Pain in Anus and Anal Fissure
Lots of people suffer from pain in anal canal. It is a distressing and annoying symptom. Fissure means an ulcer or a crack in anal canal. Anus means the passage through which we pass motion and wind. Anal fissure are of two types-Acute and chronic. Acute anal fissure causes severe pain during passing motion. In chronic anal fissure intensity of pain varies. It can occur at any age, I have seen patient as young as 40 days old. Young adults and adults suffer more. It affects both sexes equally.
Causes and how it happens:
It occurs usually due to constipation and application of force to pass motion. It is thought that hard motion tears the anal canal. It occurs less in those subjects who take food containing sufficient amount of fibre. Among fibre containing food are vegetables, raw fruits, isphagula husk etc. It has no relation with consumption of tea, coffee or wine. Frequent passage of motion and diarrhoea increase the likelihood of being attacked with fissure. During the attack it is hard to examine the inside of anus. Scientists have measured the pressure of anal canal and found that the pressure of anal canal does not rise during this period.
Main symptom of anal fissure is pain and bleeding. This kind of pain usually happens after passing motion and it may continue for few minutes to many hours. I have seen many patients complaining of pain for 24 hours. I saw about 6 patients in last nine months who complained of extreme pain in anus and could not pass motion and wind. The patients themselves asked me to do operation urgently.
'Proctalgia Fugax' is a kind of disease in which there is pain in anus but it does not have any relation to passing motion. Patients with thrombosed piles also complain of pain in anus. In this condition they complain of a lump in anus.
In anal fissure bleeding is usually minimal but I have seen patients complaining of profuse bleeding. I have met an young officer who had profound anaemia due to bleeding.
People with chronic (long standing) anal fissure complain of a different kind of symptom. They complain of lump, discharge of pus, itching or a protruding skin tag in anus.
In this condition there may or may not be any bleeding. Pain is usually slight or sometimes there is no pain at all except while passing hard motion.
Patients with anal fissure sometimes complain of urinary trouble and female patients occasionally feel pain during sexual intercourse. Though patients realise that this problem had perhaps arisen from constipation they don't respond to natures call due to fear of pain. This aggravates the constipation further. In this way I have met patients who pass motion once in seven to ten days.
Acute anal fissure:
In this stage there is severe pain and variable bleeding. Anus looks very much contracted. It is not possible to see the fissure inside because of severe pain. It's very hard to introduce any instrument inside.
Chronic anal fissure:
Chronic fissure is that when it is limited within a circumscribed margin. In this stage there is a tag of skin which hangs down. Inside the anus also there is a tumour like piece of meat called hypertrophied anal papilla.
Many doctors confuse it with a tumour. In this situation interior of the anus and rectum should be tested with instruments called sigmoidoscope or colonoscope so that we can identify any tumour or inflammatory cause. This fissure can sometimes get infected and cause abscess which ultimately leads to fistula formation and discharge of pus.
One should take care of his bowel so that constipation does not occur and during defecation one should not apply much force. We should give up the habit of going to the toilet frequently. If there is diarrhoea it should be treated immediately.
Conservative treatment :
If treatment is started soon after the problem starts there is a great chance that the patient will be cured without operation. We prescribe different kind of medicine to make stool softer, fibre containing diet to increase the volume of stool and some pain killer is used.
Sitz bath (Hip bath) is very much helpful. This is done by immersing the hip into a half filled bowl of warm water containing salt. If this does not cure the condition and If the disease continue for long time then there is less likelihood that the problem will be over without operation.
Surgical Treatment :
Dilatation of anal canal
Now a days this operation is not done because of it's poor result.
In this operation internal sphincter is divided. No need for full anaesthesia. We usually employ spinal anaesthesia in which half of the body below the umbilicus is made senseless.
Total two days hospital stay is necessary. The patient can lead normal life after 3-7 days. The success rate of this operation is 95-99%.
In my view perhaps this is the commonest anal canal problem in our country. If the patient reports early conservative treatment is satisfactory. In chronic case (long standing) operative treatment is usually required, Result of operation is excellent. So far I have never had any failure after this operation. I saw many patients saying, Doctor I have a small fissure which is so painful but how painful it will be after you operate there! I can assure all patients that the comfort of passing motion will be as normal as you had before this disease.
In last nine years We have done research on 29,635 patents all having problem in anal canal, of these 35% was anal fissure, 18% piles, 15% fistula, 2.6% cancer, 3.3% rectal polyp etc. In my series 76% anal fissure patients were cured without operation and 23% patients required operative treatment.
After operation 96% patients were cured permanently. Full anesthesia is not required for this operation but anesthesia of the lower part of body is enough. Patient will be awake during operation. If anybody wants to sleep that is also possible. Patients need to be hospitalised for 2-3 days. After operation passing stool is usually painless.
No patient had any kind of incontinence. But if the operation is not done in proper technique there is chance of incontinence, that is, the patient may find difficulty to hold stool.
PROFESSOR DR. AKM FAZLUL HAQUE, MBBS, FCPS, FICS
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