Fixing those
fissures
By Esther Williams
Embarrassing though they may be, fissures, fistulas and haemorrhoids
need to be treated. "As there is bleeding in each of the conditions,
patients need to assure themselves that it is not due to something
more sinister like cancer," explains Consultant Surgeon from
the University of Kelaniya, Prof. Kemal Deen.
Fissures: An anal fissure is a tear in the skin around the opening
of the anus that can cause intense pain, especially when opening
the bowels. A common occurrence among young and middle-aged men
and women in Sri Lanka, fissures are seen more often in those who
are stressed.
The wound that occurs in the posterior anal passage is temporary
and will heal automatically in 7-10 days if you do nothing. However
the pain is severe especially during or after a bowel movement most
often accompanied by bleeding.
Although the exact cause is unknown, fissures that are easily confused
with haemorrhoids are caused due to the lack of nitric oxide in
the muscles surrounding the anal passage. According to Prof. Deen,
it causes the sphincter muscle to contract tightly, restricting
blood supply and oxygen to the lining causing a longitudinal split
or ulcer that results in a fissure.
Fissures are also linked to constipation where straining on hard
or large stools can tear the skin of the anus.
For acute or first time fissures, treatment includes medication
to relieve patients of pain. This may come in the form of local
aesthetic gels/paste or painkillers (tablet or local application).
Laxatives are recommended for soft bowel movement and sitting in
a warm bath of water to relieve spasms in the sphincter. Occasionally
doctors recommend the use of a nitric oxide donor agent called GTN
(Glyceryl Tri Nitrate) paste. This, however, is not popular as it
can cause intense headaches.
The professor is emphatic about the significant role diet plays
in treatment of fissures. A diet rich in fibre, laxative fruits
such as sour bananas, papaya, prunes and raisins and at least 1
½ litres of water is suggested in the bowel management programme
he recommends.
Should patients with chronic anal fissures find little relief from
a bowel management programme, surgery (under local anaesthesia)
becomes imperative especially if the patient's quality of life is
impaired and if the recurrent spells are frequent. The aim of surgery
is similar to that of medicines - to relieve excessive pressure
within the anal canal. This, however, is the last resort.
Fissures cannot be prevented but can be stopped from getting worse
through diet. While stress can make the condition worse, spicy food
can make the bowel movement painful.
Fistulas: More common in Eastern people a fistula occurs when there
is an abnormal connection between the anal canal and the superficial
peri-anal skin. When this happens the anal glands get infected and
pus accumulates forming painful discharging wounds that recur frequently
around the anus.
Dr. Sanjay Abeygunawardena, (Department of Surgery, University of
Kelaniya) advises surgical intervention through spinal or general
anaesthesia for this condition. The length of hospital stay depends
on the complexity of the fistula. The first step in treating a fistula
is an examination by a doctor to determine the extent and "path"
that the fistula takes through the tissue.
 The
surgery, thereafter, assures adequate drainage of pus from the fistula
(so that pus may escape without forming an abscess) followed by
a procedure where healthy tissue is pulled over the internal side
of the fistula to keep faeces or other material from re-infecting
the channel. Patients are then educated to manage the wound until
it heals. Similar diet and lifestyle changes recommended for fissures
apply here.
Haemorrhoids (piles) that can occur at any age are more common in
middle-aged women. Although it can be a hereditary tendency, poor
toilet and dietary habits, both of which are controllable are the
main causes for haemorrhoids. Senior Lecturer, University of Kelaniya
(Department of Surgery), Dr. S. Kumarage points out that everyone
has vascular cushions within the anal passage that have the important
function of controlling bowel continence. These cushions close the
anal passage when not in use. However due to poor bowel habits,
they can get dragged down, losing their normal function. Sufferers
may experience bleeding, discomfort, obstruction or lump in the
passage.
"It is important to note that haemorrhoids are benign and will
never become cancerous, Dr. Kumarage stresses. However it is important
that patients are checked to ensure that what they suffer from is
not a cancer. "If disregarded, you may miss a cancer in the
early stage," he adds.
Haemorrhoids can be at various stages: when they are bleeding but
inside the anal passage; when they come out but go back in and when
they stay out, all of which can cause irritation, itching, bleeding
and discomfort. If neglected, haemorrhoids can get strangled causing
swelling and pain.
Once cancer is ruled out, treatment includes advice on diet and
toilet habits. In order to keep stools soft and bulky, an ideal
form for easy defecation, patients are asked to drink plenty of
water, consume fibrous foods (fruit and green vegetables) and cut
down on refined sugar. As for toilet habits, the doctor says that
patients should not postpone the task. Rather than read or listen
to music which makes them strain, they should simply finish the
job and come out. Fortunately, early haemorrhoids can be controlled.
However if bleeding is significant causing severe discomfort despite
following the dietary measures, doctors may opt to inject a drug
to make the haemorrhoids less prominent (shrink). Alternatively
they can band them with a latex free rubber which also will ensure
that they shrink and disappear. If the problem is not settled with
this, haemorrhoids may have to be surgically removed as a last resort.
Dr. Kumarage says the latest surgical treatment that fixes haemorrhoids
in their normal position (Haemorrhoid-pexy) is not favoured here
owing to its cost. However, it is reported to be effective and less
painful thereby enabling the patient to resume work faster. |
