Anal Fissure
Treatment

A small tear in the lining of the anus, an anal fissure may occur when passing hard or large stools. If rectal pain is most severe during a bowel movement, you may be suffering from an anal fissure.

Signs or symptoms of an anal fissure include:

• Pain in the rectum, more noticeable during bowel movements
• Tends to occur after a bout of constipation
• Rectal bleeding, commonly found as a streak along the side of stool

An anal fissure can cause pain and bleeding during bowel movements. Typically, stool has a streak of blood along the same side as the painful fissure, this helps differentiate between hemorrhoids and anal fissures.

Some fissures will heal on their own by using stool softeners or fiber supplements and taking regular sitz baths.

Although anal fissures can heal on their own, they can cause significant rectal pain and require medications such as Nitroglycerin ointment. Nitroglycerin rectal ointment is used to relieve moderate to severe pain caused by chronic anal fissures. An anal fissure is a tear in the skin around the opening for bowel movements, also known as the anus or rectal area.

Nitroglycerin belongs to the group of medicines called nitrates. It works to relax the muscles around the anus so there is less pressure in the area.

This medicine is available only with your doctor’s prescription.

Common treatment options for anal fissures include:

Nitroglycerin Ointment – (see question above)

Compound Prescriptions – Compound prescriptions that contain Nifedipine and Lidocaine work by relaxing and numbing the smooth muscle of the internal anal sphincter so the fissure can heal.

Botox injections -The internal anal sphincter, one of two muscles that control the anus, is always under tension. If this tension (also called resting pressure) is too high, spasms and reduced blood flow can cause an anal fissure or prevent an existing one from healing. Botulinum toxin, the substance that causes botulism, temporarily paralyzes the internal anal sphincter. This reduces the spasm and allows the fissure to heal.

Lateral Internal Sphincterotomy – When other conservative treatments fail, surgery is the last best option. A lateral internal sphincterotomy is the gold standard treatment for anal fissures that have not responded to less invasive treatments, or those that recur. After a lateral internal sphincterotomy, the risk of recurrence is greatly reduced over anal fissures treated with medicated creams alone.

During this surgery, the internal sphincter is cut, which allows it to relax. The tension in this muscle is what causes the initial tear, as well as what prevents the fissure from healing completely.

Typically, patients who have tried one or all conservative treatments listed above without a resolution of symptoms can expect surgery to be the final option. The severity of pain is different for all patients but usually, patients will try conservative treatment for 2-4 weeks before deciding on surgery. Acute anal fissures can severely impact your daily life and if this is the case, skipping conservative treatment and going straight to surgery is your best option.

Anoscopy
An anoscopy is a test in which a doctor (usually a gastroenterologist or a colorectal surgeon) uses an instrument with a light on the end to look inside the anal canal. It can be done right in a doctor’s office, usually with no preparation.
The tool is lubricated and inserted a few centimeters into the anus.

In some cases, it might be necessary to have an enema to clean out the rectum and get a better look. If a tissue sample (a biopsy) is needed, it can be taken at this time. There may be some discomfort when the anoscope is inserted and if a biopsy is taken, but it will be over quickly. This procedure is performed on most of our non-acute rectal patients at the time of their consultation.

Sigmoidoscopy
A sigmoidoscopy is a test performed to look at the rectum and the last part of the colon, which is called the sigmoid colon. It may not be needed for simple skin tags, but if there’s a suspicion that there is another cause for a lump in the anal area, it might be used.

The instrument used is called a sigmoidoscope, and it is inserted through the rectum and manipulated up into the large intestine. A physician can get a good look inside the last section of the colon and can also take biopsies if needed. This procedure is performed in our office with a light bowel prep given the day before.

Colonoscopy
Colonoscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. This procedure is done under IV sedation at an endoscopy center or outpatient facility.

At Tahir Surgical Clinic, we’re transparent about pricing. If treatment is not covered under your insurance, we’ll get the best cash-pay rate available through our contracted facilities.

For insured patients, we’ll provide a breakdown of what’s covered under your health insurance. Including any out-of-pocket expenses so you know what to expect before proceeding with surgery.

Compound ointment typically costs around $60 for a two-week supply. Insurance does not cover this ointment but we have partnerships with a few different compound pharmacies in Arizona that can provide ointment on a same-day basis.

Dr. Tahir is affiliated with several facilities but he is a separate entity, in addition to the anesthesiologist. The facility fee is separate from the professional fee and they are not collected together.

If you have any further questions, don’t hesitate to call us.

The following are instructions found on our post-opt document.

For PPH / Hemorrhoid / Rectal Surgery: Start a sitz baths 6 hours after surgery, always after a bowel movement, and several times daily. PPH (Staple Hemorrhoidectomy) patients are to remove the rectal packing with the first sitz bath. There will be a piece of the sponge packing hanging on the outside of the anus; pull gently on this to remove the packing. (It may come out of its own accord.)

Some patients with rectal surgeries will have an absorbable packing in the rectum. It may come out of its own accord or with a bowel movement. This is nothing to be concerned about, it is normal.

Patients may experience rectal bleeding (spotting) for up to 8 weeks after surgery, this is normal.

There are a few lifestyle changes that may help relieve discomfort and promote healing of an anal fissure, as well as prevent recurrences.

1. Add more fiber to your diet
2. Stay hydrated
3. Avoid straining during bowel movements

As always, consult your primary care physician for more guidance tailored to your specific needs.