Anus means the passage through which we pass motion and wind. Fissure means an ulcer or a crack in anal canal. Anal fissure are of two types -- Acute and chronic.

Acute anal fissure causes severe pain during passing motion. In chronic anal fissure intensity of pain varies. It can occur at any age. I have seen patient as young as 40 days old. It affects both sexes equally.

Causes and how it happens
It occurs usually due to constipation and application of force to pass motion. It is thought that hard motion tears the anal canal. It occurs less in those subjects who take food containing sufficient amount of fibre. Fibre containing foods are vegetables, raw fruits, isphagula husk etc. It has no relation with consumption of tea, coffee or wine. Frequent passage of motion and diarrhoea increase the likelihood of being attacked with fissure. During the attack it is hard to examine the inside of anus.

Symptoms
Main symptom of anal fissure is pain and bleeding. This kind of pain usually happens after passing motion and it may continue for few minutes to many hours. I have seen many patients complaining of pain for 24 hours. The patients themselves asked me to do operation urgently.

'Proctalgia Fugax' is a kind of disease in which there is pain in anus but it does not have any relation to passing motion. Patients with thrombosed (blood clotting or blocking of an artery or vein by a mass of coagulated blood) piles also complain of pain in anus. In this condition they complain of a lump in anus.

In anal fissure, bleeding is usually minimal but I have seen patients complaining of profuse bleeding. I have met an young officer who had profound anaemia (condition where the level of red blood cells is less than normal or where the haemoglobin is less, making it more difficult for the blood to carry oxygen) due to bleeding.

People with chronic (long standing) anal fissure complain of a different kind of symptoms. They complain of lump, discharge of pus, itching or a protruding skin tag in the anus. In this condition there may or may not be any bleeding. Pain is usually little or sometimes there is no pain at all except while passing hard motion.

Patients with anal fissure sometimes complain of urinary trouble and female patients occasionally feel pain during sexual intercourse. Though patients realise that this problem had perhaps arisen from constipation they do not respond to defecation due to fear of pain. This aggravates their constipation further. In this way I have met patients who pass motion once in seven to ten days.

Acute anal fissure
In this stage there is severe pain and variable bleeding. Anus looks very much contracted. It is not possible to see the fissure inside because of severe pain. It is very hard to introduce any instrument inside.

Chronic anal fissure
Chronic fissure is that when it is limited within a circumscribed margin. In this stage there is a tag of skin which hangs down. Inside the anus also there is a tumour like piece of meat called hypertrophied anal papilla.

Many doctors confuse it with a tumour. In this situation interior of the anus and rectum should be tested with instruments called sigmoidoscope or colonoscope so that we can identify any tumour or inflammatory cause. This fissure can sometimes get infected and cause abscess (painful swollen area where pus forms, often accompanied by high temperature) which ultimately leads to fistula (passage or opening which has been made abnormally between two organs, often near the rectum or anus) formation and discharge of pus.

Prevention
One should take care of his bowel so that constipation does not occur and during defecation one should not apply much force. If there is diarrhoea it should be treated immediately.

Some people read newspaper in the toilet which is a risk factor of the disease. So the habit must be prohibited.

Treatment
Conservative treatment:
If treatment is started soon after the problem starts, there is a great chance that the patient will be cured without operation. We prescribe different kind of medicine to soften the stool, fibre containing diet to increase the bulk of stool and some pain killers is used.

Sitz bath (Hip bath) is very helpful treating the disease. This is done by immersing the hip into a half filled bowl of warm water containing salt. If this does not cure the condition and If the disease persists for long time, then there is less likelihood that the problem will be over without operation.

Surgical treatment:
Dilatation of anal canal: Now a days, this operation is not done because of its poor outcome.

Internal sphincterotomy: In this operation internal sphincter (ring of muscle at the opening of a passage in the body, which can contract to close the passage) is divided. Full anaesthesia is not needed for the procedure. We usually employ spinal anaesthesia in which half of the body below the umbilicus is made senseless. Total two days hospital stay is necessary for the procedure. The patient can lead normal life after 3-7 days. The success rate of this operation is 95-99 percent.

Comment
This is the commonest anal canal problem in our country in recent days. If the patient reports early, conservative treatment is satisfactory. In chronic case (long standing) operative treatment is usually required, Results of operation are excellent. So far I observed not any failure in this sort of operation.

I found many patients asking me, "Doctor I have a small fissure which is very painful, but how painful it will be after the operation? I can assure all patients that the comfort of passing motion will be as normal as you had before this disease.

In last nine years we have done research on 29,635 patents all having problem in the anal canal. Of these 35% was anal fissure, 18% piles, 15% fistula, 2.6% cancer, 3.3% rectal polyp etc. In my series 76% anal fissure patients were cured without operation and 23% patients required operative treatment. After operation 96% patients were cured permanently.

Prof Dr AKM Fazlul Haque MBBS, FCPS, FICS is the Head, Department of Colorectal Surgery, Bangabandhu Sheikh Mujib Medical University.