In this episode of PodMD, experienced General Surgeon Mr Rajesh Singh will be discussing the topic of anal fissures, including what anal fissures are, how a patient would typically present, the treatment options available, its likelihood of recurrence, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Mr Rajesh Singh
Mr Rajesh Singh is an experienced General Surgeon providing care in Perth.
Mr Singh completed his General Surgery training in Western Australia as a fellow of the Royal Australasian College of Surgeons. Following this, he moved to the Northern Territory and worked as a consultant General surgeon at Alice Springs Hospital. This role gave him the unique opportunity to manage complex cases with a specific focus on emergency surgery.
Today, we’ll be discussing the topic of Anal Fissures.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Rajesh, thanks for talking with us on PodMD today.
Rajesh: Thank you for having me.
The topic of today’s discussion is anal fissures. Rajesh, can you give us a brief overview about anal fissures?
Rajesh: An anal fissure is a painful linear tear in the skin or what we call anoderm of the annual canal. Officially it may be classified as an acute or chronic, depending on the time course of the fissure, Acute anal fissure as the name implies, typically present for less than 8 to 10 weeks, while a chronic fissure may be present for over more than 12 weeks.
Typically this is a condition of young adults, but it can be found in patients of all ages. In the chronic anal fissure, there are couple of other findings which can be identified by the physician, especially there is a skin tag what we call Sentinel pile, and in a chronic fissure, you can sometimes see the fibres of the sphincter at the base of the ulcer. Now, 90% of these anal fissures are found in the posterior midline of the anal canal. But a small percentage can be found in the anterior midline of the annual canal. Thank you.
How would a patient with Anal Fissures typically present?
Rajesh: Yeah so characteristically, the patients usually report a very sharp pain which is provoked with opening on the bowels. And this pain can last from few minutes to hours after the evacuation of bowel, and this is the most common symptom. In addition, patients may report noting bright red blood on the toilet tissue. But it can also be seen in that toilet bowl sometimes. However, this is not uniformly present.
The pain which is associated with the passage of stool can be severe leading to avoidance of going to open the bowels and this can lead to Constipation. Some patients also complain of urinary retention or mucous anal discharge. But these are less frequent than the cardinal symptoms of pain and bleeding. The diagnosis of the condition can almost be made based on the patient’s history. All that is often required on examination is a gentle retraction of the buttocks to see the linear tear in the anatomy.
What is the aetiology of the condition?
Rajesh: Yeah, the cause of this condition is because of the passage of hard stool that causes trauma to the anoderm which is the skin of the annual canal. However, diarrhoea which is associated with multiple bowel movements can also cause trauma to the anal canal, leading to a fissure. Occasionally there are other causes of trauma, such as anal interceptive intercourse, rectal foreign body, and obstetric trauma, and unusual causes like inflammatory bowel disease such as Crohn’s, or a malignancy. And even sexually transmitted diseases like HIV can lead to anal fissure.
What are the treatment options?
Rajesh: Treatment of anal fissure can be divided into supportive care or pharmacological treatment and surgical treatment. The non-surgical or the supportive care like stool softeners, bulking agents, sitz bath, local anaesthetic ointment with or without topical steroids, is termed the best supportive care. And these management can be used for up to four weeks. And if the best supportive care is not effective, and the symptoms don’t resolve fairly expeditiously, then it may be necessary to escalate the treatment.
And among the many pharmacological treatments available, there have been several meta-analysis which have fairly consistently found that Nitroglycerin ointment, Calcium channel blocker ointments, as well as Botox or botulinum toxin are the three most successful medical therapies with the cure rate of up to 60 to 70%. However, if the medical treatment fails surgical treatment is possible. And this is reserved for only those people who have failed their medical treatment.
Surgical treatment used to be is sphincter stretching traditionally, which is by either fingers or by balloon dilatation, however, a procedure called lateral sphincterotomy has now supplanted the annual stretching techniques, with the cure rate of 98%. However, there is a 1% risk of incontinence.
And there are certain contraindications to surgical therapy, especially in patients who have got inflammatory bowel disease. You cannot offer them surgery and also postpartum women, where sphincter damage is suspected. The another when everything fails, there is another treatment called advancement flaps which are very advanced surgical techniques that can be offered to the patient.
Are there any warning signs a GP or their patient can look out for?
Rajesh: Thank you, that’s a very good question. Now commonly, as I mentioned, the fissures are usually present in the posterior midline of the anal canal and in small proportion of cases they can be seen in the anterior part of the anal canal. However, if their fissures are found in any other position, it should raise the suspicion of unusual causes like inflammatory bowel disease or malignancy, so I think that this is very important to be mindful of.
Also, if on examination if you do not see a linear tear in the anoderm and the patient has pain, then a suspicion of another form of sepsis, known as perianal sepsis, like an Abscess outside or inside the inner canal should be suspected. I also will emphasise that patients who present with bleeding PR and have a history of malignancy in their family should definitely be investigated with the colonoscopy.
What is the likelihood of recurrence of the condition?
Rajesh: Recurrence can occur on a long term or short term, and in cases who have recurred, we should revisit the medical history and try to find out if there’s any underlying pathological causes, especially any what we call as evacuator dysfunction of the bowel, and the most common contributing factor for the persistent of anal fissures is reported to be increased resting annual canal pressure, so examining or measuring the annual pressure with the anal manometry an also be helpful to diagnose the cause of recurrence.
When should a GP refer?
Rajesh: Yeah, so I would suggest that three main reasons when a GP should refer. First of all if the fissures fail to heal with the best supportive measures like bulking agents, topical steroids and sitz bath. If the GP is suspicious of the lesion as being something else like inflammatory bowel disease, or malignancy. And of course, chronic anal fissure which usually don’t respond to the supportive care or the medical treatment, and more often than not they need a surgical treatment. Thank you.
What role does the GP play in the treatment of the condition?
Rajesh: GP has a very important role to play in this condition because most of the patients will initially present to their doctor with acute pain and GP is in the best position to take a history and examine the patient and even start the initial best supportive management and the vast majority of the patients will heal if it’s an acute annual fissure. GP is also the most important link between the specialist and the patient, especially in coordinating surgical follow up plans.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on anal fissures?
Rajesh: Thank you, I would say the three most important take home messages, anal fissures can be acute or it can also be a chronic. Acute annual fissures usually heal with medical therapy, while chronic anal fissure most of the time will need a surgical management. A GP has to remain vigilant to exclude underlying other causes like inflammatory bowel disease and malignancy. Last but not the least, follow up after resolution of the symptoms is very important to make sure they don’t recur. Thank you.
Thanks for your time and the insights you’ve provided.
Rajesh: Thank you