• Acute or Chronic Fissure
• Recurrent Fissure
• Fissure Fistula
• Fistula in ano
• Recurrent fistula in ano
• Lateral anal sphincterotomy
• Fistula plug
• Flap procedures
Anal Fissure and Fistula. An anal fissure is a narrow tear that extends from the muscles that control the anus (sphincters) up into the anal canal. These tears usually develop when anal tissue is damaged during a hard bowel movement or when higher-than-normal tension develops in the anal sphincters.
Anal fistulas are generally common among those who have had an anal abscess. Treatment is usually necessary to reduce the chances of infection in an anal fistula, as well to alleviate symptoms.
An anal fistula is defined as a small tunnel with an internal opening in the anal canal and an external opening in the skin near the anus. Anal fistulas form when an anal abscess, that's drained, doesn't heal completely.
Different types of anal fistulas are classified by their location. In order of most common to least common, the various types include:
• Intersphincteric Fistula. The tract begins in the space between the internal and external sphincter muscles and opens very close to the anal opening.
• Transphincteric Fistula. The tract begins in the space between the internal and external sphincter muscles or in the space behind the anus. It then crosses the external sphincter and opens an inch or two outside the anal opening. These can wrap around the body in a U shape, with external openings on both sides of the anus (called a horseshoe fistula).
• Suprasphincteric Fistula. The tract begins in the space between the internal and external sphincter muscles and turns upward to a point above the puborectal muscle, crosses this muscle, then extends downward between the puborectal and levator ani muscle and opens an inch or two outside the anus.
• Extrasphincteric Fistula. The tract begins at the rectum or sigmoid colon and extends downward, passes through the levator ani muscle and opens around the anus. These fistulas are usually caused by an appendiceal abscess, diverticular abscess or Crohn's disease.
It is usually simple to locate the external opening of an anal fistula, meanwhile locating the internal opening can be more challenging. It is important to be able to find the entire fistula for effective treatment.
People who may have experience with recurring anal abscesses may have an anal fistula . The external opening of the fistula is usually red, inflamed, oozes pus, and is sometimes mixed with blood.
The location of the external opening gives a clue to a fistula's likely path and sometimes the fistula can actually be felt. However, locating its visual path often requires various tools, and often times it may not be seen until surgery.
Tools often used in diagnosis include:
• Fistula probe. An instrument specially designed to be inserted through a fistula
• Anoscope. A small instrument to view the anal canal
If a fistula is potentially complicated or in an unusual place, these tools may also be used:
• Diluted methylene blue dye. Injected into a fistula
• Fistulography. Injection of a contrast solution into a fistula and then X-raying it
• Magnetic resonance imaging
Tools used to rule out other disorders such as ulcerative colitis or Crohn's disease include:
• Flexible sigmoidoscopy. A thin, flexible tube with a lighted camera inside the tip allows doctors to view the lining of the rectum and sigmoid colon as a magnified image on a television screen
• Colonoscopy. Similar to sigmoidoscopy, but with the ability to examine the entire colon or large intestine
Treatment is delicately performed to reduce the risk of affecting bowel emptying, due to the anal fistulas' proximity to the anal sphincter muscles. The best approach requires that each patient is assessed individually.
Treatment of an anal fistula is attempted with as little impact as possible on the sphincter muscles. It will often depend on the fistula's location and complexity, and the strength of the patient's sphincter muscles.
Anal fissures can cause a vicious cycle in which the patient, in anticipation of pain associated with bowel movement, resists the urge to defecate, causing stools to become larger and harder, resulting in more pain with defecation. Treatment should be focused on breaking this cycle to allow healing. If the patient is having a great deal of pain, a topical anesthetic may be applied. Diet modification to soften stools is also indicated in patients with anal fissures. Patients should increase fruits, vegetables, and soluble and insoluble fibers in their diets and increase fluid intake to treat the acute phase and to prevent recurrence. Bulking agents such as psyllium may be prescribed. Approximately half of all anal fissures heal with nonoperative therapy within 2-4 weeks.
Use the WASH regimen in treatment of anal fissures, as follows:
• Warm water; sitz bath after bowel movement
• A nalgesics
• Stool softener
• High-fiber diet
Medications may also be prescribed for anal fissures, such as topical nitrates, calcium channel blockers, and onabotulinumtoxinA injections, and are considered first-line therapy. These medications reduce anal sphincter tone or vasodilate, which, in turn, increases anodermal blood flow. When conservative treatment fails, surgical therapy may be an option to treat anal fissures.
Historically, surgical therapy was common for the treatment of anal fissures and is considered superior to nonoperative therapies. However, due to the risk of complications, including incontinence, surgical therapy is often reserved when conservative treatment fails to heal anal fissures.
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