Tuesday, September 1, 2009

How to Find A Good Hemroids Doctor

The first hemroids doctor you probably want to look to is your general physician, with whom you hopefully already have a good working relationship. Make an appointment with him, and explain what your hemroid symptoms are to date.

If your hemroids are not complicated, not bleeding, and eligible for home treatment, your hemroids doctor will probably tell you to get more fiber in your diet, give you some recommendations for doing so, suggest warm water sitz baths, and maybe write you a prescription for a mild painkiller either in cream or tablet form for hemroid relief.

If, however, this first line hemorrhoids doctor suspects any complications, he’ll refer you to the go to the next hemroids doctor in the chain, which is to say a proctologist.

Your general physician is usually familiar with all the specialists of your local area and can recommend one that is right for you, so feel free to communicate exactly what you want in a doctor who will be looking at such a delicate and private area of your body.

Always remember that in dealing with any medical professional, you are protected by the Patient Bill of Rights, which you can always ask for a copy of. The Patient Bill of Rights may vary from country to country, and perhaps minimally from establishment to establishment, but a standard part of it is your right to fully understand any treatment that will be done to you before it is done, and your right to basic human respect and freedom from discrimination or bullying.

You also have the right to choose your own provider, so always request more clarification if needed and don’t hesitate to ask for a different provider if you should at any point feel uneasy about a given doctor.


Rubber band ligation for hemorrhoids

Rubber band ligation is a procedure in which the hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the hemorrhoid.

To perform the procedure, a doctor inserts a viewing instrument (anoscope) into the anus. The hemorrhoid is grasped with an instrument, and a device places a rubber band around the base of the hemorrhoid. The hemorrhoid then shrinks and dies and, in about a week, falls off.

A scar will form in place of the hemorrhoid, holding nearby veins so they don’t bulge into the anal canal.

The procedure is done in a doctor’s office. You will be asked whether the rubber bands feel too tight. If the bands are extremely painful, a medicine may be injected into the banded hemorrhoids to numb them.

After the procedure, you may feel pain and have a sensation of fullness in the lower abdomen, or you may feel as if you need to have a bowel movement.

Treatment is limited to 1 to 2 hemorrhoids at a time if done in the doctor’s office. Several hemorrhoids may be treated at once if the person has general anesthesia. Additional areas may be treated at 4- to 6-week intervals.

What To Expect After Treatment

People respond differently to this procedure. Some are able to return to regular activities (but avoid heavy lifting) almost immediately. Others may need 2 to 3 days of bed rest.

  • Pain is likely for 24 to 48 hours after rubber band ligation. You may use mild pain relievers (analgesics) and sit in a shallow tub of warm water (sitz bath) for 15 minutes at a time to relieve discomfort.
  • To reduce the risk of bleeding, avoid taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) for 4 to 5 days both before and after rubber band ligation.
  • Bleeding may occur 7 to 10 days after surgery, when the hemorrhoid falls off. Bleeding is usually slight and stops by itself.

Health professionals recommend that you take stool softeners containing fiber and drink more fluids to ensure smooth bowel movements. Straining during bowel movements can cause hemorrhoids to come back.

Why It Is Done

Rubber band ligation is the most widely used treatment for internal hemorrhoids. If symptoms persist after three or four treatments, surgery should be considered.

Rubber band ligation cannot be used if there is not enough tissue to pull into the banding device. This procedure is almost never appropriate for fourth-degree hemorrhoids. 1

How Well It Works

Up to 80% of people who had this procedure said their symptoms improved. 2

  • Repeat treatment for recurring symptoms is rarely needed.
  • This procedure is most useful for small to medium-sized internal hemorrhoids.
  • The procedure is less likely to be successful for large hemorrhoids.


Side effects are rare but include:

  • Severe pain that does not respond to the methods of pain relief used after this procedure. The bands may be too close to the area in the anal canal that contains pain sensors.
  • Bleeding from the anus.
  • Inability to pass urine (urinary retention).
  • Infection in the anal area.

What To Think About

Rubber band ligation is one of the least expensive treatments and also one of the most effective.

Surgical removal of hemorrhoids (hemorrhoidectomy) may provide better long-term results than fixative procedures such as rubber band ligation. But surgery is more expensive, requires longer recovery times, and has a greater risk of complications.

Rubber band ligation is considered to be the most effective nonsurgical treatment for internal hemorrhoids over the long term. Because this treatment can be painful, some people might not choose it. Although a different treatment might be less painful, it may not be as effective, and it may need to be repeated to treat recurring hemorrhoids.

Not all doctors have the experience or the necessary equipment to do rubber band ligation. This may help you decide which procedure to choose. Ask your doctor which procedure he or she has done the most, how many times he or she has done the procedure, and how satisfied patients have been with the outcome.

How to Shrink Hemorrhoids

If you have a hemorrhoid problem, one way to get rid of that problem is to shrink hemorrhoids. You can shrink hemorrhoids by reducing the size of the swollen blood vessels. Blood vessels in and near the anus and rectum swell if more pressure than they can handle gets exerted on them through straining to have a bowel movement. Pregnant women can also get hemorrhoids through the straining necessary to give birth. Anything that is going to place undue pressure on your blood vessels in that area has the possibility of causing a hemorrhoid.

Many methods exist to shrink hemorrhoids and reduce the inflammation around the swelling. Witch hazel is one example used for reducing the swelling of hemorrhoids. Witch hazel can also help relieve pain associated with hemorrhoids.

The sooner you can shrink your hemorrhoids, the faster they (and their symptoms) will disappear. Symptoms associated frequently with hemorrhoids are itching, burning, pain, and bleeding. internal hemorrhoids aren’t associated as much with pain as external hemorrhoids are but they can still cause pain, too. External hemorrhoids can be uncomfortable and annoying, as well, especially when you have to sit for a prolonged period of time. It is generally recommended that if you have a hemorrhoid, you try not to encounter long periods of sitting. You may find using a “doughnut” pillow to sit on will provide needed relief.

Other methods to reduce swelling and shrink the size of hemorrhoids come from taking the natural ingredient of horse chestnut. Taking horse chestnut orally is said to reduce hemorrhoid swelling. Sweet clover is believed to help with overall circulatory problems which will help get those swollen blood vessels back to a normal size.

Venapro is a blend of natural herbal extracts that helps reduce swelling and inflammation, as well as working to relieve pain and discomfort. It has been tested and is considered safe and free from side effects.

Preparation H is a popular name familiarly associated with hemorrhoids and this cream can provide relief by helping to reduce the size and shrink hemorrhoids as well.

Another reason you want to shrink hemorrhoids is because the larger they get, the more irritating they can be. If an internal hemorrhoid gets too large, it may bulge outside the anus. This condition is known as having a prolapsed hemorrhoid and you may need to try to gently push it back inside.

hemorrhoids are a common affliction, affecting men, women, and even children. It is not an easy topic for most people to discuss as the location of hemorrhoids can be embarrassing. However, it is a necessary topic of conversation if you have a hemorrhoid and wish to know how to go about getting rid of it, shrinking it, and finding relief from the symptoms it brings.

Whichever method you choose to shrink hemorrhoids, you will be overjoyed when they are gone. Once the cure works and the hemorrhoids disappear, decide on a plan of action to discourage their return. Such a plan should include getting more fiber in your diet, getting regular exercise, and drinking plenty of water.

Surgical Treatment Options for Hemorrhoids

Surgical Classification of hemorrhoids
Traditional Surgery
Stapled Hemorrhoidopexy (PPH Procedure)
Harmonic Scalpel hemorrhoid surgery
Laser Surgery for hemorrhoids
Atomizing hemorrhoids
Complications of hemorrhoid Surgery
Knowing What to Ask Your Surgeon

Video References

Surgical Classification of hemorrhoids
(piles) arise from congestion of internal and/or external venous plexuses around the anal canal. They are classified, depending on severity, into four degrees. First degree hemorrhoids bleed but do not prolapse outside of the anal canal; second degree prolapse outside of the anal canal, usually upon defecation, but retract spontaneously. Third degree hemorrhoids require manual placement back inside of the anal canal after prolapsing, and fourth degree hemorrhoids consist of prolapsed tissue that cannot be manually replaced and is usually strangulated or thrombosed. Symptoms associated with hemorrhoids include pain, bleeding, puritus ani (itching) and mucus discharge. In IV degree prolapse, the area where the rectal mucous membrane meets the anal skin (the dentate line) is positioned almost outside the anal canal, and the rectal mucous membrane permanently occupies the muscular anal canal.

For more detailed about information, about the concepts of hemorrhoidal anatomy as applied to rectal surgery, view our video on Overview: Anatomy of Prolapse and hemorrhoids > get Real Player , an alternative approach to the surgical treatment of hemorrhoids. In order to explain the rational of the surgical procedure for prolapse and hemorrhoids it is helpful to take a moment to review some concepts of anatomy.

Traditional Surgery
In many cases hemorrhoidal disease can be treated by dietary modifications, topical medications and soaking in warm water, which temporarily reduce symptoms of pain and swelling. Additionally, painless non-surgical methods of treatment are available to most of our patients as a viable alternative to a permanent hemorrhoid cure.

In a certain percentage of cases, however, surgical procedures are necessary to provide satisfactory, long?term relief. In cases involving a greater degree of prolapse, a variety of operative techniques are employed to address the problem.

Milligan-Morgan Technique
Developed in the United Kingdom by Drs. Milligan and Morgan, in 1937. The three major hemorrhoidal vessels are excised. In order to avoid stenosis, three pear-shaped incisions are left open, separated by bridges of skin and mucosa. This technique is the most popular method, and is considered the gold standard by which most other surgical hemorrhoidectomy techniques are compared.

Ferguson Technique
Developed in the United States by Dr. Ferguson, in 1952. This is a modification of the Milligan-Morgan technique (above), whereby the incisions are totally or partially closed with absorbable running suture.

Furgeson Technique

A retractor is used to expose the hemorrhoidal tissue, which is then removed surgically. The remaining tissue is either sutured or is sealed through the coagulation effects of a surgical device.

Due to the high rate of suture breakage at bowel movement, the Ferguson technique brings no advantages in terms of wound healing (5-6 weeks), pain, or postoperative morbidity.

Conventional haemorrhoidectomy can be performed as a day-case procedure. But due to poor post-operative care in the community and high level of pain experienced after the procedure, an in-patient stay is often required (average of 3 days).


Stapled Hemorrhoidopexy (PPH Procedure
Also known as Procedure for Prolapse & hemorrhoids (PPH), Stapled Hemorrhoidectomy, and Circumferential Mucosectomy.

PPH is a technique developed in the early 90’s that reduces the prolapse of hemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane with the use of a circular stapling device. In PPH, the prolapsed tissue is pulled into a device that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. This restores the hemorrhoidal tissue back to its original anatomical position.

The introduction of the Circular Anal Dilator causes the reduction of the prolapse of the anal skin and parts of the anal mucous membrane. After removing the obturator, the prolapsed mucous membrane falls into the lumen of the dilator.

The Purse-String Suture Anoscope is then introduced through the dilator.

This anoscope will push the mucous prolapse back against the rectal wall along a 270° circumference, while the mucous membrane that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. By rotating the anoscope, it will be possible to complete a purse-string suture around the entire anal circumference.

The Hemorrhoidal Circular Stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string, which is
then tied with a closing knot.

The ends of the suture are knotted externally. Then the entire casing of the stapling device is introduced into the anal canal. During the introduction, it is advisable to partially tighten the stapler.

With moderate traction on the purse-string, a simple maneuver draws the prolapsed mucous membrane into the casing of the circular stapling device. The instrument is then tightened and fired to staple the prolapse. Keeping the stapling device in the closed position for approximately 30 seconds before firing and approximately 20 seconds after firing acts as a tamponade, which may help promote hemostasis.

Firing the stapler releases a double staggered row of titanium staples through the tissue. A circular knife excises the redundant tissue. A circumferential column of mucosa is removed from the upper anal canal. Finally, the staple line is examined using the anoscope. If bleeding from the staple line occurs, additional absorbable sutures may be placed.

What are the Benefits of PPH over other Surgical Procedures?
1) Patients experience less pain as compared to conventional techniques.
2) Patients experience a quicker return to normal activities compared to those treated with conventional techniques.
3) Mean inpatient stay was lower compared to patients treated with conventional techniques.

What are the Risks of PPH?
Although rare, there are risks that accompany PPH:
4) If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall.
5) The internal muscles of the sphincter may stretch, resulting in short-term or long-term dysfunction.
6) As with other surgical treatments for haemorrhoids, cases of pelvic sepsis have been reported following stapled haemorrhoidectomy.
7) PPH may be unsuccessful in patients with large confluent hemorrhoids. Gaining access to the anal canal can be difficult and the tissue may by too bulky to be incorporated into the housing of the stapling device.
8) Persistent pain and fecal urgency after stapled hemorrhoidectomy, although rare, has been reported.
Stapling of hemorrhoids is associated with a higher risk of recurrence and prolapse than conventional hemorrhoid removal surgery; according to a Canadian study of 537 participants.


The Harmonic Scaplel uses ultrasonic technology, the unique energy form that allows both cutting and coagulation of hemorrhoidal tissue at the precise point of application, resulting in minimal lateral thermal tissue damage. Because the Harmonic Scaplel uses ultrasound, there is less smoke than is generated by both lasers and electrosurgical instruments. The Harmonic Scaplel cuts and coagulates by using lower temperatures than those used by electrosurgery or lasers. Harmonic Scaplel technology controls bleeding by coaptive coagulation at low temperatures ranging from 50oC to 100oC: vessels are coapted (tamponaded) and sealed by a protein coagulum. Coagulation occurs by means of protein denaturation when the blade, vibrating at 55,500 Hz, couples with protein, denaturing it to form a coagulum that seals small coapted vessels. When the effect is prolonged, secondary heat is produced that seals larger vessels. Because ultrasound is the basis for Harmonic Scaplel technology, no electrical energy is conducted to the patient.

By contrast, electrosurgery coagulates by burning (obliterative coagulation) at temperatures higher than 150oC. Blood and tissue are desiccated and oxidized (charred), forming eschar that covers and seals the bleeding area. The reduced postoperative pain after Harmonic Scalpel hemorrhoidectomy compared with electrocautery controls, likely results from the avoidance of lateral thermal injury.

Harmonic Scalpel Applied to Tissue
Harmonic Scalpel Hemorrhoidectomy

The protein coagulum caused by the application of the Harmonic Scaplel is superior at sealing off large bleeding vessels during surgery. It has been my experience that this method is useful on large hemorrhoids that may bleed during surgery, thus minimizing blood loss and reducing the time needed for surgery.

For more detailed information, view our video on Hemorrhoidectomy Using Harmonic Scalpel > get Real Player


 Laser Surgery for hemorrhoids
Skilled surgeons use laser light with pinpoint accuracy. The unwanted hemorrhoid is simply vaporized or excised. The infinitely small laser beam allows for unequaled precision and accuracy, and usually rapid, unimpaired healing.

The result is less discomfort, less medication, and faster healing. A hospital stay is generally not required. The laser is inherently therapeutic, sealing off nerves and tiny blood vessels with an invisible light. By sealing superficial nerve endings patients have a minimum of postoperative discomfort. With the closing of tiny blood vessels, your proctologist is able to operate in a controlled and bloodless environment.

Procedures can often be completed more quickly and with less difficulty for both patient and physician. Laser can be use alone or in combination with other modalities. For more detailed information on combining modalities in surgery, view our video on the performance of both a Laser & Harmonic Scalpel Hemorrhoidectomy. Get > Real Player

A study of 750 patients undergoing laser treatment for hemorrhoids reported successful results of 98%. The patient satisfaction was 99%.

For more detailed information, view our page on Published Laser Research.


Atomizing hemorrhoids
A new technique to remove hemorrhoids is called atomizing. The Atomizer? is a medical device that was developed specifically to atomize tissue. The term “atomizing hemorrhoids” was coined because the hemorrhoids are actually reduced to minute particles into a fine mist or spray, which is immediately vacuumed away. An innovative waveform of electrical current and a specialized electrical probe, the Atomizer Wand?, was created for this purpose (patent pending).

With a wave of the Atomizer Wand, the hemorrhoids are simply excised or vaporized one or more cell layers at a time. The hemorrhoids are essentially disintegrated into an aerosol of carbon and water molecules. Using the Atomizer, the tissue is sculpted into a desired shape and smoothness. As a
result, the surgeon operates with minimal bleeding, and gets better homeostasis than with traditional electrosurgical techniques. With the Atomizer, the patient gets better postoperative results, and fewer anal tags than with traditional operative techniques.

In the United States, the Ferguson hemorrhoidectomy is considered the gold standard by which most other surgical hemorrhoidectomy techniques are compared. A clinical study at the hemorrhoid care Medical Clinic, of thirty patients, compared the traditional Ferguson hemorrhoidectomy with the CO2 laser hemorrhoidectomy, and the Atomizer hemorrhoidectomy, and revealed the following:

Atomizer Graph

Figure 1: Hemorrhoidectomy: Atomizing vs. the CO2 laser.

The results of atomizing hemorrhoids are similar to that of lasering hemorrhoids, except that there is less bleeding using the Atomizer, and the Atomizer cost less. In both procedures, it is noted that there is less discomfort, less medication, less constipation, less urinary retention, and a hospital stay is generally not required. Complications using the Atomizer are rare, and excellent results are typical.

Atomizing hemorrhoids is offered exclusively in Arizona.


 Complications of hemorrhoid Surgery

Early Complications Include:
1) Severe postoperative pain, lasting 2-3 weeks. This is mainly due to incisions of the anus, and ligation of the vascular pedicles.
2) Wound infections are uncommon after hemorrhoid surgery. Abscess occurs in less than 1% of cases. Severe necrotizing infections are rare.
3) Postoperative bleeding.
4) Swelling of the skin bridges.
5) Major short-term incontinence.
6) Difficult urination. Possibly secondary to occult urinary retention, urinary tract infection develops in approximately 5% of patients after anorectal surgery. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study).

Late Complications Include:
1) Anal stenosis.
2) Formation of skin tags.
3) Recurrence.
4) Anal fissure.
5) Minor incontinence.
6) Fecal impaction after a hemorrhoidectomy is associated with postoperative pain and narcotic use. Most surgeons recommend stimulant laxatives, or stool softeners to prevent this problem. Removal of the impaction under anesthesia may be required.
7) Delayed hemorrhage, probably due to sloughing of the vascular pedicle, develops in 1 to 2 percent of patients. It usually occurs 7 to 16 days postoperatively. No specific treatment is effective for preventing this complication, which usually requires a return to the operating room for one or more stitches.


Knowing What to Ask Your Surgeon
Before choosing the procedure you wish to have performed, there are questions you should ask the surgeon:
1. What types of procedures have they performed?
2. How many of each procedure have they performed?
3. Why are they recommending one particular procedure over another?
4. How long will the procedure take?
5. Will this procedure require a hospital stay and how long do they anticipate your hospital stay will last?
6. How long do they expect the recovery process to take?
7. How soon will you be able to return to “normal” activity?
8. Will having the procedure mean having to change how I live, work or eat?

hemorrhoids diet

A high-fiber diet will help prevent conditions of hemorrhoids, constipation, diverticulosis, diverticulitis, colon polyps, colon cancer, and high cholesterol.

Fiber keeps stool soft and lowers pressure inside the colon so that bowel contents can move through easily. Fiber works best when water is ingested, so remember to drink at least 6 to 8 glasses of water per day. On average, Americans eat about 5 to 20 grams of fiber daily. The American Dietetic Association recommends 20 to 35 grams of fiber each day. Over 35 grams of fiber a day may cause excess bowel gas, and therefore some discomfort. The table below shows the amount of fiber in some foods that you can easily add to your diet.

The doctor may also recommend taking a fiber product such as Citrucel, Konsyl, or Metamucil once a day. These products are mixed with water and provide about 2 to 3.5 grams of fiber per tablespoon, mixed with 8 ounces of water.

Hemorrhoids Medicine that Works

hemorrhoids.  Even the word sounds painful.  No wonder so many sufferers would do anything to find an effective hemorrhoids medicine that actually works.  Before we get on to that, I want to take a look at why people get hemorrhoids in the first place.   But if you’d like to go straight to the product I recommend then click here.

hemorrhoid risk factors include:

? Persistent constipation or diarrhea. These conditions may lead to straining with bowel movements.
? Being overweight.
? A family history of hemorrhoids. Often the tendency to get them is inherited.
? Being age 50 or older. Half of all people aged 50 or older seek treatment for hemorrhoids.
? Pregnancy and labor and delivery. 

Then there are the factors that make hemorrhoids worse.  These include:

? Prolonged sitting or standing. This may cause blood to pool in the anal area and increase pressure on the veins.
? Frequent heavy lifting or holding your breath when lifting heavy objects. This can cause a sudden increase of pressure in blood vessels.

Apart from finding an effective hemorrhoids medicine, here are some things you can do to help relieve the condition:

? Avoid constipation and eat more fiber. Include foods such as whole-grain breads and cereals, raw vegetables, raw and dried fruits, and beans. Limit your intake of low- or no-fiber foods, such as ice cream, soft drinks, cheese, white bread, and red meat.
? Drink 8 to 10 glasses of water each day. Avoid liquids that contain caffeine (such as coffee and tea) or alcohol. These liquids may cause dehydration, which can lead to constipation.
? Avoid laxatives because they can cause diarrhea, which can irritate hemorrhoids.
? Avoid foods and drinks that can make your symptoms worse. These may include nuts, spicy foods, coffee, and alcohol.
? Use soaps that contain no perfumes or dyes.
? Wear cotton underwear to prevent a build up of moisture which can irritate hemorrhoids.
? Wear loose clothing to allow freedom of movement and to reduce pressure on the anal area.
? Do not use a ring (”doughnut”) cushion. It will restrict blood flow and may make your symptoms worse.
? Regular, moderate exercise, along with a high-fiber diet, will promote healthy bowel movements.

As well as adopting the above measures, you can also practice healthy bowel habits:

? Go to the bathroom as soon as you have the urge.
? Don’t strain when passing stools. Relax and let things happen naturally.
? Don’t hold your breath while passing stools.
? Avoid rubbing the anal area. You can rinse off in the shower or on a bidet instead of wiping yourself with toilet paper. After cleansing, gently pat the anal area dry with a soft, absorbent towel or cloth.
? Don’t read while sitting on the toilet. Get off the toilet as soon as you have finished.

Home treatment, which mainly involves establishing healthy bowel habits, may stop your piles from getting worse. For an effective hemorrhoids medicine which can be used as a home treatment, click here.

Aspirin and other anti-inflammatory drugs such as ibuprofen, can cause hemorrhoids to bleed more. If you need to use a nonprescription pain reliever, choose one that is not an NSAID, such as acetaminophen (for example, Tylenol).

Here are some other measures which can provide temporary relief:

? Apply ice several times a day for 10 minutes at a time. Follow this by placing a warm compress on the anal area for another 10 to 20 minutes.
? Apply moist heat (such as warm, damp towels) several times a day.
? Go to bed and rest to take pressure off inflamed, irritated veins. If you are 3 to 6 months pregnant, you may find it helpful to lie on your side. If you are not pregnant, sleeping on your stomach with a pillow under your hips will help decrease swelling of hemorrhoids.

But for a permanent, effective solution that cures hemorrhoids fast, CLICK HERE to visit the H Miracle product page.

hemorrhoids fissures

Causes of Anal Fissure
Medical Treatment
Surgical Treatment

An anal fissure (AY-nul FISH-er) is a tear in the anus causing a painful linear ulcer at the margin of the anus. An anal fissure, also known as fissure-in-ano, may cause itching, pain or bleeding. Fissures can extend upward into the lower rectal mucosa; or extend downward causing a swollen skin tab or tag to develop at the anal verge, also known as a sentinel pile.

Fissures with sentinel pile.
Anal Fissure as seen
through an anoscope.


Causes of Anal Fissure
Either extreme constipation or diarrhea, usually combined with nervous tension over a prolonged period of time, may produce anal abrasions, simple slit-like fissures, or acute ulcers at the anal verge. With constipation, this condition is usually caused by the passage of a hard dry stool that tears the anal lining upon defecation. With diarrhea, this condition is usually caused by an over use and over-wiping of an inflamed anal canal.

Because of an associated anal crypt infection, causing cryptitis, a fissure, an ulcer, or possibly even an abscess may occur at the superior aspect of the anal canal where it attaches to the lower rectal mucosa.

In some patients, the anal fissure doesn’t heal and becomes a painful sore that is constantly re-injured or torn with each bowel movement. The fissure usually develops a white fibrous base over time. Additionally, an external anal skin tag called a sentinel pile, and an enlarged papillae at the superior anal margin may develop.

A patient can pass shards of undigested material (i.e., stone ground corn chips, and sunflower seed shells) through the anus, tearing the anal skin, thus causing a fissure. Anal fissures also may be secondary to anorectal surgery, proctitis, tuberculosis, or cancer of the anus.

An anal fissure, a thin slit-like tear in the anal tissue, is likely to cause itching, pain, and bleeding during a bowel movement. View hemorrhoid gallery for a detailed photo.

A fissure produces pain at defecation and persists for hours. A small amount of bright red blood, which may or may not be mixed with stool, is common. A fissure produces pain disproportionate to its size. It is the third most painful common condition affecting the anus; the second most painful condition is an anal abscess, the first most painful condition is recovering from recent anal surgery.

Rarely, a spasm of the levator ani muscles, also known as proctalgia fugax, can be associated with chronic anal fissures. This condition may contribute to lack of healing of fissures… or may be caused by it.

Diagnosis can be made by inspection. Closer inspection will frequently reveal a tag or sentinel pile. After gentle separation of the skin of the anal verge, the ulcer usually posterior can be seen. Frequently the fibers of the internal anal sphincter muscle can be seen at the base of this punched-out ulcer. A well-lubricated finger with lidocaine ointment and a small caliber anoscope will help delineate the extent of the lesion. A colonoscope or sigmoidoscope exam might be useful to rule out abscesses, colitis, and other causes of rectal bleeding.

A fissure should be distinguished from an ulcer caused by Crohn’s disease, leukemia, or malignant tumors, because it is not shaggy, large or indolent. Fissures are seldom multiple. A biopsy can help to determine the diagnosis.

Medical Treatment
At least 50 percent of fissures heal by themselves without the need for an operation. The longer that a fissure has persisted over time, the less likely it will be to heal by itself. Oftentimes, acute fissures heal by themselves spontaneously, with good anal hygiene consisting of a thorough cleansing after each bowel movement with cotton and witch hazel. Cleaning gently after bowel movements with thick quilted baby wipes is just as effective as using cotton pads with witch hazel. The use of sitz baths (soaking the anal area in plain warm water for 20 minutes, several times a day) helps to relieve fissure symptoms, but may not actually aid in the healing process. A topical hydrocortisone preparation applied to the folds of the anal verge several times a day will help to relieve symptoms and aids the healing process.

A high fiber, well balanced diet, and encouragement of regular normal stools are important in helping to heal the fissure. If pain is severe, an anesthetic ointment can be introduced freely and frequently with the finger, utilizing finger cots.

Chemical sphincterotomy has been attempted using a wide range of agents, including nitric oxide and botulinum toxin. Since anal fissures are characterized by spasm of the internal anal sphincter and a reduction in mucosal blood flow, the aim of treatment is to relieve ischemia by reducing resting anal pressure and improving mucosal perfusion.

It has been shown that a local application of topical nitrates reduces anal sphincter pressure and improves anodermal blood flow. This dual effect results in fissure healing in more than 80% of patients. The principal side effect is headaches in 20%-100% of cases.

It has also been shown that local a local injection of botulinum toxin near the fissure, causes denervation, sphincter muscle weakness, and reduction of resting anal sphincter pressure, which allows the fissure to heal. Fissure healing occurs in more than 60% of patients. The principal side effect is incontinence of flatus and or feces, which last for up to two months in 2% to 21% of cases.

Surgical Treatment
When surgical excision is required, the chronic fissure along with the sentinel pile, papilla, and adjacent crypts are dissected free from the underlying muscle. Associated internal and external hemorrhoids are removed. Usually the scar tissue in the posterior anal quadrant is completely denuded. The criteria for excision of fissures are chronicity and association with other anorectal disease such as hemorrhoids, mucosal prolapse, skin tags, enlarged papillae, anal contraction, and diseased crypts.

Sometimes, an anal dilation is performed to gently disrupt the scar tissue in the base of the fissure. Other times, cauterization by: laser, electrosurgical, or a chemical (i.e., silver nitrate) method; is used to simply denude or resurface the fissure base, to encourage the growth of new anal tissue.

Lateral partial internal sphincterotomy has been utilized for uncomplicated fissures. This surgery consists of a small operation to cut a portion of the anal muscle. This helps the fissure to heal by preventing pain and spasm, which interferes with healing. Cutting this muscle rarely interferes with the ability to control bowel movements.

At least 90% of patients who require surgery for this problem have no further trouble from fissures. More than 95% of patients achieve prolonged symptomatic improvement. About 5-percent of patients with fissures are “chronic fissure formers”, and for a variety of reasons (i.e., chronic constipation, failure to heal without scar tissue, etc.), will continue to develop new fissures despite all the efforts of medical and surgical treatment.