Anal fissure, perianal ulcer is observed within a sentinel hemorrhoid, which is chronic aspect, perianal fissures usually cause symptoms such as:
1. Rectal bleeding bright red especially when cleaning with toilet paper.
2. Rectal Pain.
The treatment should be evaluated each case, depending on the evolution, size, chronicity and visualization of the sphincters etc. may be medical or surgical.

Perianal tuberculosis:

Perianal Tuberculosis



Thrombosed External Hemorrhoid



Peri anal condylomas

Perianal fistula showing external opening.

Same as above.

ANAL FISSURE OVERVIEW

An anal fissure is a tear in the lining of the anus, the opening where feces are excreted. The tear typically extends into a circular ring of muscle called the internal anal sphincter. The fissure is described as acute if it has been present for less than six weeks, or chronic if present greater than six weeks.

Once a fissure develops, the internal anal sphincter typically goes into spasm, causing further separation of the tear, impairing healing and causing pain. Exposure to feces also slows healing.

There are no reliable estimates of the frequency of anal fissures in the general population; some studies suggest that as many as one in five persons develop a fissure during their lifetime. This may be an underestimate since some people may be too embarrassed to discuss it with their healthcare provider.

ANAL FISSURE SYMPTOMS

Patients with an anal fissure may first note bleeding and a sensation of tearing, ripping or burning following a bowel movement. Once a fissure develops, these symptoms can occur after every bowel movement; the rectal pain can last several minutes to hours.

Bleeding is usually mild and limited to a small amount on toilet paper or the surface of stool. However, the bleeding may discolor the toilet bowl, giving it the appearance of heavy bleeding. As the fissure becomes chronic, the bleeding may stop, although the pain persists. Some patients also note itching or irritation of the skin around the anus.

WHAT IS AN ANAL FISSURE?

An anal fissure (fissure-in-ano) is a small, oval shaped tear in skin that lines the opening of the anus.  Fissures typically cause severe pain and bleeding with bowel movements.  Fissures are quite common in the general population, but are often confused with other causes of pain and bleeding, such as hemorrhoids.

WHAT ARE THE SYMPTOMS OF AN ANAL FISSURE?

The typical symptoms of an anal fissure include severe pain during, and especially after, a bowel movement, lasting from several minutes to a few hours.  Patients may also notice bright red blood from the anus that can be seen on the toilet paper or on the stool.  Between bowel movements, patients with anal fissures are often relatively symptom-free. Many patients are fearful of having a bowel movement and may try to avoid defecation secondary to the pain. 

WHAT CAUSES AN ANAL FISSURE?

Fissures are usually caused by trauma to the inner lining of the anus.  Patients with tight anal sphincter muscles (i.e., increased muscle tone) are more prone to developing anal fissures.  A hard, dry bowel movement is typically responsible, but loose stools and diarrhea can also be the cause.  Following a bowel movement, severe anal pain can produce spasm of the anal sphincter muscle, resulting in a decrease in blood flow to the site of the injury, thus impairing healing of the wound. The next bowel movement results in more pain, anal spasm, decreased blood flow to the area, and the cycle continues.  Treatments are aimed at interrupting this cycle by relaxing the anal sphincter muscle to promote healing of the fissure.

Other, less common, causes include inflammatory conditions and certain anal infections or tumors.  Anal fissures may be acute (recent onset) or chronic (present for a long period of time).  Chronic fissures may be more difficult to treat, and may also have an external lump associated with the tear, called a sentinel pile or skin tag, as well as extra tissue just inside the anal canal (hypertrophied papilla) .

WHAT IS THE TREATMENT OF ANAL FISSURES?

The majority of anal fissures do not require surgery.  The most common treatment for an acute anal fissure consists of making the stool more formed and bulky with a diet high in fiber and utilization of over-the-counter fiber supplementation (totaling 25-35 grams of fiber/day).  Stool softeners and increasing water intake may be necessary to promote soft bowel movements and aid in the healing process.  Topical anesthetics for pain and warm tub baths (sitz baths) for 10-20 minutes several times a day (especially after bowel movements) are soothing and promote relaxation of the anal muscles, which may help the healing process. 

Other medications (such as nitroglycerin, nifedipine, or diltiazem) may be prescribed that allow relaxation of the anal sphincter muscles. Your surgeon will go over benefits and side-effects of each of these with you.  Narcotic pain medications are not recommended for anal fissures, as they promote constipation.  Chronic fissures are generally more difficult to treat, and your surgeon may advise surgical treatment.

WILL THE PROBLEM RETURN?

Fissures can recur easily, and it is quite common for a fully healed fissure to recur after a hard bowel movement or other trauma.  Even when the pain and bleeding have subsided, it is very important to continue good bowel habits and a diet high in fiber as a lifestyle change.  If the problem returns without an obvious cause, further assessment is warranted.

WHAT CAN BE DONE IF THE FISSURE DOES NOT HEAL?

A fissure that fails to respond to conservative measures should be re-examined.  Persistent hard or loose bowel movements, scarring, or spasm of the internal anal muscle all contribute to delayed healing.  Other medical problems such as inflammatory bowel disease (Crohn’s disease), infections, or anal tumors can cause symptoms similar to anal fissures.  Patients suffering from persistent anal pain should be examined to exclude these symptoms.  This may include a colonoscopy or an exam in the operating room under anesthesia.

WHAT DOES SURGERY INVOLVE?

Surgical options for treating anal fissure include Botulinum toxin (Botox®) injection into the anal sphincter and surgical division of a portion of the internal anal sphincter (lateral internal sphincterotomy).  Both of these are performed typically as outpatient, same-day procedures, or occasionally in the office setting.  The goal of these surgical options is to promote relaxation of the anal sphincter, thereby decreasing anal pain and spasm, allowing the fissure to heal.  Botox®injection results in healing in 50-80% of patients, while sphincterotomy is reported to be over 90% successful. If a sentinel pile is present, it may be removed to promote healing of the fissure.  All surgical procedures carry some risk, and a sphincterotomy can rarely interfere with one’s ability to control gas and stool.  Your colon and rectal surgeon will discuss these risks with you to determine the appropriate treatment for your particular situation.

HOW LONG IS THE RECOVERY AFTER SURGERY?

It is important to note that complete healing with both medical and surgical treatments can take up to approximately 6-10 weeks. However, acute pain after surgery often disappears after a few days.  Most patients will be able to return to work and resume daily activities in a few short days after the surgery.

CAN FISSURES LEAD TO COLON CANCER?

Absolutely not.  Persistent symptoms, however, need careful evaluation since other conditions other than an anal fissure can cause similar symptoms.  Your colon and rectal surgeon may request additional tests, even if your fissure has successfully healed.  A colonoscopy may be required to exclude other causes of rectal bleeding.

What is an anal abscess?

An anal abscess is an infected cavity filled with pus found near the anus or rectum.

What is an anal fistula?

An anal fistula (also called fistula-in-ano) is frequently the result of a previous or current anal abscess, occurring in up to 50% of patients with abscesses. Normal anatomy includes small glands just inside the anus. Occasionally, these glands get clogged and potentially can become infected, leading to an abscess. The fistula is a tunnel that forms under the skin and connects the infected glands to the abscess. A fistula can be present with or without an abscess and may connect just to the skin of the buttocks near the anal opening. Other situations that can result in a fistula include Crohn’s disease, radiation, trauma and malignancy.                                          

How does someone get an anal abscess or a fistula?

The abscess is most often a result of an acute infection in the internal glands of the anus. Occasionally, bacteria, fecal material or foreign matter can clog the anal gland and create a condition for an abscess cavity to form.  Other medical conditions can make these types of infections more likely.

After an abscess drains on its own or has been drained (opened), a tunnel (fistula) may persist, connecting the infected anal gland to the external skin. This typically will involve some type of drainage from the external opening and occurs in up to 50% of abscesses. If the opening on the skin heals when a fistula is present, a recurrent abscess may develop.

What are the specific signs or symptoms of an abscess or fistula?

A patient with an abscess may have pain, redness or swelling in the area around the anal area.  Fatigue, general malaise, as well as accompanying fever or chills are also common.  Similar signs and symptoms may be present when patients have a fistula, with the addition of possible irritation of the perianal skin or drainage from an external opening.

Is any specific testing necessary to diagnose an abscess or fistula?

No. Most anal abscesses or fistula-in-ano are diagnosed and managed on the basis of clinical findings.  Occasionally, additional studies such as ultrasound, CT scan, or MRI can assist with the diagnosis of deeper abscesses or the delineation of the fistula tunnel to help guide treatment. 

What is the treatment of an anal abscess?

The treatment of an abscess is surgical drainage under most circumstances. An incision is made in the skin near the anus to drain the infection. This can be done in a doctor’s office with local anesthetic or in an operating room under deeper anesthesia. Hospitalization may be required for patients prone to more significant infections such as diabetics or patients with decreased immunity.

Are antibiotics required to treat this type of infection?

Antibiotics alone are a poor alternative to drainage of the infection. For uncomplicated abscesses, the addition of antibiotics to surgical drainage does not improve healing time or reduce the potential for recurrences. There are some conditions in which antibiotics are indicated, such as for patients with compromised or altered immunity, some cardiac valvular conditions or extensive cellulitis. A comprehensive discussion of your past medical history and a physical exam are important to determine if antibiotics are indicated.

What is the treatment of an anal fistula?

Surgery is almost always necessary to cure an anal fistula. Although surgery can be fairly straightforward, it may also be complicated, occasionally requiring staged or multiple operations. Consider identifying a specialist in colon and rectal surgery who would be familiar with a number of potential operations to treat the fistula.

The surgery may be performed at the same time as drainage of an abscess, although sometimes the fistula doesn’t appear until weeks to years after the initial drainage. If the fistula is straightforward, a fistulotomy may be performed. This procedure involves connecting the internal opening within the anal canal to the external opening, creating a groove that will heal from the inside out. This surgery often will require dividing a small portion of the sphincter muscle which has the unlikely potential for affecting the control of bowel movements in a limited number of cases.

Other procedures include placing material within the fistula tract to occlude it or surgically altering the surrounding tissue to accomplish closure of the fistula, with the choice of procedure depending upon the type, length, and location of the fistula.  Most of the operations can be performed on an outpatient basis, but may occasionally require hospitalization.