FISSURE-IN-ANO

• An anal fissure is a longitudinal tear of the perianal skin distal to the dentate line, often due to an increased anal sphincter tone
• Patients (usually women ,between 30 to 50 years of age, sometimes in children too) frequently complain of sharp agonizing pain during defecation which lasts for one hour or more even after defecation , with streaks of blood on stool with a history of chronic constipation
• It is an elongated ulcer in the long axis of the anal canal

Sites:

• Occurs most commonly in the midline posteriorly and the least protected part of the anal canal
• Males - Fissures usually occur in the midline posteriorly (90%) and much less commonly than anterior (10%)
• Females - fissures on the midline posteriorly are slightly common than anterior

• Constipation
• Spasm of internal sphincter
• Low fiber intake
• When too much skin has been removed during the operation of haemorrhoids, anal stenosis
• In females – trauma caused by the foetal head on the anterior wall of the anal canal during delivery
• Secondary causes – ulcerative colitis, crohns’s disease, syphilis, tuberculosis, malignancy

• Sharp agonizing pain during defecation
• Pain usually follows for an hour or more after defecation
• Constipated hard stool
• Passage of bright streaks of blood along with the stool
• Slight discharge may be associated in a chronic fissure
• Pruritus ani

• O/E – sentinel tag may or may not be present
• If the margins of the anus are gently separated, the lower end of the anal fissure may be inspected
• Digital examination - not possible when intense pain is present
• Chronic fissure can be easily palpable by digital examination using 5% xylocaine ointment
• Proctoscopy
• Chronic fissure - Characteristic crater of the vertical fissure can be felt

Acute ulcer:

Conservative management

• Oral pain medication
• Stool softener
• Weak bulk laxatives or cathartics
• Nitric oxide is a neurotransmitter which induces relaxation of the internal sphincter
• Soothening ointments
• Self-dilatation
• Injection of long acting anesthetic solutions

Chronic ulcer:

Surgical-

• Lord’s procedure of anal dilatation
• Posterior sphincterotomy and fissurectomy
• Lateral end sphincterotomy
• Excision of anal ulcer
• Anal advancement flap

Ayurvedic Treatment

Internal medicines

• Gandharvahasthadi Kashaya
• Tiktaka Kashaya
• Kankayana Vati
• Vaishwanara Choorna
• Triphala choorna
• Avipathi choorna
• Kalyanaka Gudam

Procedure

• Avagaha in Triphala Kashaya
• Ext application – Sathadhouta gritha
• Anal dilation
• Apamarga Kshara Lekhana
• Jathyadi Ghrita – Varthi prayoga
• Infiltration with Yashtimadhu Ghrita , Murivenna