Hi everybody and welcome to my VLOG. This week we're going to talk about Anal
Fissures and we're doing this because somebody's requested it on one of the
comments that they make after the VLOGs. And as always I say I would do it if you
asked me for it. So to start with, what is an anal fissure?
Well to put it in technical terms, its a tear in the mucosa, just inside the anal
sphincter. So if you imagine that this was your bottom, where the poo comes out,
it's a tear in the skin just going inside this bit, which is called the
sphincter. So they're very small but they cause an excruciating amount of pain.
Usually once you've passed a stool (a bowel movement). But then the pain lasts
for quite some time and that's one of the typifying symptoms of an anal
fissure or a hemorrhoid. In that when you have pain on the bowel movement that
then lasts for one to two hours afterwards it's most commonly an anal
fissure, and as a GP that's how we differentiate. And that's why we ask that
question. It can be acute, and by that I mean it's sudden onset, its a one-off and
it usually resolves without much intervention in under six weeks. Or it
can be chronic and when they're chronic they don't resolve and they last for
more than six weeks. So those are the two different types that you get. So who gets
them? Well they're really common. We don't know exactly how many people get them at
any one time but we do know there's an 11% chance, or just over a one in ten
chance, that you'll get one within a lifetime. So it's reasonably high. Anybody
can get them, even kids get them, but in the main people between the ages of 20
and 40 is the typical age range in which we see them. Men and women get them
exactly the same. And the acute types (that get better in under six weeks) are
much more common than the chronic type. So that's the good news. So how do you
classify them? Well we classify them as primary; where there's no obvious cause,
or secondary; where there's an underlying obvious cause, like for example constipation,
inflammatory bowel disease (like Crohn's) or sexually transmitted infections occasionally.
Or even rectal cancer can cause them. So most of them occur as
secondary, in people with constipation. So people that are passing very hard or
very large stools. People that get persistent diarrhoea get them as well. As
I said, people with inflammatory bowel disease, when you're pregnant or go
through childbirth, they can get caused because of straining and constipation.
Very occasionally, as I said, a sexually transmitted disease. Some people
have just naturally got an unusually tight anal sphincter muscle and that can
cause it as well because of the pressure that's required to open that sphincter
to pass a stool. And in lots of people there's no clear cause at all.
So going back to the symptoms; as I've said, it severe pain on passing a stool.
But when I say severe pain, patients quite often describe it as trying to
pass shards of glass. And you can imagine that is excruciating. The pain can
persist, as I said, for a couple of hours after passing and you can get blood on
passing as well. Quite often bright red blood on the paper, but you can also have
it in the in the pan and it can be quite a lot of blood. And it can also bleed for
a while afterwards as well, because you've got an open wound. And some people
get constant pain just on sitting. So as you can see, they really are quite
debilitating. Embarrassing because you can't talk about it
and just wrecking life really. Because when all you can focus on is that pain,
it's difficult to do other things. So how do we diagnose them? Well, ordinarily the
patient will present to their GP (to me) and we'll take that thorough history,
including the pain duration. What your toilet habits are. How much straining
there is. What your diet's like. We will have to pop a finger inside your back
passage to see what's going on there and to inspect the back passage. Because if a
fissure, we can usually see when we just have a look. And if we're suspicious that
it's more than a fissure, that there might be some kind of
underlying cause, we will refer you on to a specialist for further investigations.
And they will do an investigation under anaesthetic, and they may even look at
your anal sphincter pressures. But most of the time, because the acute type of
fissures are the most common, we can deal with it in a GP practice. So how do we
do that? Well it depends firstly whether it's acute or chronic, and we'll know
that from your history. And the acute phase, which is the most common, they're
likely going to get better on their own, without any treatment within six weeks.
However, if you're presenting to a GP it's because you're in pain we will
treat and just the degree of treatment depends on what's going on. It's
important to know that even the acute ones that heel within six weeks can
come back again. If the constipation, for example, continues. So we always talk
about self-help and softening up your stools. So to do that we recommend
adding lots of fibre to your diet. But it's a lots of fibre. We know that the
average person needs to eat between about 18 and 30 grams of fibre a day and
that's actually quite a lot. I once did an experiment on myself because my diet is
really really good and I eat loads of fruit and loads of veg and I couldn't
get my fibre above about 12 grams a day! So it's difficult to do, especially in
today's world where we're all rushing around. So rehydration is important, again
because of constipation. So lots of water or fluid of some description. And we
know that exercise gets bowels moving and if you keep them moving
most also likely to be softer because they're not sitting in your colon or
your small intestine for a long time. When they sit in your colon, more water
gets absorbed out of them back into your body. So that's why it's important to
have regular bowel movements. So what's the treatment initially? So first
of all we would aim to take away the pain. And we would do that initially with
paracetamol or ibuprofen but obviously that's not always enough. We
would recommend warm baths because that's quite soothing. We might give you
a topical anesthetic: lidocaine. You actually put this on your sphincter (your
bottom) just before you pass a stool. And it actually numbs it. You do it about 20
minutes before and it numbs it so that you don't feel that excruciating pain
when you open your bowels. We recommend not holding stools, so if you
have the urge to open your bowels, to do it, because holding obviously exacerbates
the situation; increases constipation. Again, for the same reason, we also say
stay away from any wipes with fragrances or alcohol. And a lot of people use those
nowadays for their bottom after going to the toilet. We would advise, if
you want to wash your bottom that's fine but just water. Stay away from anything
that might irritate the skin. So after that there are some medications that we
can use. So initially always going to be laxatives to try and soften up the stool;
fybogel, which is almost like fibre in a glass of water
is very good and we would probably start
with that. It's a stool softener. And then we can go to an ointment called GTN
ointment. And you will have heard of GTN for
people that have angina or heart pain. Well this is the same substance but it's
in an ointment and if you've had the fissure for over a week and there has been
no improvement, we would sometimes recommend this as a treatment. You have
to use it twice a day for up to eight weeks and you have to measure out two
and half centimeters on your finger and get it right up inside your bottom so it
gets to all of the relevant areas. And it does work very well but about thirty
percent of people do get quite a bad headache. So it's a side effect that you
should always know about so that you're not shocked when it happens. So when
that doesn't work (and sometimes it doesn't work) we see patients again. Would we refer you?
Who gets referred? Well if it was a child and theirs had not healed naturally,
within two weeks, we should refer. if it's an adult who's got ongoing pain without
improvement for more than six to eight weeks we would probably think about
referral. If it was an adult who had no symptoms but the fissure is still there,
(so the cut in the skin is still there) after 12 to 16 weeks we should refer.
Although I sometimes wonder about that because if you hadn't got
symptoms you probably wouldn't know and nor would we as GP's because you
wouldn't be coming back! So I'm not sure about that one.
And elderly people with new fissures we should refer because it's unusual to be
able to get fissures if they've got no history and it could be that there's an
underlying cancer there that's causing it. So what happens once you've been
referred in to secondary care? So they use some medical treatments as well.
So they have another cream called topical diltiazem 2% and it does work,
but it has less headaches as a side effect than GTN, so for some people
that's a bonus because the headaches can be debilitating and then they can't use
it. So that's one option. There's a blood pressure tablet called Nefidipine
that people can take orally, but that does have more side effects so that's
that's used secondarily to the ointment if things are really not
improving. There's Botox. Botox is used for many many things. So it's
botulism toxin and there is a high recurrence rate of fissures with Botox and
you can get temporary incontinence of wind and poo; so that's really a very very
unpleasant side effect. It's also unlicensed for this use, and that doesn't
necessarily matter; so we use drugs unlicensed in the NHS we just need to
tell you about it. But Botox is not the be-all and end-all for this particular
problem because the side effects are difficult to handle. So surgery is an option
once you are in secondary care. We rarely do surgery in children. This is mainly reserved
for adults. There would have to be really special reasons why we would do this for children.
So the aim of surgery, whatever the type, is to lower the anal resting tone. So thats
how tight your sphincter is. We need to reduce the tightness and the tone and the
reason for that is that when the sphincter tone is very tight it actually reduces the blood flow well, so oxygen doesn't get there quite
to the area and that reduces the oxygen which gets carried in the blood to the area which
then reduces the healing. So if we can lower that tone and allow more blood into the area,
then more oxygen it actually heals better.
So that's the aim of all surgeries. There are various different surgeries that we
can use and I'm not going to list every single one of them because that's by no
means my area of expertise. And it will be down to your surgeon to discuss with
you the best surgery for you. And that's the most important thing. I will say
however, there's one particular surgery called a lateral internal sphincterotomy
and that's the gold standard almost, the best surgery, it works better
than medical treatments (so the creams and the ointments and the tablets) and
it's got an 85 percent cure rate. So that's pretty high for any kind of
surgery, for anything. There are however some downsides as with anything in
medicine. So there are continence issues; up to 30% of people after that surgery faeces or wind. so I'm afraid more farting essentially
In layman's terms, 20% of people will actually have some soiling of poo and
three to ten percent of people (so three to ten in a hundred) will actually have a
leakage of poo! So it's a pretty serious consideration because those numbers are
quite high. Another option, is a fissurectomy, where they actually often combine
this with Botox, because it's a less successful surgery.
So they do it with botox as well, to reduce that tone. And its where they
actually cut away the area of the fissure.
Anal flaps can be used; where they take skin from elsewhere and rebuild that
particular part of the sphincter. And in the past they used to do something
called manual anal stretching (and to me that sounds as hideous as it probably is)
and that's not recommended now. So if you hear of that, it's no longer a
recommended procedure, so not something that should be done. So having had any of
these medical treatments or even surgery, what's the prognosis? What's the
long-term outlook? Well, as I've said, most anal fissures will heal within 6 weeks,
however recurrence is common, especially if constipation is the
underlying cause. And you don't sort that out long term with the GTN ointment that
I spoke to you about, that a GP can give you. Recurrence is up to 50%, so one in two
people will get another fissure. So it's not brilliant because although they only
last a short time, in that time you are in lots of pain. If there's underlying
disease, so crohn's for example, and irritable bowel disease, anything like
that, then the prognosis is difficult to predict. We don't actually have any
figures on that and so unfortunately I can't tell you whether it's good or bad.
If the fissure is chronic, so lasting more than six to eight weeks,
and not responding very well to treatment, following surgery there is a
very high cure rate; so 85% and much less in terms of recurrence. But the long-term
consequences of side effects, as I've just outlined to you, are not brilliant.
So it really is a balance of weighing up how much this is interfering with
life and how much the side effects (if they happen to you) would interfere with
life and what would be better or worse. But obviously these are discussions to
have with your surgeon. So I hope I've shown you, in a brief snapshot, what an
anal fissure is. What you can do personally in terms of lifestyle and
diet; basically not being constipated - that really is the key. And it's finding
a food (when we come to constipation) that might work for you. So for some
people they tell me that nuts and seeds work brilliantly, for some people they
drink half a glass of prune juice every evening, and that means they go to the
toilet in the morning. It's just increasing dietary fibre, but it's
finding one that works for you and then sticking to it. And it's a case of trial
and error obviously. Hopefully I've shown you what happens when the fissure just
won't go away, or it's just interrupting life too much and staying past six weeks and
you have to go for surgery. So that you can consider what things are important
to you and really weigh up the pros and cons of all of the different medical
versus surgical treatments that we have. But always, for all of these, whether
chronic or acute, alongside lifestyle change! It's a really unpleasant thing to
happen, but it isn't uncommon; as we've said - 11 percent lifetime risk.
So if you've got that kind of pain and you've got bleeding from your bottom you
need to see a GP, and you need to find a solution with the GP that works for you.
Hopefully that's been informative. Please do ask me any questions, because if I've
missed things I'm more than happy to answer them in the comments afterwards.
And just as this person did for me recommending a topic - please recommend a
topic that you'd like me to cover in the future. Thanks ever so much for watching
again and your continued support - it's really appreciated. Bye for now.