Fistula or commonly called Anal Fistula has plagued mankind for centuries together. There had been no satisfactory treatment available. The options available were either too painful or cumbersome. But now with new advancements in science, all these problems seem to be a past. A fistula is an abnormal communication between the inside of a hollow organ and the skin.  In the case of an anal fistula the communication is from inside the rectum to the skin outside the anus or on the buttock.  The inciting cause is trauma of defecation which causes a break in the mucosa of the rectum.  Bacteria track into the tissue under the mucosa and form an abscess.  The abscess eventually finds its way to the skin where it ruptures and drains.  The outer opening may heal but the inner opening remains and permits the cycle to repeat itself.  Patients often present with years of repeated abscesses in this area which drain, heal and return again.

Piles is one of the most common diseases of humans. It is estimated that one out of  every three persons suffer from piles. A good satisfactory treatment of Piles has eluded human beings ever since they became two legged. The surgery for Piles was undoubtedly more dreaded than the disease itself.

A fissure is simply a crack or tear in the anal skin in the anal canal.  The cause is also straining with bowel movement.  They are often exquisitely painful.  So much so, that when I see a patient in excruciating pain in the anus, the patient will not allow me to do a digital exam and I cannot see a thrombosed hemorrhoid, I will usually just treat for a fissure as the presumptive diagnosis.  Surgical treatment involves doing a lateral sphincterotomy.  The skin in the outer part of the anus is opened slightly to expose the sphincter muscle and the muscle is divided superficially.  This does not carry the same risk of incontinence as when dividing the muscle for a fistula, because the location and degree of muscle division can be completely controlled by the surgeon.  With a fistula, the area of muscle involvement is dictated by the disease.

Surgery for fissures can often be avoided with the use of topical Nitroglycerine applied directly to the anus.  Nitroglycerine relaxes the muscles of the anal sphincter the same way it relaxes the smooth muscle of blood vessels when treating Coronary Artery Disease.  It may cause a low blood pressure in normal patients even when applied to the anus in this manner and therefore, may not be suitable for everyone.  It is; however, a good first line treatment option that often resolves the problem and avoids the need for surgery.

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