Fissures - in - Ano (Parikartika)
What are fissures ?
  • Superficial linear tear in the squamous epithelium of the anal canal distal to the dentate line.
  • Most commonly caused by passage of a large, hard stool.
  • In the short-term, usually involves only the epithelium and, inthe long-term, involves the full thickness of the anal mucosa
What are the symptoms of fissures ?
  • An anal fissure, a thin slit-like tear in the anal tissue, is likely to cause itching, pain, and bleeding during a bowel movement.
  • A fissure produces pain at defecation and persists for hours.
  • A small amount of bright red blood, which may or may not be mixed with stool, is common.
  • Swelling over anal region: patient with a large sentinel tag may complaint of a painful external swelling over anal region.
  • A fissure produces pain disproportionate to its size. It is the third most painful common condition affecting the anus; the second most painful condition is an anal abscess, the first most painful condition is recovering from recent anal surgery.
  • Rarely, a spasm of the levator ani muscles, also known as proctalgia fugax, can be associated with chronic anal fissures. This condition may contribute to lack of healing of fissures... or may be caused by it.
How common are fissures ?
  • Anal fissures are common in infancy, and they represent the most common cause of bright rectal bleeding at any age.
  • The site of affinity for an anal fissure is mid line posterior. The next most frequent situation is the mid line anterior and exceptionally it is found elsewhere on the circumference of the anus.
  • In woman, the anterior anal fissure is common; whereas in men, posterior anal fissures are common.
  • If not promptly diagnosed and treated, these small tears and their occasionally associated superficial infection cause severe ano-rectal pain during bowel movements and set in motion a cycle of stool negativism, constipation, and increasing pain with subsequent defecation
What causes fissures ?

    Anal fissures are most commonly caused by damage to the anus or the anal canal. Most cases first develop when a particularly hard or large stool damages the anal canal.

    The main causes of anal fissures include:

  • constipation which can cause people to strain when passing a stool
  • diarrhoea particularly reoccurring (chronic) diarrhoea
  • inflammatory bowel disease (IBD) such as Crohn s disease and ulcerative colitis
  • pregnancy your risk of developing an anal fissure is increased during the third trimester of pregnancy (from week 29 to birth)
  • childbirth the continual straining of your muscles during childbirth can cause the lining of your anus to tear
  • a sexually transmitted infection (STI) if the lining of the anus becomes infected it can cause the tissue to break down, leading to an anal fissure
    • STDs known to affect the anus include:
  • syphilis a bacterial infection that causes a wide range of symptoms
  • human papilloma virus (HPV) the virus that causesgenital warts
  • herpes a viral infection that can cause blistering around the genitals
  • chlamydia a bacterial infection that can cause pain when passing urine but often shows no symptoms
Chronic anal fissures

Some people may have underlying problems with the ring of muscle that surrounds their anal canal, known as the internal sphincter. These problems can prevent the anal canal from healing in the normal way, leading to the development of chronic anal fissures.

It is thought that some people have a sphincter muscle that is larger than normal, which produces muscle tension stronger than normal. The increased muscle tension causes increased pressure in the anal canal, making it more susceptible to tearing.

The increased pressure in the anal canal also restricts the blood flow to the anus. Reduced blood flow prevents your body from being able to heal itself as well as it usually can, making it difficult for your fissure to heal naturally. Furthermore, each time that you pass a stool, the injured tissue inside the anal canal is further damaged. This may be why some people develop chronic anal fissures.

Another common problem is that some people try to avoid passing stools due to the pain of an anal fissure. This can trigger the symptoms of constipation, which means that the fissure

How are fissures diagnosed ?
  • Diagnosis can be made by inspection. Closer inspection will frequently reveal a tag or sentinel pile.
  • After gentle separation of the skin of the anal verge, the ulcer usually posterior can be seen. Frequently the fibers of the internal anal sphincter muscle can be seen at the base of this punched-out ulcer.
  • A well-lubricated finger with lidocaine ointment and a small caliber anoscope will help delineate the extent of the lesion.
  • A colonoscope or sigmoidoscope exam might be useful to rule out abscesses, colitis, and other causes of rectal bleeding.
  • A fissure should be distinguished from an ulcer caused by Crohn's disease, leukemia, or malignant tumors, because it is not shaggy, large or indolent. Fissures are seldom multiple.
  • A biopsy can help to determine the diagnosis.
How are fissures treated ?
  • The majority of anal fissures do not require surgery. The most common treatment for an acute anal fissure consists of making the stool more formed and bulky with a diet high in fiber and utilization of over-the-counter fiber supplementation (totaling 25-35 grams of fiber/day). Stool softeners and increasing water intake may be necessary to promote soft bowel movements and aid in the healing process. Topical anesthetics for pain and warm tub baths (sitz baths) for 10-20 minutes several times a day (especially after bowel movements) are soothing and promote relaxation of the anal muscles, which may help the healing process.
  • Other medications (such as nitroglycerin, nifedipine, or diltiazem) may be prescribed that allow relaxation of the anal sphincter muscles. Your surgeon will go over benefits and side-effects of each of these with you. Narcotic pain medications are not recommended for anal fissures, as they promote constipation. Chronic fissures are generally more difficult to treat, and your surgeon may advise surgical treatment.
What are the complications in surgical mangement?

    Sphincterotomies (cutting the anal sphincter) are normally performed in the lateral quadrants as most fissures are posterior or anterior and cuts would not heal due to impaired blood supply and spasm.

    The very common complications of Sphincterotomy includes :
  • Infection
  • Bleeding
  • The most feared incontinence
  • fistula development
  • Anal abscess etc.
AAHARA & VIHARA (DIET & LIFE STYLE MANAGEMENT) :
  • simple diet and lifestyle changes often reduce the wounds of fissures and relieve symptoms of pain and bleeding.
  • eating a high-fiber diet can make stools softer and easier to pass, reducing the pressure on fissures caused by straining
  • good sources of fiber are fruits, vegetables, and whole grains. These fibers cannot be digested by the human body but helps in improving digestion and preventing constipation
  • regular intake of takra(butter milk), mooli (radish), soorana (yam) are very much useful in healing of anal fissures
  • drinking six to eight glasses of water or other non-alcoholic fluids each day.
  • sitting in a tub of warm water for 10 minutes several times a day
  • exercising to prevent constipation
  • Avoid straining during bowel movements
MEDICAL & NON-SURGICAL MANAGEMENT IN AYURVEDA :
    Conservative treatment:

    Avoidance of constipation:

  • It is important because, the repeated anal trauma, while passing hard faecal matter, iti is to be avoided for rapid healing of the fissure without any other treatment. This can be achieved by the use of mild aperients and laxatives.
  • In case the fissure heals up completely then care should be taken for the regular bowel habits, till the patient feels that he can manage the smooth bowels without a laxative. Care should be taken that the stools are not made watery.
  • Diet plan & regime:
  • Warm sits bath:
  • Patient should be advised to have warm sits bath preferably by adding some antiseptics, anti-inflammatory e.g. panchvalkala kwath (decoction made of five specific Ayurvedic herbs)
Local medication:
  • Instillation of Ayurvedic healing oil (e.g. jatyadi oil) at frequent intervals and after passing stools; For healing of anal fissure , frequently apply of Ayurvedic healing oil/ astringent ointment over the wound; Application of Matra basti - Ayurvedic medicated enema made of Ayurvedic herbal oil
Oral medication:
  • Patient has to be treated with Ayurvedic herbal drugs which are having tanulomana & Agnidipana effects as per given by the Ayurvedic classical texts such as,
  • Haritaki Powder (Latin name:Terminalia Chebula) with Jaggery (2-3 times a day)- orally
  • Haritaki Powder (Latin name:Terminalia Chebula) with Dry zinger power, in equal portions followed with luke warm water (2-3 times a day)- orally
  • Abhayarishta orally
  • Takrarishta- orally
  • Agatsya Haritaki avleha- orally
  • Application of Jatyadi oil- Local application
  • Ancare ointment- Local application
  • Proper anal hygiene and the use of anaesthetics:
Non-Surgical procedure :
  • Gudavidarana: Manual dilatation of anal canal along with applications of specialized Ayurvedic compound herbal ointments/oils/malams under quite aseptic precautions in a pain free way securing haemostasis.
  • This non-surgical procedure is much reliable and more effective treatement which has no complications with significant outcome.