What Treatments Are Available for Anal Fissures And Anal Fistulas?

Abstract

Anal fissures and anal fistulas are prevalent conditions that affect the anorectal area, causing significant discomfort and disruption. An anal fissure refers to a small tear or cut in the skin around the anus, often resulting in sharp pain and bleeding, especially during or after bowel movements. It is commonly caused by constipation, hard stools, or trauma to the area. Anal fistulas are abnormal passageways that develop between the anal canal and the surrounding skin, typically following an infection of the anal glands. These conditions can lead to recurring abscesses, pain, and discharge. Although both conditions share symptoms like pain and swelling, they differ in their causes and treatment approaches

Introduction

Anal fissures and anal fistulas are common but often painful anorectal conditions that can significantly impact an individual’s quality of life. An Anal fissure is a small tear or crack in the skin around the anus, typically caused by trauma from passing hard stools or prolonged constipation. It can result in intense pain, bleeding, and discomfort during or after bowel movements. On the other hand, an Anal fistula is an abnormal tunnel that forms between the anal canal and the surrounding skin, often following an infection of the anal glands. Fistulas can lead to recurrent abscesses, persistent drainage, and discomfort.

Types

Types of Anal Fissure

• Acute Anal Fissure: A recent tear that typically occurs within 6 weeks and is often the result of a single traumatic event, like passing a large stool.
• Chronic Anal Fissure: A tear that lasts longer than 6 weeks. It may be associated with scarring, skin tags, and long-lasting pain, requiring more complex treatment.

Types of Anal Fistula

• Intersphincteric Fistula: Most common, formed between the internal and external anal muscles. Its opening is usually close to the anus and can cause discomfort.
• Transsphincteric Fistula: Extends from the anal canal through the anal muscles. This can cause significant pain, particularly when the infection is active.
• Suprasphincteric Fistula: Located above the sphincter muscles, this type is more complex and may lead to complications with bowel control if left untreated.
• Extrasphincteric Fistula: A rare form, originating outside the sphincter muscles, often linked with conditions like Crohn’s disease.

Causes

Causes of Anal Fissures

• Constipation: Straining during bowel movements or passing hard, dry stools is a primary cause of anal fissures. This can damage the delicate skin around the anus.
• Trauma: Any injury or physical trauma to the anal area, such as from anal intercourse or a medical procedure, can lead to fissures.
• Chronic Diarrhea : Frequent, loose stools can irritate the anal skin and lead to tearing.
• Childbirth: The pressure and stretching during vaginal delivery can cause tears in the anal area.
• Low Fiber Diet: A diet low in fiber can lead to constipation and harder stools, which increase the risk of anal fissures.
• Inflammatory Conditions : Diseases like Crohn’s disease or other inflammatory bowel diseases (IBD) can cause chronic irritation and damage to the anus, resulting in fissures.

Causes of Anal Fistulas

• Infections of Anal Glands: In most cases, an anal fistula develops after an infection in the anal glands, which leads to an abscess. The abscess may drain, and an abnormal tunnel (fistula) can form.
• Crohn’s Disease: This inflammatory bowel disease can cause chronic inflammation in the gastrointestinal tract, leading to the formation of fistulas in the anal region.
• Trauma or Injury: Injury to the anus or rectum, whether due to surgery or a traumatic event, can lead to the development of an anal fistula.
• Tuberculosis (TB): In rare cases, TB can infect the anal area, causing the formation of fistulas.
• Radiation Therapy: Treatment involving radiation, particularly for pelvic cancers, can lead to damage to the tissue around the anus, causing fistulas to form.
• Chronic Inflammatory Conditions: Conditions like ulcerative colitis or diverticulitis can contribute to the development of fistulas by causing long-term inflammation in the rectal or anal area.

Symptoms

Symptoms of Anal Fissure

The typical symptoms of an anal fissure include

• Sharp Discomfort During or After Bowel Movements
• Blood on Stool or Toilet Paper
• Irritation or Itching
• Visible Tear
• Muscle Spasms
• Chronic Discomfort
• Skin Tags

Symptoms of Anal Fistula

An anal fistula symptoms may include

• Discomfort
• Inflammation
• Leaking Fluids
• Itching or Redness
• Recurrent Abscesses
• Fever or Chills
• Difficulty with Bowel Movements

Diagnosis

Diagnosis of Anal Fissure

• Visual Inspection: The doctor will inspect the anal area for any visible tears or cracks in the skin. This is typically the first step in diagnosing an anal fissure.
• Anoscopy : A lighted tube (anoscope) may be inserted into the anus to examine the inner canal for deeper fissures that might not be visible externally.
• Digital Rectal Examination: A finger is gently inserted into the rectum to check for tenderness, inflammation, or abnormal findings that could suggest the presence of an anal fissure.
• Proctoscopy: A proctoscope, a longer tube with a light, may be used to inspect the anal canal and rectum for fissures that may be located further inside the canal.
• Endoscopic Procedures: In cases where an underlying gastrointestinal condition such as Crohn’s disease is suspected, procedures like colonoscopy or sigmoidoscopy may be recommended to evaluate the rest of the digestive system for related issues.
• Biopsy: If the fissure is chronic or non-healing, a biopsy might be performed to rule out other conditions, such as cancer or inflammatory bowel disease.

Diagnosis of Anal Fistula

• Initial Physical Examination: The doctor begins by visually inspecting the area around the anus for any unusual openings or swelling. They may gently press on the area to check for any lumps or abscesses, which could indicate the presence of a fistula.
• Rectal Exam: The physician may perform a rectal exam, inserting a finger into the rectum to feel for abnormalities or signs of infection within the anal canal, such as a fistula tract.
• Anoscopy: A small, lighted tube (anoscope) is used to look inside the anal canal, allowing the healthcare provider to see any internal fistula openings or abnormalities.
• Fistulogram: This diagnostic test involves injecting a contrast dye into the fistula opening. The dye helps create detailed X-ray images, which show the path and structure of the fistula.
• MRI: For more complex fistulas, especially those involving the anal muscles, an MRI may be ordered. It provides a clearer view of the fistula’s route and helps the doctor determine the best treatment approach.
• Endoanal Ultrasound: This imaging technique uses sound waves to capture detailed images of the anal canal, allowing doctors to examine the fistula and its relationship to the surrounding tissues, especially in complex cases.

Treatment

Treatment for Anal Fissure

• Conservative Approaches: Dietary Adjustments, Sitz Baths, Topical Creams
• Medications: Calcium Channel Blockers, Botox
• Surgical Solutions: Sphincterotomy, Fissurectomy
• Advanced Techniques: Laser Therapy

Treatment for Anal Fistula

• Non-Surgical Options: Warm Sitz Baths, Pain Relief Medications, Antibiotics
• Surgical Interventions: Fistulotomy, Seton Technique, Fibrin Sealant or Collagen Plug, Tissue Flap Surgery
• Minimally Invasive Treatments: Ligation of the intersphincteric fistula tract (LIFT), Fistula Plug

Ayurvedic Overview

According to Ayurveda Anal Fistula is correlated with Bhagandar and Anal Fissure is correlated with Parikartika.

• Bhagandar is a painful opening in and around Guda (Anal region), Vasti (Urinary Bladder), and Bhaga (Pubic region). When these blisters remain unripe then it is called Pidika, when it gets ripen they are called Bhagandar. This condition is caused due to excessive consumption of Kashya (Astringent taste food) and Ruksha (Dry food) and sitting in an awkward position, forceful defecation, and improper use of Basti Netra vata get aggravated and cause Pidika (Blisters) in the anal region, if left untreated, can lead to Bhagandar.
• Parikartika, “Pari” means “All around” and “Kartika” means “to cut”. It is defined as Cutting pain in the anal region. The excruciating cutting pain seems to be experienced all around the Basti (Urinary bladder), and Nabhi (Navel region). The term Parikartika has been mentioned in complications of Vamana (Therapeutic emesis) and virechana (Therapeutic Purgation). It has also been mentioned as a complication of vatika jwara (Fever of Predominantly Vata Origin), vatika pakvatisara (Chronic Diarrhea of Vata Origin), and gagrbhini vyapad (Disorders of Pregnancy). When Vata increases, it causes excessive dryness in the body, which can lead to hard, dry stools and result in constipation. Chronic or severe constipation, coupled with the effort of straining during bowel movements, is a primary cause of anal fissures.

Treatment

Here are some Panchkarma therapies home remedies, yoga, and acupressure tips that may help alleviate the symptoms of anal fissures and anal fistulas.

Panchkarma therapies and surgical procedures for Anal Fistula and Anal Fissure

1. Virechana (Purgation Therapy) – Therapeutic Laxatives / Colon Cleansing – A detoxification process using herbal purgatives or enemas to eliminate toxins and relieve digestive disorders.
2. Eshana (Probing) – Fistula Tract Probing / Diagnostic Examination – A method to assess the depth, direction, and extent of the fistulous tract.
3. Chedana (Excision) – Fistulectomy / Surgical Excision – Surgical removal of the fistula tract to prevent recurrence and promote healing.
4. Marga Vishodana (Cleansing of Fistulous Tract) – Debridement / Irrigation of Fistula Tract – Cleaning of the infected tract to remove pus, debris, and bacteria for faster healing.
5. Cauterization (Burning / Sealing of Tissue) – Electrocautery / Chemical Cauterization – Using heat or chemicals to destroy infected tissue and stop bleeding.
6. Vrana Chikitsa (Post-Operative Wound Management) – Wound Care / Post-Surgical Management – Treatment of wounds after surgery using dressings, antiseptics, and herbal applications.
7. Kshara Sutra (Medicated Thread Therapy) – Seton Therapy – Use of a medicated alkaline thread to gradually cut through and heal the fistula tract.
8. Raktamokshana (Bloodletting Therapy) – Leech Therapy / Cupping Therapy – Removal of impure blood to reduce inflammation and detoxify the body.
9. Agnikarma (Thermal Cauterization) – Thermal / Heat Therapy – Application of controlled heat to treat chronic conditions and promote healing.
10. Kshara Karma (Alkaline Therapy) – Chemical Cauterization / Sclerotherapy – Use of alkaline herbal preparations to destroy diseased tissue and facilitate healing.

Home Remedies for Anal Fissures and Anal Fistulas

1. Warm Sitz Baths: Soaking in a warm sitz bath can help relax the muscles around the anus, reduce pain, and improve blood circulation. You can add Epsom salt, turmeric, or neem leaves to the water for added antiseptic and healing benefits.
2. Aloe Vera: Apply fresh Aloe Vera gel to the affected area to reduce pain and inflammation. Aloe has natural soothing and healing properties that can help reduce irritation and promote faster healing.
3. Coconut Oil: Coconut oil is known for its antibacterial and anti-inflammatory properties. Applying it to the affected area can soothe the skin, reduce inflammation, and help in the healing of anal fissures and fistulas.
4. Turmeric Paste: Turmeric has natural anti-inflammatory and antibacterial properties. A paste made from turmeric and water or coconut oil can be applied to the area to reduce inflammation and promote healing.
5. High-Fiber Diet: A diet rich in fiber (fruits, vegetables, whole grains) helps soften stools, preventing further strain during bowel movements. This is crucial for the healing of both fissures and fistulas.
6. Hydration: Drinking plenty of water helps prevent constipation and ensures smooth bowel movements, reducing the risk of fissures and exacerbating fistulas.

Yoga for Anal Fissures and Anal Fistulas

• Apanasana (Knees to Chest Pose): This gentle yoga pose helps relieve constipation and promotes the movement of gas in the intestines, which can ease pressure and discomfort in the anal region.
• Malasana (Squat Pose): Malasana helps in improving digestion and eliminating toxins by stimulating the lower abdomen and easing bowel movements.
• Setu Bandhasana (Bridge Pose): This pose can help with the release of tension in the pelvic muscles, improving blood circulation to the anal area and aiding in digestive health.
• Child’s Pose (Balasana): A restorative pose that helps relax the body, ease abdominal tension, and promote smooth bowel movements.
• Cat-Cow Pose (Marjaryasana-Bitilasana): This sequence of movements helps improve flexibility in the spine and lower abdomen, encouraging digestive health and promoting overall relaxation.

Acupressure Tips for Anal Fissures and Anal Fistulas

• Large Intestine 4 (LI4): Located between the thumb and index finger, this point is known for its ability to help with digestive issues, pain relief, and inflammation. Pressing this point gently can help relieve the discomfort associated with fissures and fistulas.
• Stomach 36 (ST36): Located below the kneecap, this point supports digestion, bowel movements, and general health. Stimulating this point can help improve the digestive system and prevent constipation, which is beneficial for the healing of anal conditions.
• Bladder 32 (BL32): Located in the sacral area of the lower back, this point helps with lower abdominal discomfort and promotes overall pelvic health. Applying pressure here may provide relief from anal discomfort.
• Spleen 6 (SP6): This point is located on the inner side of the lower leg, about four finger widths above the ankle. It helps regulate the digestive system, improving circulation and easing pain and inflammation in the pelvic region.

Herbal remedies for Anal Fissure and Anal Fistula By Planet Ayurveda

Planet Ayurveda is a reputable GMP-certified brand that offers a wide range of herbal products based on Ayurvedic principles, aimed at promoting overall health and addressing specific concerns with natural, plant-based formulations. All their formulations are prepared under the supervision of MD (Ayurveda) scholars. The Fistula care pack by Planet Ayurveda is a combination of Ayurvedic remedies designed to support the treatment and healing of anal fistulas and fissures. The pack typically includes Triphala guggul, Curcumin capsule, Nirgundi Oil, and Vara churna. These formulations aim at reducing inflammation, promoting detoxification, and healing the fistula tract.

1. Triphala Guggul
2. Curcumin Capsules
3. Nirgundi Oil
4. Vara Churna

Product Description

1. Triphala Guggul

This tablet is a combination of amalaki (Emblica officinalis), haritaki (Terminalia chebula), bibhitaki (Terminalia bellerica) and shuddh guggulu (Commiphora mukul). It has anti-inflammatory properties, along with healing and tissue regeneration properties. The combination of Triphala and Guggul helps eliminate accumulated toxins (Ama) from the body, which is one of the primary causes of chronic conditions like fistulas.

Dosage: 2 tablets three times a day with lukewarm water.

2. Curcumin Capsules

This capsule is a pure extract of haridra (Curcuma longa). It has anti-inflammatory, antioxidant, antibacterial, and wound-healing properties. In conditions like anal fistula, curcumin helps to support the body’s natural healing process. Its natural wound-healing properties help in tissue repair, reducing the chances of recurrence.

Dosage: 2 capsules two times a day with warm water.

3. Nirgundi Oil

This oil is a blend of nirgundi (Vitex negundo), kalihari (Gloriosa superba), haridra (Curcuma longa), manjistha (Rubia cordifolia), and tila oil (Sesamum indicum). This extract helps in alleviating inflammation and pain. It aids in the healing of fistulas by enhancing blood circulation to the affected area, thus improving tissue tone and healing. The oil enhances blood circulation, promoting faster wound healing and tissue regeneration, which is crucial for fistula recovery.

Dosage: Local Application

4. Vara Churna

This powder is a pure blend of amalaki (Emblica officinalis), bhibhitaki (Terminalia bellerica), and haritaki (Terminalia chebula). It also helps in improving digestive health. It also has anti-inflammatory and antibacterial properties that help reduce pain, swelling, and infection in the fistula area, while its detoxifying effects cleanse the body of accumulated toxins that may contribute to the condition. By enhancing blood circulation, it promotes tissue repair and can support the healing of the fistula tract and surrounding tissues.

Dosage: 1 teaspoon two times daily with warm water.

Conclusion

In conclusion, anal fissures are painful tears around the anus caused by factors like constipation, while anal fistulas are abnormal passages usually resulting from infections. Both conditions cause discomfort and require proper treatment to avoid complications. Treatment options include medical and Ayurvedic remedies, and panchkarma therapies. Ayurvedic formulations like Triphala guggul, Curcumin capsule, and Vara Churna etc, can help reduce inflammation, promote healing, and improve digestive health.