Much Suffered, Less Talked

‘Oh, it hurts! I am not going to the toilet anymore! It is bleeding'. These are expressions of a feeling, which more or less everyone has gone through. They are the cry of a hush-hush trouble that people experience and are shy to discuss. These are caused by Piles or Anal fissure. Piles are something more complex, and require expert handling, but fissures are simple yet equally painful.

An anal fissure is a small tear of the skin around the anus. Although the tear is small (usually less than a centimetre), it can be very painful. Anus is very sensitive; hence this tear is different from common skin breaches. The pain tends to be worse while you pass stool or after passing stool. Fissures are a common condition of the anal canal and are responsible for approx. 10 percent of the visits to a colorectal surgeon. They affect men and women equally and also both the young and the old.

The pain is mostly accompanied by fresh blood staining the toilet, which is an upsetting scene. In some cases, people are exhausted due to this undue loss of blood. The bleeding occurs right before or after the stool is passed, with a minute straining. Sometimes extreme uncomfortable itching may be felt in the anal region.

Symptoms of Anal Fissures
The following symptoms may be noticed if one is suffering from Anal Fissures-
! extreme pain in the anal area during defecation
! streaks of blood on stools or on tissue paper after wiping
! burning or itching in the anal area
! a visual tear on the anus
! a lump to skin in the anal region

Causes of Anal Fissure
Chronic constipation is the prime cause of anal fissures. Stretching and tearing of the skin in the anal passage can occur when a person passes hard stools. These tear usually heals normally and pain subsides within a few days without any treatment. Fissure does not develop in such cases.
But in some people, the tone of the muscles around the anus (that works as a sphincter) is high, reducing blood supply and ultimately delays the healing process. As a result anal fissures develop. Sometimes, long history of cough, lifting weight, child birth and excessive diarrhoea, which ultimately strains the anal region can cause Anal Fissure to develop.

Many famous persons in history had piles. Karl Marx became beset with haemorrhoids when he was writing Das Kapital. In a letter to Friedrich Engels he said, “To finish I must at least be able to sit down… I hope the bourgeoisie will remember my carbuncles.”

Treatment
Treatment is simple and aims to ease the pain and keep the stools soft, giving time to the fissure to heal. Doctors usually prescribe
! Anaesthetic ointment or cream- These creams are prescribed, to numb the anal region and relieving pain. They are applied in the anal region 15 minutes before and after defecation to ease pain. They are prescribed for short periods (5-7 days), to avoid undue irritations.
! Steroid Ointments- They are prescribed to decrease inflammation and to ease itching and pain. They should also be used for short duration, as steroids delay healing.
! Venotonic- In acute cases Venotonics such as 'Daflon,' an oral medication, is prescribed to decrease swelling of the blood vessels in the anal region.
! I prefer an ointment named 'Protosedyl' or 'Erian' which is a combination of both anaesthetics and steroids.
! Warm water bath with drops of antiseptic- This sooths the anus, and prevents infection in the tear. It helps to relax the anal tone.
! High fibre diet- Regular drinking of 'Isapgul' (rice husk), before going to bed, increases the bulk of stool and softens it. I have seen many young guys and girls who suffer from constipation only due to lack of fibber in their diet or due to irregular meal consumption.
! Lactulose- This medication helps in relieving constipation and regularises the bowel. It can be taken in the first few days of treatments. But if diarrhoea occurs it is better to avoid it.
! Painkillers- I personally do not prescribe them, but they can be taken to relieve extreme pain from defecation. Avoid codeine containing painkillers in these cases.

Preventive measures
! Drinking plenty of water and eating plenty of fibre- These softens the faeces and helps to avoid constipation.
! Regular Defecation- Some people suppress the need of passing stools due to various reasons, which is an unhealthy practice, and causes formation of hard stools.

Surgery
An operation is an option if the fissure fails to heal despite the above treatments. It is also an option if you have fissures which recur. This is a minor operation which is usually done as day case surgery. The success rate with surgery is very high - at least 9 in 10 cases are cured.
But surgery has its complications (though minute), so it is better to avoid it as much as possible.

Anal Fissure Facts
! A few drops of blood may be seen in the toilet pan or when wiping. In an infant, there may be blood in the diaper.
! Diagnosis is made by gleaning the patient's medical history and inspection of the anus. No other tests are usually needed.
! Surgery is considered only after diet and medications have failed.

**Anal fissures and Haemorrhoids (Piles) show nearly the same symptoms. Please don't get baffled. Consult a doctor if needed.

The writer is a Research Physician of Centre for Child and Adolescent Health (CCAH), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr'b)