The anal fissure is a longitudinal tear that appears in the most distal portion of the anal canal and may require medical or surgical anal fissure treatment in Delhi. Its most frequent location is the posterior midline (90-98%), another less common location is the anterior midline (12% of those that appear in women and 7% in men). It has an equal incidence in both sexes and is more frequent in the middle age of life. Most are of unknown origin. The most likely explanation is an acute traumatism of the anal canal, defecation (large, hard stools) and rarely due to the explosive expulsion of liquid stools. The fact that the posterior wall of both the subendothelial space and the sphincter are less vascularized makes them more vulnerable to the location of the fissures. The transition to chronicity is due both to sphincter hypertonia and to ischemia.
The presence of multiple fissures or in places other than those mentioned requires us to rule out diseases such as ulcerative colitis, Crohn’s disease, tuberculosis, syphilis, immunodeficiency syndrome … (it must be taken into account that more than half of the fissures secondary to intestinal inflammatory diseases occur in the posterior midline and are painful).
The main symptom of a fissure is a pain. It is an intense pain that is triggered by defecation, lasting in a variable way, from a few minutes to hours. There may also be bleeding, itching or itching and inflammation of the base of the fissure, which is often confused with hemorrhoid (“sentinel hemorrhoid”) and causes misdiagnosis if a laparoscopic surgeon in Delhi is not consulted.
The formation of an anal fissure results in the establishment of a “vicious circle” that hinders or prevents its healing: the existence of the fissure causes the defecation to produce pain, the pain causes a hypertonia or reflex spasm of the internal anal sphincter (responsible for the pain after defecation); hypertonia of the sphincter produces an alteration of the vascularization of the anal region that hinders the healing of the fissure, thus favoring the persistence of the “vicious circle”
It should be done with great care because given the hypertonia of the canal it is very painful. The patient is placed in the left lateral decubitus position (Sims position), the anal margins are separated and the patient is asked to perform a Valsalva maneuver (it is often necessary to previously apply a topical anesthetic or oral analgesics). Rectal examination is contraindicated due to the risk of vasovagal syncope and even cardiac arrest; if it could be done, it would show a sphincter hypertonia. Anoscopy and rectoscopy are only necessary when a secondary fissure is suspected.
The therapeutic attitude will be different before an acute form or if signs of chronicity already exist (deep fissure, sentinel hemorrhoids, etc).
In the acute phase is when medical treatment has more chances of success. This consists of :
- Abundant intake of fluids
- Diet rich in fiber.
- Additives that contain fiber such as plantago (Plantaben, cenat, etc.)
- Seat baths with warm-hot water.
- Topical ointments
- In patients with a high risk of incontinence: botulinum toxin type A
Can the fissure be operated?
It must be taken into account that medical anal fissure treatment in Delhi should always be attempted, even in chronic cases, where the percentage of success is smaller. The success rate of medical treatment is 60%.
The surgical treatment of choice is the internal lateral sphincterotomy. The intervention consists in the controlled section of the internal anal sphincter that eliminates the hypertonia of the same, disappearing the pain and getting the healing of the fissure in a few days. The operation is carried out by sedation + local anesthesia or spinal anesthesia under outpatient surgery.
Other techniques such as anal dilation have become obsolete or limited to very specific cases, especially after the demonstration of unsuspected sphincter injuries after anal dissemination in endoanal ultrasound studies.