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An anal fissure is synonymous with fissure in ano. It is an elongated ulcer in the long axis of the lower anal canal. It is one of the most painful conditions resulting in a lot of discomfort and embarrassment to the patient.

Symptoms of Fissure
This condition is more common in women and generally occurs during the meridian of life.
Sharp, agonizing pain during defecation and great integrity, may last for an hour or more. The patient is comfortable until the next defecation, periods of remission occur for days or weeks.
Due to severe pain during defecation, the patient tends to become constipated. He has to take some laxative to move his bowels.
This is painful, occurs at the end of defecation. It does not cause anemia.
A slight discharge accompanies fully established cases. This causes itching.

Causes of Fissure in Ano
  1. Chronic constipation: Due to overeating, eating a diet that is less in fiber (in a non–vegetarian diet) leads to constipation. Hard stools cause damage to anal epithelium, leading to fissures.
  2. An incorrectly performed operation causes hemorrhoids in which much skin is removed. This results in anal stenosis and tearing of the scar when hard stools are passed.
  3. Inflammatory bowel diseases, particularly Cohn’s disease.
  4. Sexually transmitted diseases.
Pathophysiology with Anatomical Considerations
The commonest site of the anal fissure is posterior midline. The posterior wall of the rectum is curved forwards from the hollow of the sacrum to join the anal canal, which then turns sharply backwards. During defecation the pressure of a hard fecal mass is mainly on the posterior anal tissues, in which event the overlying epithelium is greatly stretched and, being relatively unsupported by muscle, is placed in a vulnerable position when a fecal mass is being expelled. So, in 90% of the cases, the fissure is situated in the midline in the posterior.

The next common situation is the midline in the anterior. This is much more common in females, particularly in those who have borne children. This can be explained by the lack of support of the anal mucus membrane by a damaged pelvic floor and an attenuated perineal body. The upper internal end of the fissure stops at the dentate line. Since the fissure occurs in the sensitive epithelium of the lower half and the anal canal, pain is the most prominent symptom.
Every patient of anal fissure lands into a vicious cycle.

Cases of fissure in ano can be categorized into acute and chronic – depending on the duration of the disease.
  1. Acute:
    • Short history.
    • Inflammatory.
    • Induration is less.
    • There is always accompanying spasm of the internal sphincter.
  2. Chronic:
    • Long history.
    • Associated with edematous skin known as, “Sentinel pile”.
    • It has inflamed and markedly indurated margins and base.
    • There may be spasm of the internal sphincter.
Clinical Examination of Fissure in Ano
On local examination, a sentinel pile is noticed. At its base, longitudinal tissue can be seen. The anus is puckered and tightly closed.

The digital examination of the rectum is very painful. If some other pathology is suspected, it is done only after application of a surface anesthetic such as 5% xylocaine. If there is a strong suspicion, inflammatory bowel disease such as Cohn’s disease or carcinoma and an anal examination is in order with general anesthesia being recommended.

Routine investigations viz. hemogram, and routine urine analysis are done for evaluation and anesthesia fitness.

Management of Fissure in Ano
The main objective of all management for this condition is to obtain complete relaxation of the internal sphincters. This relaxation will allow healing of the fissure.
The main symptom of the disease is severe, intense pain, which demands urgent relief.
Conservative Management
  1. Application of 5% xylocaine (water soluble).
  2. Diet alteration: Restriction of non–vegetarian products, and spicy food.
  3. Sitz bath: Warm water fomentation helps in reducing edema and sphincter spasms.
  4. Administration of antibiotics covering both gram positive and gram negative with anaerobic organisms.
  5. Laxatives: To soften stools.
If the above conservative treatment does not provide pain relief, surgical treatment is preferred.
Surgical Management
Land’s dilation: 3 x 3 fingers to 4 x 4 finger dilatation is done under general anesthesia. This is a day care procedure, the patient can go home the same day in the evening. The patient should be warned that there may be some minor fecal incontinence lasting probably a week to 10 days.

Management of Chronic Anal Fissure
This condition does not respond to conservative management. Medical therapy is given only to those patients who refuse surgery or are unfit for anesthesia.

Surgical Procedures of Fissure in Ano
One of the following procedures is done:
Lateral Anal Sphincterotomy
This can be done under local anesthesia. But, General Anesthesia is preferred. The internal anal sphincter is divided from the tissue itself – usually either in the eight o’clock or the left lateral position. The procedure can be done by the open or closed method. The healing is usually complete within three weeks. This can be done as a day care procedure.
Dorsal Fissurectomy And Sphincterotomy
In this operation, transverse fibers of the internal sphincter are divided in the floor of the fissure. At the same time, the sentinel pile is excised. Here also treatment is completed in three weeks’ time.

Post–Operative Care
  1. The patient has to take laxatives for smooth, semi–solid stools, analgesics to relieve pain and antibiotics to prevent infection.
  2. A topical (local) anesthetic gel like 2% xylocaine gel should be applied to the wound to avoid pain.
  3. Sitz bath: The patient should be bathed in warm water (in which potassium permagnate or Dettol should be added) for about five to 20 minutes.
  4. After the operation, the patient may pass a few drops of blood during defecation. It stops on its own as the wound of the fissure starts healing. The patient must avoid getting hard stools during the early post–operative phase because it may trigger bleeding and pain.