FISSURE
– IN – ANO
This is a crack in the extremely sensitive mucous
membrane of the anal canal. The condition is very painful and this pain causes
spasm of the underlying internal sphincter. As long as this spasm remains, the
crack in the overlying mucosa does not heal. Thus a vicious cycle is set up.
Hence, a fissure, which to start with is acute, becomes chronic.
Fissures are commonest in the midline posteriorly. In
males 90% occur posteriorly and 10% anteriorly, in the midline. In females, the
incidence is 60% and 40% respectively
DESCRIPTION
To start with, a fissure is a superficial ulcer. As it
gets chronic, it gets converted into a canoe-shaped ulcer. At the upper end,
there is frequently a hypertrophic anal papilla. A tag of hypertrophic skin hangs
at its lower end. This is called sentinel pile and is found in long-standing
fissures. A constant feature is a severe spasm of the internal sphincter.
TYPES
1. Acute – Superficial crack with thin margins
2. Chronic – A deep ulcer with thick and oedematous
margins
CLINICAL
FEATURES
The patient presents with severe pain during and after
defaecation, with blood streaked faeces. A history of constipation is very
common.
* The depth of the fissure varies greatly, sometimes
being a simple groove or furrow, at others extending down to the subcutaneous
cellular tissue.
* The surrounding parts are usually highly inflamed,
and the sphincter spasmodically contracted.
* The pain attending stool is described as being
horrible, and the dread of its recurrence causes the sufferer to delay emptying
the bowels as long as possible. The pain is more or less constant, walking,
riding, sitting in a hard chair, sexual indulgence, or the pressure and
friction of the clothing particularly aggravate it, but the sufferings are as
nothing compared to the positive agony of defecation.
* Bleeding is bright red, with only a few streaks or
flecks. The blood is on the surface of the bowel movement or on the toilet
tissue after wiping.
* The bladder becomes irritable, the bowels irregular,
the sleep disturbed, and indigestion soon becomes established; the patient
becomes week and pale and the expression is one of much suffering.
The causes are various – indigestion, chronic
diarrhoea, piles, ulcers, or laceration of the parts from hard difficult stools
or others traumatic agencies. Probably all of these conditions may prove
causative in different cases, but trauma alone can never produce a rent that
would remain open and take in these characters without some constitutional
taint, operating as a maintaining cause.
HOMOEOPATHIC
APPROACH AND MANAGEMENT
Homoeopathic management of anal fissures has to be
considered at the level of supportive measures as well as medicinal treatment.
SUPPORTIVE
MEASURES
* Warm saline baths - Warm bath for two to three times
a day. The patient should sit in a basin or tub of warm water with about 2
ounces of table salt added. Do not use any soap on the irritated area. Then
gently dry the anal area.
* Bowel movements - After bowel movements gently
cleanse the anus with warm water. Do not use dry toilet tissue until the
fissures are healed.
* Diet - The most important aspect of treatment is to
have a non-constipating diet. Increase the amounts of fresh fruits and
vegetables, beans, and bran products.
MEDICINAL
TREATMENT
Acute episodes of anal fissures after treatment with
suitable homoeopathic medicines, on the basis of symptom totality and
similarity should be followed up by suitable constitutional medicine, with
proper dietary considerations.
REPERTORIAL
REFERENCE
FISSURE:
Cham.,
Graph., Nit-ac., Rat., Sep., Thuj.
Agn.,
all-c., ars., calc-p., caust., cund., fl-ac., hydr., ign., lach., led., merc.,
nat-m., nux-v., paeon., petr., phos., phyt., plb., sed-ac., sil., sulph.,
Aesc., alum., ant-c., arg-m., arum-t., berb., calc-f.,
calc., carb-an., cur., grat., kali-c., med., merc-i-r., mez., mur-ac., plat.,
rhus-t., syph.,
* Bleeding
* Ars.,
calc., graph., lac-d., nat-m., nit-ac., rhus-t., syph. Bleeding, stool after
* Ars.,
calc., lac-d., nat-m., nit-ac. Cold water amel
* Rat.
Hammers in, as if
* Lach.
Infants
* Kali-i
Ointments agg
* Aloe.
Oozing
* Graph.,
Paeon., syph., tub. Painful, very
* Cham.,
graph., lac-d., rat., syph., thuj. Painless
* Acon.,
aloe., carb-ac., phos. Pregnancy during
* Ars.,
caust., grat., ign., lach., mez., nat-m., nit-ac., nux-v., phos., plb., sep.,
sil., sulph., tab., thuj., zing. Ulcerate
* Graph.
Perineum
Am-c.
THERAPEUTIC
INDICATIONS
Graphites
This remedy is an antipsoric of great power. It is
especially indicated in individuals who are stout, of fair complexion, fat, and
chilly. Constipation – large, difficult, knotty stools united by mucous
threads. In eczematous subjects where the anus is extremely sore and the stools
are covered with mucus, with no tenesmus or constriction. The fissures are
usually caused by large faeces. Smarting, sore anus, itching.
Nitric acid
Bowels constipated with fissures in rectum. Tearing
pains during stools. Rectum feels as if torn. Violent cutting pains after
stools, lasting for hours. From its affinity to the muco-cutaneous junctions,
this remedy becomes an important one in fissure where there is a sensation as
if splinters or sticks were in the anus. There is much tenesmus and constriction,
and a constant oozing of the fetid matter from the parts, with burning, rawness
and smarting. Improvement of all symptoms while riding in a carriage.
Ratanhia
Ratanhia has much constriction about the anus, which
aches and burns for hours after stool, there are cutting and lancinating pains
in the rectum, and dryness of the anus with sudden stitches in it. Rectum
aches, as if full of broken glass. Fissure of anus, burning like fire,
temporarily relieved by cold water. It is also a useful remedy for pinworms.
Chamomilla
Soreness of anus with painful fissures. Chamomilla is
sensitive, irritable, thirsty, hot and numb. Oversensitiveness from abuse of
coffee and narcotics. Pains unendurable.
Sepia
Fullness of rectum. Constipation – large, hard stools;
feeling of a ball in rectum. Great tenesmus, with pains shooting upwards.
Constant oozing from anus.
Thuja
Constipation, with violent rectal pain, causing stool
to recede. Fissured anus, painful to touch, with warts.
Paeonia
Has fissures with much oozing. The anus if offensively
moist and sore, smarts all the time. Burning and biting, lasting several hours
after stool, may also be present; must walk the floor all night.
Silicea
Fissures painful, with spasm of sphincter. Stool comes
down with difficulty; when partly expelled, recedes again. Faeces remain a long
time in rectum. Constipation always before and during menses.
Causticum
Acrid, thin, bad-smelling discharge; the anus and
perineum are sore and excoriated, and there is most persistent long-lasting,
and violent pruritus; the excoriation is so great that the patient can scarcely
walk. Stools hard, tough, covered with mucous, shines like grease. Rectum sore
and burns.
Ignatia
Itching and stitching up the rectum. Painful
constriction of anus after stool. Worse when stool is lose. Pressure as of a
sharp instrument from within outward.
Nux vomica
In persons with sedentary habits, or who are
habituated to intoxicating drinks, or high livers generally. Constipation, with
frequent ineffectual urging. Stools are hard, dry, infrequent, and passed only
after many efforts, with headache in the morning, and dullness of intellect.
Sulphur
For chronic rhagades, not very painful, accompanied by
much moisture, and constant pruritis; cold water is unbearable, and causes intense
smarting, followed by a scalding feeling and much itching. Redness around the
anus.
Hydrastis
Anus fissured with constipation and sinking feeling in
stomach and dull headache. During stool, smarting pain in rectum with
contraction and spasm. Hydrastis is especially active in old, easily tired
people, cachectic individuals.
Lachesis
Constipated, offensive stool. Anus feels tight, as if
nothing could go through it. Pain darting up rectum every time the patient
sneezes or coughs. Cannot bear anything tight anywhere.
Natrum mur
Burning pains and stitching after stool. Anus
contracted, torn, bleeding. Constipation; stool dry, crumbling.
DR. SUMIT GOEL M.D. (Hom)