Anal pain during defecation is one of patients’ common complaints when they go for a medical examination of Anorectology specialty. There are many disorders which can be presented by the symptoms as above such as: anal fissures, perianal infections, thrombosed hemorrhoids or malignant diseases of anus - rectum … Not like other disorders, anal fissures are only presented as stabbing pain during defecation, and can be accompanied with a little of bright red outside stools. The pain can last from a few minutes to many hours and make patients terrible in defecation.
What are causes of anal fissures?
Local lesions make overstretched on anal canal such as: hard stool in defecation causing longitudinal lacerations on mucous membrane. In addition, diarrhea in many times or anorectal inflammations are also able to lead to the problem as above. The acute fissures are usually shallow and easy to heal if treated properly. The chronic fissures (longer than 1 month) can make ulcers deep to anal sphincter and are usually caused by untreated etiologic factors. Recent studies show that there is a poor perfusion in area of anal and hypertonicity of internal anal sphincter. Those above factors jeopardize the poor perfusion and at consequence, the fissure is difficult to be healed, therefore in treatment, doctors will consider fixing these factors.
How can anal fissures be treated?
Non surgical treatment: This a basic therapy applied for all anal fissures to remove etiologic factors and help to increase blood flow to the damaged mucosa. This method can heal up to 90% of acute fissures. Anti-constipation or stool softening can help to remove etiologic factors. Patients have to drink much water (more than 2 liters/ day) and enhance fibers in their meals such as: vegetables, beans, fresh fruit. Drinking much water is very important because water softens stool and it’s not able to damage anus and avoid recurrence. In addition, doctors can prescribe some laxatives or stool softeners to reduce symptoms of pain and bleeding. Sitz bath in warm water (40 degree Celsius) in 10 – 20 minutes, 3 -4 times per day will help to relax sphincter, increase perfusion, relieve pain and make patients feel more comfortable. Anal hot compressing is possible but be careful otherwise it burns you.
Doctors can prescribe some more topical applications of nitroglycerin or calcium channel antagonist ointments to help relax the internal sphincter and increase blood perfusion for the fissure area. This therapy can help to heal diseases at a rate from 65% to 90%. However, side effects of the medications above such as headache, flushing, hypotension... make patients not able to continue their long treatment dose for weeks. Another applied therapy is the botulinum toxin (Botox) injection into internal anal sphincter to relax it in a 2 to 3 month period. Chronic fissure can be healed up to 60-80% of cases but the cost of Botox injection is very high and also causes recurrence.
When the above changes in life-style and the above therapies still don’t heal the lesion, acute fissures can change to be chronic. At that time, it’s necessary to determine other etiologic factors such as bacteriologic testing, anal examination under local or general anesthesia, measuring the muscular tone of internal sphincter to assess hypertonicity. Surgery is the last choice of chronic fissure treatment if the supportive treatment is not successful.
Surgical therapy: Medical therapy has such advantages as repeatability of many times, and combination of many medication groups to enhance efficacy and less complication. Although a surgical therapy can be considered as a gold standard, it is applied less than medical supportive therapy because the risk of complication occurrence is not controlled (5-15%).
Surgical procedure is simply lateral internal sphincterotomy (under local anesthesia). It helps relieve pain fast, relax sphincter and heal the wound. Patients are able to be discharged from hospital the day after, the pain is relieved 1 day after surgery and fissure is healed after 1 weeks. The successful rate of this surgery is up to 90%. In case of failure or recurrence, it can be resulted from inadequacy of sphincterotomy. In this case, a surgery can be performed again with incision on the opposite site of sphincter. If over-incision occurs, the risk of incontinence can occur.
In summary, anal pain after defecation can be resulted from anal fissures and anorestoscopy and anal examination can be used to diagnose it
Perirectal abscess is an abscess of soft tissue next to anal canal. Anal fistula is a small fistulous tract connecting the infected anal gland to the skin in anal area. Fistula usually occurs after abscess.
What causes abscess?
When small anal glands secrete mucus are obstructed and fulminantly infected, they can become an abscess. This abscess develops in a loosing tissue around perirectal spaces and can gain access to the skin. Some of underlying diseases such as colitis or enteritis can cause the problem easier.
What causes anal fistula?
After the abscess drainage, the fistula connecting the infected anal gland with the skin outside still exists. Discharging fluid continuously from a small opening adjacent anus orifice proves the existence of anal fistula. If the opening outside fistula is obstructed, then the fluid is accumulated causing recurrent abscess.
What are signs and symptoms of abscess or anal fistula?
The signs and symptoms of problems both include prolonged perianal pain, sometimes accompanied with edema and swelling. It’s not necessarily accompanied with defecation. Other signs and symptoms include skin irritation around anus orifice, pus-discharging (then no pain anymore), fever and fatigue.
Do all abscesses develop into anal fistula?
Just about 50% of anal abscess develop into an anal fistula after drainage. There’s no accurate method that can raise a correct forecast of this problem.
How can anal abscess be treated?
Abscess is treated by draining pus from the abscess to outside and opening a hole next anal orifice to deflate it. As usual, it can be done under local anesthesia. For big abscess and in the deeper positions, it can be drained under spinal or general anesthesia. For patients with higher risk of infections such as immunodepression , diabetes, it’s necessary for them to use generalized antibiotics. Antibiotics can not replace the drainage because antibiotics are not infiltrated through the abscess wall.
How can anal fistula be treated?
It’s necessary to be operated to remove fistula. Although surgery is simple, it’s still able to cause complications. Therefore, it’d better to be performed by special surgeon. It can be performed at the same time with the surgery of anal abscess drainage although the fistula occurs 4 – 6 weeks after abscess drainage or sometimes takes months or years later. Surgery of fistula tract removal is usually relating to sphincterectomy to open the tract and connect the internal and external openings together, open the tract to change it become to groove which is easy for wound healing from inside. In most cases, patients are needed to stay in hospital a short time after being operated.