Treatment of Anal Fissure (Parikartika):

Symptoms:
Fissure –in- Ano, Anal fissure, Crack in the anal canal, Parikartika (In Ayurvedic terminology)

Definitions:

• Parikartika (परिकर्तिका):
  (Pari= all around & Kartanam= cutting)
  The disease in which there is a cutting like pain all around the anus is known as ‘Parikartika’.

• Fissure-in-Ano (Anal fissure):
  ‘Fissure’ means a crack.
  So, an anal fissure is a longitudinal crack in the long axis of the lower anal canal, but in reality, it is a true ulcer of the skin of the wall of the anal canal.

Location:
The site of affinity for an anal fissure is midline posterior. The next most frequent situation is the midline anterior and exceptionally it is found elsewhere on the circumference of the anus.
In a woman, the anterior anal fissure is common; whereas in men, posterior anal fissures are common.

Classification:
Mainly it is divided into two types.

• Acute fissure:
  This is often a mere crack in the epithelial surface, but may never the less, cause severe pain and spasm in the anal canal.

• Chronic fissure:
  This has thickened margin edges. The skin at the lower edges of the fissure is often oedematous, hypertrophied and undermined producing the so-called ‘sentinel tag’. Sentinel means, an umbrella or a guard.

Symptoms of anal fissure:

• Anal pain: in the acute fissure, pain is often severe.
• Bleeding: usually, stools are streaked with blood.
• Burning sensation in the anal canal: in case of hard stool or constipation, after defecation patient has often feeling of burning sensation for few minutes.
• Discharge and pruritus ani (itching all around the anal region): in fully established cases there may be some discharge leading to soiling of the undergarments and increased moisture of the perianal skin with resulting pruritus ani.
• Swelling over the anal region: a patient with a large ‘sentinel tag’ may complain of a painful external swelling over the anal region.
• Change of bowel habit: the patient can quickly make out that pain is either aggravated after passing stool. So there is a tendency to defer going to stool, thereby the normal bowel habit is gradually taken over by constipation.

Complications:
Main complications are:

• Abscess and fistula
• Sentinel tag
• Enlarged papilla
• Anal contracture

Treatment:
Conservative treatment:

• Avoidance of constipation:
  • It is important because, the repeated anal trauma, while passing hard fecal matter, it is to be avoided for rapid healing of the fissure without any other treatment. This can be achieved by the use of mild aperients and laxatives.
  • In case the fissure heals up completely then care should be taken for the regular bowel habits, till the patient feels that he can manage the smooth bowels without a laxative. Care should be taken that the stools are not made watery.
  • Diet plan & regime:

Follow the ‘Ayurvedic lifestyle’ (For details, look forward on the home page of this site).

• Warm sitz bath:
  • The patient should be advised to have warm sitz bath preferably by adding some antiseptics, anti-inflammatory e.g. ‘panchvalkal kwath’ (decoction made of five specific Ayurvedic herbs)
• Local medication:
  • Installation of Ayurvedic healing oil (e.g. jatyadi oil) at frequent intervals and after passing stools; For healing of anal fissure, frequently apply of Ayurvedic healing oil/ astringent ointment over the wound; Application of ‘Matra Basti’- Ayurvedic medicated enema made of Ayurvedic herbal oils
• Oral medication:
  • Patient has to be treated with Ayurvedic herbal drugs which are having ‘Vātanuloman’ & ‘Agnidipan’ effects as per given by the Ayurvedic classical texts such as,
  • Haritaki Powder (Latin name: Terminalia Chebula) with Jaggery (2-3 times a day)- orally
  • Haritaki Powder (Latin name: Terminalia Chebula) with Dry zinger power, in equal portions followed with lukewarm water (2-3 times a day)- orally
  • Abhayarishta –orally
  • Takrarishta- orally
  • Agatsya Haritaki avleha- orally
  • Application of Jatyadi oil- Local application
  • Ancare ointment- Local application
  • Proper anal hygiene and the use of anesthetics:

Careful cleaning of the anal outlet after passing stool is very essential. Similarly to lessen the pain of the anal fissure and relieve anal spasm, application of an ointment containing 5% xylocaine in the water-soluble lubricant is introduced in the anal canal, with the help of a fine nozzle. It is further advised that such an ointment must be introduced just before the urge of defecation and also again after the motion has been passed and the part is cleaned properly. Frequent used of xylocaine ointment impair the local bold supply and delays healing. Therefore Ayurvedic antiseptic ointments are quite useful for fissure healing such as,

• Jatyadi great,
• Ancare ointment,
• Sunarin ointment,
• Cut far ointment,
• Nimbaadi Kalk (Nimb(Azadirachta indica Linn.)leaves+ Honey+ Ghee(Clarified butter)+ Til(Sesame) oil- each drug in equal proportion, mix well and make a paste)
• Use of anal dilators: (In chronic fissure):

In case of chronic fissure or long-standing fissure, after application of the ointment, an attempt should be made to introduce an anal dilator of small size. Such a practice should be continued for a month, by which time the fissure is usually healed. This must not be tried in acute fissures. Only in chronic and less painful conditions, it is advised.

Operative procedures:

Where the conservative line of management fails to heal the fissure, a patient is advised for operative procedures with each have its specific indications.

These procedures are mainly,

• Lord’s dilation
• Fissurectomy & Anoplasty
• Sphincterotomy