2Anal Fissurean unnatural crack or tear in the anus, usually extending from the anal opening and located posteriorly in the midline. This location is probably because of the relatively unsupported nature of the rectal wall in that location.
4Etioloogy / Pathophysiology Most anal fissures are caused by stretching of the anal mucosa beyond its capability. Various causes of this fissure include:Straining to defecate, especially if the stool is hard and drySevere and chronic constipationSevere and chronic diarrhea
5Etioloogy / Pathophysiology Crohn's disease and Ulcerative colitisAnal sex or dildo useAnal stretchingInsertion of foreign objects into the anusTight sphincter musclesExcessive anal probing
6Clinical Mainfestations The symptoms of anal fissure include:Pain during, and even hours after, defecationVisible tear in the anusBlood on the stool or on toilet paper or toilet bowlConstipationBurning, possibly painful, itch
7Medical ManagementMost anal fissures are shallow or superficial (less than a quarter of inch or 0.64 cm deep). These fissures self-heal within a couple of weeks. While waiting for the fissure to heal, topical or suppository containing anti-inflammatory agents and local anesthetic can be used. Furthermore, treatment used for hemorrhoid such as eating a high-fiber diet, using stool softener, taking pain killer and having a sitting bath
8Medical ManagementPainful deep fissures, on the other hand cut through the sphincter muscle thus making it prone to spasm, which exacerbates the fissure and aborts the healing process. Medications such as nitroglycerine and nifedipine ointments can relax the sphincter muscle
9Medical ManagementSurgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. Procedures include:Internal lateral sphincterotomy or excising a portion of the sphincterAnal dilation or stretching of the anal canal is no longer recommended because of the unacceptably high incidence of fecal incontinence
10Anal Fistula Abnormal opening on the cutaneous surface near the anus. Abnormal connection between the epithelialised surface of the anal canal and (usually) the perianal skinUsually this is from a local crypt abscess and also is common in Crohns.
12Symptoms Anal fistulae can present with many different symptoms: Pain Discharge - either bloody or purulentPruritus ani - itchingSystemic symptoms if abscess becomes infected
13Objective The opening of the fistula onto the skin may be seen The area may be painful on examinationThere may be rednessAn area of induration may be felt - thickening due to chronic infectionA discharge may be seen
14Medical ManagementDoing nothing - a drainage seton can be left in place long-term to prevent problems. This is the safest option although it does not definitively cure the fistula.Conversion to a cutting seton - this involves a similar process to a draining seton but the suture is tied tightly. This gradually cuts through the muscle and skin involved, leaving behind a small area of scarring. This cures the fistula in most cases, but can cause incontinence in a small number of cases, mainly of flatus (wind).
15Medical Managementinvolves an operation to cut the fistula open and let it heal naturally. This cures the fistula but leaves behind a scar, and can cause problems with incontinence. This option is not suitable for complex fistulae, or those that cross the entire anal sphincter.Fibrin glue injection is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient.
16Medical ManagementFistula plug is an "advanced" version of the fibrin glue method. It involves "plugging" the fistula with a "plug" made of porcine small intestine submucosa (sterile, biodegradable), fixing the plug from the inside of the anus with suture, and, again, letting the fistula heal "naturally" from the inside out. According to some sources, the success rate with this method is as high as 80%.
17Medical ManagementEndorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The external opening is cleaned and sutured. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula.