

5. Botulinum Toxin (Botox) Injection

• Procedure: Although not a traditional surgery, Botox injections are a minimally invasive option. Botox is injected into the internal sphincter to temporarily paralyze the muscle, reducing spasms and allowing the fissure to heal.
• Advantages:
  • No incision required.
  • Lower risk of incontinence compared to surgical sphincterotomy.
• Risks:
  • Temporary effect (lasts 2-3 months).
  • May require repeated injections.
  • Possible recurrence after the effect wears off.

When is Surgery Recommended?

Surgery is typically considered when:

• Symptoms persist for more than 6-8 weeks despite conservative treatment.
• The fissure is chronic or recurrent.
• There is significant pain, bleeding, or impact on quality of life.

Summary of Surgical Options

1. Lateral Internal Sphincterotomy (LIS): Gold standard for most patients.
2. Anal Advancement Flap: Preferred in high-risk patients (e.g., women with prior obstetric trauma).
3. Posterior Sphincterotomy: Rarely used due to high risk of incontinence.
4. Manual Dilatation of the Anus (MDA): Largely obsolete due to high risk of complications.
5. Botulinum Toxin (Botox) Injection: Minimally invasive option with temporary effects.