Anal Fissure, Abscess, and Fistula

The gastrointestinal tract is a long tube in which the digestive process occurs. It extends up to the rectum, which is continuous with the anus, the tract's outer opening through which faecal material is defecated.

The lower part of the rectum is called the anal canal. There are various clinical conditions associated with the lower part of the rectum.

Haemorrhoids are the most common ailment of GIT, and most people are aware of it. Other conditions are less common than haemorrhoids, such as anal fissures, abscesses, and fistula.

Anal fissure:

An anal fissure is a small tear in the mucosal lining of the anal canal. It is similar to the tears that occur at the corners of the mouth in some people during the cold weather.

However, anal fissure isn't caused by cold weather. Instead, the primary condition leading to anal fissure is constipation(1).

The anal canal is lined by mucosa that has specific epithelial arrangements. In constipation, the stool becomes hard and dry, and it becomes extremely difficult to pass the stool. There is the possibility that hard stool will tear away the mucosal lining of the anal canal leading to anal fissure(2).

Anal fissures can also occur during childbirth. Severe bouts of diarrhoea or inflammatory conditions of the anal canal can also lead to anal fissures.

Anal fissures are very painful, and the condition aggravates on passing the stools. It is because sensory nerve fibers richly supply the lower part of the anal canal. So, any tear in this area causes severe pain. Bleeding or itching may also be observed in the case of anal fissures.

Diagnosis of anal fissure:

An anal fissure is diagnosed by physical examination. Your physician will take a thorough history and will examine the anal region.

Usually, anal fissure is visible and physical examination is sufficient to confirm the diagnosis of anal fissure.

An anal fissure can be classified into acute or chronic. They can be differentiated by physical examination and taking history carefully.

image 14 The anal fissure that looks like a fresh tear is usually acute, while the fissure that lasts for more than eight weeks is chronic and looks like a more profound tear and has some external growths.

The location of the anal fissure also points towards its cause. Anal fissures commonly occur at the front or back of the anal canal and are usually due to physical trauma.

A fissure on the sides of the anal canal rather than front or back is usually caused by any other underlying pathology such as Crohn's disease.

Your physician may recommend other tests if he suspects any other underlying pathology. For example, depending upon the conditions, you may be advised anoscopy, sigmoidoscopy, colonoscopy, etc.

Treatment for anal fissure:

An anal fissure usually heals on its own. However, stool softeners are often used to reduce pain during bowel movements. Special ointments and creams are also used to control symptoms and speed up healing(3).

Diluted nitroglycerin is also used to improve blood flow so that the healing process speeds up. It's the same medication used to treat coronary angina.

To avoid the risk of infection, it's essential to keep the area between the buttocks clean and dry. After taking a bath, you should dry up the area using a soft towel.

Talcum powder is also applied to relieve the symptoms. A Sitz bath is also helpful in anal fissures. A Sitz bath involves soaking the anal area in plain warm water for about 15-20 minutes several times per day.

Muscle spasms or scarring can interfere with the healing process. If the fissure doesn't get well with the usual treatment, then surgery is the treatment of choice(4).

Surgical treatment is usually done on an outpatient basis. It's a minor operation that involves the removal of fissure or any scar tissue.

A small portion of anal muscle can be cut to relieve muscle spasms and improve blood flow to the affected side. It speeds up the healing process.

The healing process may take a few weeks. However, pain decreases in severity in a few days with proper management.

Taking dietary fibers in diet and adopting a healthy attitude reduces the risk of developing anal fissures(5).

Anal abscess:

An anal abscess is a pus-filled localized pocket formed due to infection caused by bacteria. An abscess may develop in any part of the human body. An anal abscess occurs when bacteria seep down in the anal canal and cause infection.

Certain diseases increase the susceptibility to an anal abscess, such as Crohn's disease, AIDS, or cancer. In addition, when a person's immune system is compromised, susceptibility to infections is greatly enhanced, causing abscess formation.

An abscess is associated with pain, swelling, and tenderness. You may also experience chills, fever, fatigue, or weakness. The symptoms are usually relieved when the pus is drained out.

Diagnosis of the anal abscess:

An anal abscess is usually confirmed on physical examination. Near the anus, it's often accompanied by severe pain, redness, or swelling.

Treatment for anal abscess:

An abscess is usually drained out surgically to promote healing and relieve the pain and pressure(6). It's usually done under local anesthetics on an outpatient basis. However, a diabetic patient may require hospitalization for the procedure.

Antibiotics are usually prescribed along with the surgical treatment of anal abscesses.

Anal fistula:

Anal Fistula A fistula is a tinny channel that usually connects two body parts such as two blood vessels, two organs, or another structure.

The anal fistula usually connects a part of the rectum to the skin around the anus and forms an abnormal opening. Certain diseases like Crohn's disease increase the risk of anal fistulas.

In women, abnormal communication may form between the rectum and vagina or between the rectum and bladder due to birth injuries.

Fistulas often get infected,
and pus is drained from them. In addition, they may irritate the skin around them.

Diagnosis of anal fistula:

An anal fistula is usually observed physically. If it opens on the skin, it's visible on general examination. However, a fistulogram, colonoscopy, and other radiographic techniques are required for detailed analysis.

Treatment of anal fistula:

Treatment of the anal fistula is greatly dependent on whether Crohn's disease or any injury causes it. If it's due to Crohn's disease, it's treated with various medications, and surgery is usually not required.

However, if it's unresponsive to medicine and is caused by injury, the treatment of choice is surgery(7). Surgery for fistula is usually a short procedure. The patient may feel discomfort for a short period.

Summary:

Anal fissure, abscess or fistula can cause pain and drainage from the anus and the surrounding area. These ailments are irritating but are easy to diagnose and treat.

If you feel discomfort or pain in the anal region, you shouldn't ignore it. Visiting a physician usually brings a good outcome.

References

1.Constipation in children and young people: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2017.

2.Patkova B, Wester T. Anal Fissure in Children. Eur J Pediatr Surg. 2020 Oct;30(5):391–4.

3.Newman M, Collie M. Anal fissure: diagnosis, management, and referral in primary care. Br J Gen Pract. 2019 Aug;69(685):409–10.

4.Fathallah N, Spindler L, Zeitoun J-D, De Parades V. [Anal fissure]. Rev Prat. 2019 Nov;69(9):1005–10.

5.Yang J, Wang H-P, Zhou L, Xu C-F. Effect of dietary fiber on constipation: a meta analysis. World J Gastroenterol. 2012 Dec 28;18(48):7378–83.

6.Ommer A, Herold A, Berg E, Fürst A, Sailer M, Schiedeck T. German S3 guideline: anal abscess. Int J Colorectal Dis. 2012 Jun;27(6):831–7.

7.Pigot F. Treatment of anal fistula and abscess. J Visc Surg. 2015 Apr;152(2 Suppl):S23-29.

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