I. Overview
Anal fissure is a laceration of the anal area, a chronic disease in which the whole layer of skin of the anal canal cracks longitudinally and forms an infected ulcer. Among anal disorders, it is second only to hemorrhoids in incidence. It can affect both men and women, and is usually found in the front and back of the median line of the anus, and is rare on both sides, with the posterior side of the anus being the most common. The majority of young women aged 20 to 40 years old suffer from hemorrhoids, and due to anatomical factors, it is more common for female patients to be located in the anterior midline. It is characterized by periodic anal pain, bleeding, and constipation.
Second, the etiology of anal fissure
Modern medicine believes that the occurrence of this disease is related to anatomical factors such as weak anatomical tissues in front and behind the anal area, lack of necessary protection; poor blood supply to local tissues and insufficient healing ability of the wound. In addition, it is also related to mechanical injury, inflammatory factors, sphincter spasm, congenital anal stenosis and other factors.
Diagnosis of anal fissure
(I) Clinical manifestations
1.Symptoms Anal fissures are usually found at 6 and 12 points of the truncated bladder; the symptoms are mainly pain, bleeding and constipation, and they are mutually causal.
(1) pain: it is cyclical, and the pain increases during defecation, with paroxysmal knife-like pain or burning pain, and the pain decreases or disappears within a few minutes to more than ten minutes after defecation, which is called intermittent pain period. Subsequently, the pain is severe due to persistent spasm of the sphincter muscle, which often lasts for several hours before it can be gradually relieved. In severe cases, coughing and sneezing can cause pain that radiates to the pelvis and lower extremities. The degree and length of pain varies greatly from person to person. Pain is also the main reason for most patients to visit the clinic.
(2) Bleeding: bleeding is seen during stool, usually blood stained by hand paper or dripping blood, bright red in color, but in small amounts or only adhering to the surface of the stool.
(3) Constipation: Patients often have habitual constipation, and dry stool often tears the skin of the anal canal and causes anal fissure.
2.Signs
(1) Fissure: early patients have fresh, superficial, red-colored trauma with soft texture and no fibrous tissue growth. The trauma surface is grayish or grayish, hard, and can be touched with strips of hard nodes
(2) Pathological changes in the anal canal: there are no pathological changes in the early stage, but six kinds of pathological changes such as “cylinder mouth” thickening, thickening of the pectineal zone, enlarged connective tissue external hemorrhoids, anal hypertrophic papillae, subcutaneous fistula and anal sinusitis are formed around the trauma, the anal canal and the dentate line over a long period.
(B) Other auxiliary examinations
1.Local visual examination The examination of anal fissure is mainly local visual examination, the patient usually takes the lateral lying position, riding position or knee-chest position, pay attention to the warmth and light, ask the patient to cooperate and relax the anus, the examiner gently separates the anus to both sides with both thumbs and index fingers, from outside to inside, check one by one, do not miss.
2. Other rectal examinations, anoscopy and speculum examination often cause severe pain and aggravate the patient’s suffering, so they are generally not used as routine examination items.
In short, the main points of diagnosis of anal fissure are as follows.
(1) Medical history: Most of them have a history of constipation.
(2) Clinical symptoms: periodic anal pain, blood in the stool, constipation, etc.
(3) Anal canal signs: longitudinal fissure trauma on the anal canal skin.
(4) Finger palpation or anoscopy: note that this type of examination should preferably be performed under anesthesia. Common complications of anal fissures, such as sinus tracts or fistulas, sentinel hemorrhoids, and anal papillary hypertrophy, can be detected.
(5) Clinical differentiation is needed from anal chancre, anal canal skin abrasion, anal canal tuberculous ulcer, Crohn’s disease anal canal ulcer, anal hard chancre ulcer, early anal canal cancer, and anal canal epithelial defect.
(C) Disease staging Generally divided into two stages, namely.
1.Early anal fissure There is a small poke-shaped ulcer on the skin of the anal canal with shallow trauma, bright red color, neat and elastic edges, no scar or hard node formation, with a short course and easy to cure.
2, old anal fissures history of repeated attacks of anal fissures, early anal fissures without timely and appropriate treatment, ulcer color light white, deep bottom, irregular trauma edge, “jar mouth” thickening, the bottom of the formation of flat and hard gray and white tissue (pectineal belt), poor elasticity, more difficult to heal.
Four, the treatment of anal fissure
The treatment principle of anal fissure is to open the stool and eliminate the fissure. Soften the stool, keep it open, stop the pain, release the spasm of the sphincter, interrupt the vicious cycle, and promote the healing of the wound.
There are many ways to treat anal fissures. If the lesion is early, it can be cured by actively treating constipation, keeping the stool open, protecting the ulcerated wound and preventing infection. If early anal fissures are not treated in time, recurrent attacks and local pathological changes are formed, conservative treatment is often ineffective and surgical treatment is required.
(I) General treatment
1. Regulate diet You should take foods rich in dietary fiber to increase the amount of stool, such as coarse cereal products, beans, potatoes, vegetables, fruits, etc.; avoid or reduce spicy foods and condiments, such as chili, cumin, curry, pepper, white wine, etc.
2, appropriate to take laxatives laxatives can soften the stool, such as liquid paraffin, laxative, hemp pills, rhubarb tablets, senna, phenolphthalein, mushroom combination, etc., pay attention to the application must master the dose, because the amount of small can not play a role, the amount of large easily cause diarrhea. The dose of individual differences, should be used according to the different conditions of each patient and discretion.
3, to develop the habit of regular defecation Generally advocate defecation before and after breakfast. For patients with prolonged constipation, self-massage can be performed. Massage method: start from the lower right abdomen, gradually up to the upper right abdomen, upper abdomen, upper left abdomen, lower left abdomen in the order, the technique first heavy and then light, to the lower left abdomen when completely relaxed, generally repeated 10 to 20 times. You can also do some other exercises that help accelerate intestinal peristalsis.
4. relieve mental tension Most patients with anal fissures have the psychological fear of defecation, and when they do not defecate, they hold back their stool first, and then have to defecate only after they have the urge to defecate several times, resulting in dry stool, thickened fecal diameter, difficult to discharge, and increased anal pain. In fact, in most cases, the stool of patients with anal fissures is only dry and hard at the front and normal afterwards. Therefore, it is very important for the doctor to explain clearly to the patient the process of defecation in order to relieve the patient’s tension. The author found that many patients after anal fissure surgery still have this psychological barrier to defecation, which leads to patients feeling that the surgical result is not satisfactory.
(II) Internal treatment method
Combine with Chinese medicine identification.
(III) External treatment methods
1. Fumigation Applicable to all stages of anal fissure. It mainly has the function of activating blood circulation and removing blood stasis, reducing swelling and relieving pain. Commonly used formulas include thorny root formula, bitter ginseng soup, poison removal soup, pepper, or 1:5000 potassium permanganate solution, etc. Fumigation followed by washing can maintain local cleanliness and hygiene, and also promote blood circulation, reduce stimulation and accelerate healing.
2.Compounding medicine Applicable to all stages of anal fissure. It has the function of clearing heat and detoxification, relieving pain and stopping bleeding. Commonly used are Jiuhua ointment, raw muscle yuhong ointment, anal tai ointment, taining cream (keratanate), Ma Yinglong musk hemorrhoid ointment, dragon pearl ointment, moist burn ointment, etc., 1～2 times a day.
3. Plugging medicine Suitable for all stages of anal fissure. It has the function of clearing heat and detoxification, relieving swelling and pain, and stopping bleeding. Commonly used anti-inflammatory pain plugs (indomethacin), hemorrhoid nin plugs (methinazolone), Puji hemorrhoid plugs, Xietai plugs, Tai Ning plugs (carrageenan), etc.
4. Corrosion It is suitable for recurrent old anal fissures. It has the effect of activating blood circulation and eliminating blood stasis, decaying and generating muscle. Commonly used drugs are eight two Dan, seven three Dan, red ascending Dan, withered hemorrhoids, etc. Or use 5% glycerin of petrolatum to rub the affected area and then wipe off with 75% alcohol. The main usage: apply a little bit of the elixir externally on the old fissure, 1 to 2 times a day, and when the trauma is fresh, you can change to the use of raw muscle scatter to make the trauma heal.
(IV) Other therapies
1.Anal expansion method Suitable for early anal fissures, no connective tissue external hemorrhoids, papillary hypertrophy and other comorbidities.
2.Closure therapy is suitable for old anal fissure with obvious pain.
(E) Surgical treatment
Applicable to old anal fissures or early anal fissures for which non-surgical treatment is ineffective.
1.Sphincter lateral incision method Applicable to early anal fissure without comorbidities such as external hemorrhoids, papillary hypertrophy, subcutaneous fistula, etc.
2.Sphincterotomy is suitable for old anal fissures with external connective tissue hemorrhoids, papillary hypertrophy, etc.
3.Longitudinal incision and transverse suture method is suitable for old anal fissure with anal canal stenosis.
Prevention and care of anal fissure
1.Cultivate good defecation habits, timely treatment of constipation, elimination of inflammation and avoid mechanical injury.
2, the diet is mainly light vegetarian, eat more fresh vegetables and fruits, avoid eating spicy stimulating food.
3, to develop good habits, pay attention to the combination of work and rest, and actively exercise to enhance physical fitness.
4. Pay attention to keep the anal area clean and hygienic, wash the anus in time after stool to avoid infection. Once the diagnosis of anal fissure is confirmed, early treatment should be given to prevent the secondary development of other anal diseases.
5.Local massage and moderate anal lifting exercise are effective methods to prevent this disease.