New Protocol to Treat Anal Fissures
New protocol to treat anal fissures offers excellent results, without cutting the muscle.
Sometimes the most difficult thing about a problem is overcoming the fear of facing it. When people have painful conditions of the anus, they tend to be embarrassed to talk about that part of the body and even less enthusiastic about inviting a doctor to take a look. But anal pain is best treated sooner than later, and an earlier diagnosis can improve patients' outcomes in the long run.
Reflecting their commitment to doing everything possible to ease patients' suffering, the surgeons in the Division of Colorectal Surgery at NewYork-Presbyterian/Columbia have recently developed a new protocol to treat anal fissures, a painful condition frequently misdiagnosed as hemorrhoids. What's more, the new protocol offers superb results without cutting the anal sphincter muscle.
What are anal fissures?
Anal fissures are small cuts or tears at the skin of the anal opening. They typically cause pain when a person has a bowel movement, and pain can be severe for hours afterwards. Some patients also experience bleeding. Many people assume that pain in that part of the body signifies hemorrhoids, so they self-treat with hemorrhoid remedies first, says Daniel L. Feingold, MD, an attending surgeon in the Division since 2004. Very often, it is only after suffering for a long time that people finally seek help from a gastroenterologist or colorectal specialist.
According to Dr. Feingold, anal fissures can happen to anyone: the majority of patients are healthy, and fissures do not appear to have anything to do with age, gender, diabetes, smoking, diet, sexual practices, or any other known factors. Although some anal fissures heal without treatment, some do not, and these go on to cause chronic pain problems. The fissure cycle goes like this: if the cut of the fissure stays open, pain causes spasms of the muscles around the anus, which prevents blood flow to the area, which prevents healing. This leads to more pain and more spasm.
Medical therapy, primarily a muscle relaxant cream applied around the anus, is effective in healing about 70% of anal fissures. By relaxing the muscle so that spasms resolve, blood flow to the area improves and healing can occur. Hot baths and stool softeners can help promote healing. About 30% of patients fail to heal with this approach, however. These patients traditionally have had two options, the first of which is injection of botox into the fissure. By paralyzing a portion of the muscle and relaxing the spasm, the hope is that the fissure will heal. This works only in about 30% of patients, however. The gold-standard approach is a surgical procedure called sphincterotomy, in which the surgeon cuts a piece of the anal sphincter. This relaxes the spasm, which relieves the pain and allows nearly all fissures to heal. The drawback to sphincterotomy is that some people develop function-related problems, meaning that they can have increased urgency or impaired control of bowel movements, gas, etc. Women, in particular, are at risk of having function-related problems after sphincterotomy.
When patients first meet Dr. Feingold, he reassures them of several important things. First, he acknowledges that it is normal to feel embarrassed and anxious. Second, he explains that they are in the right place, where he and his colleagues are experts in colorectal conditions like anal fissures. Third, he emphasizes that his exam will be pain free; when evaluating a patient with a fissure, he does no internal exam, just a visual examination of the external anus. In fact, he says, "Many of my patients are surprised and ask, 'That was it? That's the whole exam?'"
Beneath his ability to help his patients feel comfortable and even laugh, Dr. Feingold means every word. To the point, he was so determined to find a better option for his patients with anal fissures that he took it upon himself to develop a new protocol to improve upon available treatment options.
Wound care protocol
Dr. Feingold performs the procedure in the operating room because it has the best lighting and allows patients to have sedation during the procedure. It takes about 15 to 20 minutes, and patients go home after a few hours.
The procedure entails four steps.
- Gently dilate the anus with special retractors
- Clean out the fissure with curettage to stimulate healing
- Cauterize the wound with electrocautery to seal the wound
- Inject traimcinolone (generic Kenalog), a steroid, into the fissure.
Dr. Feingold says that he developed the idea for the Kenalog protocol by considering the best-known approaches to treating chronic wounds. He has treated 115 patients with the new method, and virtually all have had superb outcomes. He is in the process of publishing results from his first 100 patients, two thirds of whom were pain free within ten days. Among the other third of patients, it took as long as six weeks for their pain to disappear. None of the patients have had control-related complications. "Patients report they are very happy with this approach," says Dr. Feingold.
Dr. Feingold explains, "This has a good record of fixing the problem and a low risk profile. The beauty is that it is muscle-sparing, so it does not cause control related problems. But it also doesn't burn any bridges, so if it fails, it would still be possible to do a sphincterotomy, if need be." Although he no longer performs sphincterotomies because of the success of this approach, other surgeons in the Division of Colorectal Surgery do, should it be needed.