Fissure, fistula, and constipation are common anorectal disorders with significant clinical implications. Their pathophysiology, diagnosis, and management require a detailed understanding of both Ayurvedic and modern medical approaches for comprehensive patient care.
I. Anal Fissure
1. Definition & Pathophysiology
Anal fissure is a linear tear in the anoderm (squamous epithelium of the anal canal), typically in the posterior midline due to high resting anal pressure and trauma from hard stool passage.
🔹 Acute fissure: Recent tear (<6 weeks), usually heals with conservative management.
🔹 Chronic fissure: Persistent (>6 weeks), often with fibrosis, sentinel pile, and exposure of internal anal sphincter fibers.
2. Etiology & Risk Factors
| Cause | Pathophysiology |
|---|---|
| Hard stool passage | Increased anal canal pressure tears the mucosa |
| Chronic constipation | Straining leads to ischemic damage |
| Diarrhea | Frequent bowel movements cause mucosal irritation |
| Hypertonic internal anal sphincter | Increased resting pressure leads to poor healing |
| Pregnancy & Childbirth | Increased intra-abdominal pressure damages the anal mucosa |
| Crohn’s Disease | Ulceration & inflammation lead to recurrent fissures |
3. Clinical Features
✔️ Pain – Severe, sharp pain during and after defecation (lasting minutes to hours).
✔️ Bleeding – Bright red blood on stool or toilet paper (mild).
✔️ Spasm – Reflex spasm of the internal anal sphincter leads to worsening pain.
✔️ Sentinel Pile – Thickened skin at the distal end (seen in chronic fissures).
4. Investigations
✔️ Perianal Examination – Reveals a linear tear, usually in the posterior midline.
✔️ Digital Rectal Examination (DRE) – Avoided in acute cases due to pain.
✔️ Proctoscopy – Done if secondary causes (Crohn’s, malignancy) are suspected.
5. Management
A. Conservative Treatment (First-line for Acute Fissures)
✔️ High-fiber diet – Reduces stool hardness.
✔️ Sitz baths – Warm water immersion relaxes the anal sphincter.
✔️ Topical nitrates (GTN 0.2%) or Calcium Channel Blockers (Diltiazem 2%) – Reduce sphincter tone and improve blood flow.
B. Surgical Treatment (For Chronic & Refractory Fissures)
✔️ Lateral Internal Sphincterotomy (LIS) – Gold standard; reduces sphincter tone.
✔️ Botulinum Toxin Injection – Temporarily relaxes the internal sphincter.
II. Anal Fistula (Bhagandara in Ayurveda)
1. Definition & Pathophysiology
An anal fistula is an abnormal communication between the anorectal canal and perianal skin, usually caused by chronic infection of the anal glands (cryptoglandular abscess formation).
2. Etiology & Risk Factors
| Cause | Pathophysiology |
|---|---|
| Perianal abscess | Most common cause; untreated infection leads to fistula formation |
| Crohn’s Disease | Chronic inflammation leads to non-healing fistulae |
| Tuberculosis | Granulomatous infection in the anorectal region |
| Hidradenitis Suppurativa | Recurrent skin abscesses cause fistula formation |
3. Clinical Features
✔️ Perianal discharge – Pus or serous fluid.
✔️ Perianal pain – Associated with abscess formation.
✔️ Recurrent swelling & abscesses – Suggestive of a fistulous tract.
4. Classification of Fistulae (Parks’ Classification)
| Type | Description |
|---|---|
| Intersphincteric | Most common (45%); confined between internal & external sphincters |
| Transsphincteric | Crosses both sphincters, opening in the ischiorectal fossa |
| Suprasphincteric | Extends above the puborectalis |
| Extrasphincteric | Passes outside the anal sphincters (seen in Crohn’s disease) |
5. Investigations
✔️ MRI Pelvis – Gold standard for fistula mapping.
✔️ Endoanal Ultrasound – Useful for complex fistulas.
✔️ Fistulography – Injects contrast into the tract to visualize its extent.
6. Management
✔️ Fistulectomy – Excision of the fistula tract.
✔️ Seton Placement – Preserves sphincter function while allowing drainage.
✔️ LIFT Procedure – Used for high transsphincteric fistulas.
✔️ Kshar Sutra Therapy (Ayurvedic) – A medicated thread is passed through the fistula for gradual cutting & healing.
III. Chronic Constipation
1. Definition & Pathophysiology
Chronic constipation is defined as infrequent (<3 bowel movements/week) or difficult stool passage for more than 3 months. It results from slow colonic transit or defecatory disorders.
2. Etiology & Risk Factors
| Cause | Pathophysiology |
|---|---|
| Low fiber diet | Decreased stool bulk leads to slow colonic transit |
| Dehydration | Hardens stool consistency |
| Sedentary lifestyle | Decreased gut motility |
| Hypothyroidism | Slows metabolic rate and gut motility |
| Neurological diseases | Parkinson’s, spinal cord injuries affect colonic peristalsis |
| Chronic opioid use | Causes opioid-induced constipation (OIC) |
3. Clinical Features
✔️ Hard stools, straining – Difficulty in passing stool.
✔️ Incomplete evacuation – Feeling of persistent stool in rectum.
✔️ Bloating & Abdominal Discomfort – Due to prolonged stool retention.
4. Diagnostic Workup
✔️ Digital Rectal Examination (DRE) – Checks for rectal tone, fecal impaction.
✔️ Colonoscopy – If alarm symptoms (weight loss, rectal bleeding) are present.
✔️ Anorectal Manometry – Assesses defecatory function.
5. Management
A. Lifestyle & Dietary Modifications
✔️ High fiber intake (20-35g/day) – Fruits, vegetables, whole grains.
✔️ Increased water intake – At least 2-3 liters per day.
✔️ Regular exercise – Promotes gut motility.
B. Pharmacological Therapy
| Drug Class | Examples | Mechanism |
|---|---|---|
| Bulk-forming laxatives | Psyllium, Methylcellulose | Increase stool bulk |
| Osmotic laxatives | Lactulose, Polyethylene Glycol | Draw water into the colon |
| Stimulant laxatives | Bisacodyl, Senna | Enhance peristalsis |
| Prokinetics | Prucalopride | Improves colonic transit |
C. Surgical Management
✔️ Colectomy – Reserved for severe refractory constipation.