The anal region (anus) is the last part of the gastrointestinal system. Disorders regarding this region are usually very painful. The most common three anal disorders are hemorrhoid, perianal fistula, and anal fissure.
Hemorrhoid, which is also called piles, occurs as a result of the dilatation of the vessels surrounding the anal region like varicose veins in the legs. It may be caused by prolonged standing, diarrhea, constipation, immobility, heart failure, liver cirrhosis, prolonged cough and vomiting, pregnancy, and tumors of the distal colon. It is hereditary in some families. It is hard to find an individual who had not suffered from hemorrhoids in their life. Sometimes it remains asymptomatic and is extremely rare in children. The most common symptom is bleeding. Pain, burning sensation, a feeling of pressure and heaviness, swelling, a sensation of itching, constipation, discharge, and piles are other emerging symptoms. Anal disorders are usually diagnosed with physical examination. Endoscopic examination (inspection of the anal region and colon with a particular instrument) can be performed if necessary. As the symptoms of anal cancer are very similar, hemorrhoids should never be treated without a definitive diagnosis. There are different treatment methods according to the characteristics of the patient and the stage of the disease at diagnosis. Medical treatment is possible, and surgical methods like sclerotherapy and band ligation can also be implemented. Your physician will decide on a suitable treatment method.
Small chaps and tears, in the skin around the anus, are called anal fissures. It usually occurs after large or hard stools during constipation and is more common in infants and women after pregnancy. It may lead to bleeding and pain. Regional (local) anesthesia or spinal anesthesia (anesthesia of the lower body) are convenient for this surgery. General anesthesia is not needed. The patient is placed in the proctological position. The anal region is re-examined thoroughly under anesthesia, and the length and depth of the fissure are determined. Then a 1-cm incision is made at the anal margin. The internal sphincter muscle, which regulates the tension of the anus, is isolated and a partial incision is made for relaxing the muscle. In some patients, the sentinel pile is cut and the area is flattened. The surgery lasts only a few minutes following the anesthesia and other preparations. The fissure is not stitched during surgery. The internal sphincter muscle, which is accessed from the other site, is relaxed. The rational of surgery is based on the relief of the regional spasm and correction of the impaired circulation. Bleeding will disappear within a week. The wounds will recover in a few weeks. The total recovery rate is over 95%.
Fistula is an inflamed canal around the anus. The canal has one internal and one external opening. The external opening can easily be observed in the skin surrounding the anal region. It is a pimple-like formation with a hole in the middle. The internal opening is in the intestinal mucosa located 2-3cm above the anal opening. It is sometimes tough to identify during the physical examination. Therefore, contrasted imaging or MRI is required in some patients. A hardness is observed between the internal and external openings as a result of the inflammation. If fissure developed once, it means that there will be a continuous inflamed discharge. Spontaneous recovery is not expected.
This method is preferred if the fissure’s inflamed canal is extended to the deep and distant tissues because standard surgery may impair the defecation control. The seton treatment is actually based on the same principles (closure of the canal) with the standard method, but the closure occurs gradually. A nonabsorbable thick string is passed through the canal and tied in a circular shape outside in the anus margin. This hoop-shape string, which is called seton, tightened gradually, squeezing the tissue around anus once in a few weeks. The canal will shift slowly towards the anus and open to the outside. The seton enables the repair of the remaining tissues while cutting the inflamed canal slowly in the direction of the anal opening. Thus, the defecation function is not permanently damaged and the canal disappears in a few weeks’ time.
Surgery is the treatment of choice for the majority of anal fissures. Spinal anesthesia (anesthesia of the lower part of the body) is preferred for this intervention. It is also expected that the patient drinks a surgical bowel preparation to empty the bowels before surgery. During the intervention, the internal and external openings of the fissure are exposed, and a guidewire is placed through the canal. The tissues are cut from the anal margin to the canal into the deeper region and the wire is exposed. This process is similar to open the ceiling of an underground tunnel and to shape it as a valley. In some cases, the walls of the canal are scraped off. This process is called the fistulotomy or excision of the fistula tract in the medical terminology. Thus a 1-2cm long cleft is formed at the anal margin. The patient may be discharged on the same day. If necessary, they may be hospitalized for one day.