Fissures
A anal fissure is a small tear at the margin of the skin and the anal canal , canoe shaped, and measuring about an eighth of one-inch, very much like a split lip. They are extremely painful particularly during bowel movements. Anal fissures are caused by constipation. They are common, and almost all heal immediately if caught before the fissure develops scar tissue. Treatment consists of anal care, such as stool softeners and moist baby wipes. The anal fissure causes the internal sphincter muscle to go into spasm, decreasing blood flow to the area, thus preventing the fissure from healing. The internal sphincter is the circular muscle at the anal opening.
Occasionally the fissure fails to heal due to continued spasm of the internal sphincter muscle. The fissure now develops scar tissue and turns into a chronic ulcer which causes severe pain and often bleeding during and after bowel movement. The pain may last for hours.
Chronic fissures may heal for months and then break open again. Most are in the posterior anus, that is towards the tail bone. Treatment requires a small nick in the internal sphincter muscle in order to relax it, called a sphincterotomy. This muscle relaxation allows the fissure to heal after vaporization of the scar tissue surrounding it, using the wide beam of the laser.
The procedure is done in our outpatient facility, under twilight sleep and long acting local anesthesia. Patients are given antibiotics to prevent infection. Recovery is almost immediate and recurrence is rare. Post operative discomfort is managed with warm baths, alternating with ice packs to the area.
Complications are rare. Infection is prevented by post operative antibiotics. Because we use such a small incision in the sphincter muscle, it heals without loss of function.
Anal Itching (Pruritus Ani)
Anal itching is a very common complaint, more common in men than women. There are several causes of anal itching
Hemorrhoids. One of the commonest symptoms of hemorrhoids is anal itching. This is probably due to swelling and drainage. Laser hemorrhoidectomy successfully treats this problem.
Over zealous cleaning of the anal area. This is most common in men. The skin around the anus is as delicate as the white area of the eye, and is easily damaged by aggressive cleansing. It is important to wash away any soap, as it is an irritant. The area should be dried by gentle patting, and the best results are achieved by drying with a hair dryer. Our typical patient with anal itch is male, and works out frequently with resulting sweat accumulation in the anal area. He does not wash all the soap away and rubs the area aggressively with a rough towel. The anal area now becomes inflamed due to damaged anal skin. Instead of controlling the problem with a change in anal skin care, the patient starts using prescription and over the counter creams and salves. At first things improve, as the medications are soothing, but they in turn damage the skin or become allergenic. Eventually the skin is so damaged that the patient is in misery, which is when we see them. It requires a change in life style to return the anal skin to normal. Avoidance of all irritants, thorough washing with water, and gentle drying with a hair dryer, if necessary. Desinex powder seems to be non irritating and helps to keep the area dry. It is also anti fungal.
Fungal infection. The fungus, Monilia Candidans, thrives in a moist, warm climate such as the anal area. It causes severe anal itching, but can be prevented by treating the anal area gently, and keeping it clean and dry. Desinex powder helps keep the area dry and is also an anti fungal. It is inexpensive and can be purchased over the counter at most pharmacies. Patients who develop a fungal infection are treated with an anti fungal oral medication called Diflucan, and an anti fungal cream to be applied to the anal area.
Abscesses and Fistulas
Abscesses in the anal area usually develop quickly (in a matter of days), and are extremely painful with swelling and redness. They are caused by infected anal glands which lie under the skin around the anus at a depth of about an inch. It is unknown what causes the glands to become infected.
These abscesses are treated by making an incision in the skin over the abscess and allowing the pus to drain out. Antibiotics are not used as they mask the symptoms, and make the abscess difficult to treat.
Half of these abscesses will go on to form a tunnel that runs from the skin outside the anus to the inside of the anal canal. This is called a fistula.
Fistulas are treated by locating the tunnel with a probe and, using a laser to divide the tissue over the tunnel, thus exposing it and allowing it to heal. Care is taken not to damage any sphincter muscle fibers.
The procedure is done in the out patient facility under twilight sleep and local anesthetic. Healing is quick and with little discomfort. Complications are rare.
Anal Leakage (incontinence).
Anal leakage is the difficulty in controlling rectal gas or stool. Patients suffering from these symptoms fall into two groups.
Elderly patients (usually women) lose strength in the anal sphincter muscle as they age, just as they do in all their muscles. If the sphincter muscle is intact, physical therapy using Kagel exercises will improve leakage in almost all patients.
During vaginal delivery, the anal sphincter muscles are occasionally damaged. This weakens the muscle but symptoms often do not appear until middle age. At the laser surgery center we specialize in repairing these muscles. This is done under twilight sleep and local,anesthesia.
Infection is controlled with antibiotics.
Anal Warts
Anal warts are caused by a virus and are sexually transmitted. They feel like small bumps around the anal area. We have been able to eradicate warts with the laser and careful follow up. Safe sex is essential until the warts are completely gone. Complications are rare. Patients are under twilight sleep and local anesthesia.
Anal opening is too Small (anal stenosis)
Anal stenosis is caused by injury or surgical scarring from traditional (non laser) anal surgery for hemorrhoids. We increase the size of the anal opening by a plastic surgical procedure in which normal skin next to the anus, is transferred to the area of narrowing. Antibiotics to prevent infection are used. This is done at our outpatient facility under twilight sleep and local anesthesia.