Anal Fissure Treatment
| Anorectal symptoms and complaints are common and may be caused by a wide spectrum of conditions. Although most conditions are benign and may be successfully treated by primary care practitioners, a high index of suspicion for colorectal cancer should be maintained, and all patients should be appropriately investigated. Inspection, palpation and anoscopic examination using an Ive's slotted anoscope provide adequate initial assessment. Pruritus ani usually represents a self-perpetuating itch-scratch cycle and is uncommonly due to infection. The history, as well as the physical examination, can distinguish anal pain due to hemorrhoids, fissure, abscess, cancer or proctalgia fugax. The most frequent causes of rectal bleeding are hemorrhoids, fissures and polyps. Diagnoses associated with difficulty in passing stool can range from constipation to fecal incontinence. |
Patients frequently consult primary care physicians because of concerns about or symptoms related to the anorectal area. Although many anorectal conditions are benign and easily treated, patients may delay seeking medical advice because of embarrassment or fear of cancer. Thus, both malignant and nonmalignant conditions often present as advanced disease, requiring more extensive treatment and causing greater patient distress than if conditions had been adequately diagnosed and managed at an earlier stage.
Conversely, both patients and physicians should be aware of the need for adequate assessment of all anorectal symptoms because of the high incidence of colorectal cancer. The average American is estimated to have a one in 18 lifetime risk of developing colorectal cancer.This risk is equal for men and women and increases with age. In 2001, an estimated 138,000 new cases of cancer of the colon, rectum or anus will be diagnosed; these cancers will cause the death of more than 57,200 adults each year in the United States.1 In nonsmokers, colorectal cancer is the leading cause of death from cancer.
Colorectal cancer may present as rectal bleeding and coexist with a benign condition such as hemorrhoids. Every patient with anorectal symptoms, especially those with rectal bleeding, must have an assessment that includes, at a minimum, digital rectal examination and visual inspection by anoscope. Increasing access to primary care physicians leads to earlier detection of colorectal cancer.
Current American Academy of Family Physicians (AAFP) and American Cancer Society (ACS) guidelines call for screening of all patients for colorectal cancer beginning at 50 years of age in the general population and 40 years of age in those with risk factors or a family history of the disease.Family physicians can play a major role in the prompt recognition of cancer and appropriate management of other anorectal conditions. All clinicians can and must perform a basic examination to appropriately treat or refer patients with anorectal complaints. After proper evaluation, the majority of nonmalignant anorectal conditions can be treated by the primary caregiver.
Anal/Rectal Anatomy
The anus is the outlet to the gastrointestinal tract, and the rectum is the lower 10 to 15 cm of the large intestine . The valves of Houston are not true valves but are prominent mucosal folds. The dentate or pectinate line divides the squamous epithelium from the mucosal or columnar epithelium. Four to eight anal glands drain into the crypts of Morgagni at the level of the dentate line. Most rectal abscesses and fistulae originate in these glands. The dentate line also delineates where sensory fibers end. Above (proximal to) the dentate line, the rectum is supplied by stretch nerve fibers but not pain nerve fibers. This allows many surgical procedures to be performed without anesthesia above the dentate line. Conversely, below the dentate line there is extreme sensitivity, and the perianal area is one of the more sensitive areas of the body. The evacuation of bowel contents depends on action by the muscles of both the involuntary internal sphincter and the voluntary external sphincter.
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Anorectal Examination
Anorectal assessment consists of inspection, palpation and anoscopic examination. The patient can be positioned in the left lateral decubitus position for this examination and for almost all anorectal procedures. This position is much more comfortable for the patient than the traditional head-down “jackknife” position, yet still allows adequate visualization and access for the examiner.
The glutei must be spread to provide adequate visualization of the anus. If necessary, the patient can assist by raising the right gluteal area with the right hand to better expose the perianal area. Inspection alone can reveal fissures, fistulae, perianal dermatitis, masses, thrombosed hemorrhoids, condyloma and other growths.
Unless the patient is experiencing extreme pain, a digital examination should always be performed. In males, the prostate should be palpated in addition to digital assessment of the anal canal. The finger sweep must include all 360 degrees around the anal canal, and any palpable mass must be defined. Because of the redundant mucosa, small tumors may not be visualized even with the anoscope but can often be detected by palpation.
Common Anorectal Symptoms
Pruritus ani is an extremely common symptom and is associated with a wide range of mechanical, dermatologic, infectious, systemic and other conditions . Regardless of the etiology, the itch/scratch cycle becomes self-propagating and results in chronic pathologic changes that persist even if the initiating factor is removed.
ANAL PAIN
A careful history focusing on the nature of the pain and its relationship to bowel movements frequently provides the diagnosis of pain in the anorectal area. Aching after a bowel movement can occur with internal hemorrhoids. Pain during bowel movements that is described as “being cut with sharp glass” usually indicates a fissure. This pain is most intense during the bowel movement and usually persists for an hour or so afterward. It may then either abate until the next bowel movement or continue, usually to a lesser degree. The pain of anal fissure is frequently accompanied by bright red rectal bleeding and often begins after a hard, forced bowel movement.
The acute onset of pain with a palpable mass is almost always due to a thrombosed external hemorrhoid . This intense pain typically lasts 48 to 72 hours and then subsides spontaneously but may take several days to abate. Internal hemorrhoids, because they start above the dentate line, are not painful even if prolapsed or thrombosed. Similarly, rectal cancer seldom causes pain unless it is extremely advanced because of the innervation of the rectal area. Anal cancers more commonly cause pain after invasion of the sphincter muscle. Anorectal pain that begins gradually and becomes excruciating over a few days may indicate infection. A localized area of tenderness could signal an abscess. Anal pain accompanied by fever and inability to pass urine signals perineal sepsis and is a medical emergency.
RECTAL BLEEDING
Many conditions can cause rectal bleeding , but all cases of rectal bleeding must be evaluated and the cause identified. Even the occasional finding of blood on toilet paper after a bowel movement (“wipe hematochezia”) must be taken seriously. Significant pathologic conditions such as cancers and polyps can bleed intermittently. A study of patients presenting to family physicians found the most common causes of rectal bleeding to be hemorrhoids, fissures and polyps . The authors of that study concluded that if one of these common conditions were identified as the probable site and cause of bleeding, colonoscopy and other investigations were not usually necessary. Indications for further investigation include older age, significant family history of bowel disease or cancer, and nonresolution of the bleeding after treatment of the condition that is presumed to be the source of bleeding. Total colon examination is mandated if rectal bleeding is accompanied by systemic symptoms, if there is a clinical suspicion of proximal disease and when the cause of rectal bleeding cannot be readily established.
FECAL IMPACTION
Fecal impaction can present with either constipation or fecal incontinence (“overflow”). It is common in bedridden or nursing home patients or after a cerebral vascular accident and is the most common gastrointestinal disorder occurring in patients with a spinal cord injury. Medications such as narcotics predispose to this problem, and it is a common complication of anorectal procedures as a result of reflex spasm of the anal sphincter. The patient may present with acute abdominal pain or chronic large-bowel obstruction. Rectal examination reveals hard, bulky stool. Medical therapy is usually attempted first in an otherwise ambulatory patient. Careful administration of one or two enemas (Fleet) into the bolus to soften and hydrate the stool should be followed one hour afterward by the administration of a mineral oil enema to assist in passage of the softened stool.
Manual disimpaction is required in most patients. This may require a circumanal block of the anal musculature with local anesthetic. A four-quadrant field block allows for complete muscle relaxation and a painless disimpaction. After disimpaction, a bowel program that includes the use of a laxative, stool softeners and/or enemas should be initiated to prevent recurrence. If impaction recurs, it is important to rule out an anatomic cause of obstruction such as an anal or rectal stricture or tumor.
FECAL INCONTINENCE
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Fecal incontinence is the inadvertent passage of flatus, liquid or solid stool. Normal continence depends on many interrelated factors, including stool volume and consistency, colonic function, rectal compliance, rectal sensation and sphincter function. Patients may be partially or completely incontinent. It is important to rule out fecal impaction with overflow before seeking a pathophysiologic cause for uncontrolled passage of liquid stool. Patients at risk for fecal incontinence include the elderly, mentally ill and parous women, particularly those with a history of sphincter damage during delivery.
Fecal incontinence with significant decrease in sphincter tone can be caused by any prior anorectal operative procedure or birthing injury. Obstetric injury can include direct sphincter disruption (usually anterior) or injury to the pudendal nerves. Not uncommonly, these may occur simultaneously. Neuropathy, particularly that associated with diabetes mellitus, can result in fecal incontinence. Other causes include rectal prolapse, diarrheal states, radiation injury to the rectum and overflow fecal incontinence secondary to impaction.
The Authors
Parijatak Ayurveda is an exclusive Ayurvedic Hospital in Nagpur, Maharashtra, India run by Dr. Nitesh Khonde. Parijatak offers congenial surrounding for the powerful cures of the most revered, timeless healing tradition Ayurveda, to work its magic on your mind, body, and spirit. The healing methods employ time-proven strategies and the finest Ayurveda treatment in India to effect fast, yet the lasting cure. Our friendly team of distinguished Ayurvedic doctors will meet with you regularly to share your thoughts and discuss your progress, making your healing experience seamless and enjoyable.
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