What are the common causes of sphincter cramps. How can you identify the symptoms of anal fissures. What are the most effective treatments for sphincter cramps and anal fissures. Is surgery always necessary for treating chronic anal fissures. What are the potential risks and side effects of various treatment options.

Understanding Anal Fissures: The Primary Cause of Sphincter Cramps

Anal fissures are a common cause of sphincter cramps and anal pain. These small tears in the lining of the anus can cause significant discomfort and often lead to muscle spasms in the anal sphincter. But what exactly are anal fissures, and why do they occur?

An anal fissure is essentially an ulcer in the squamous epithelium of the anus, typically located just distal to the mucocutaneous junction. In most cases, these fissures appear in the posterior midline of the anus. The pain associated with anal fissures is characteristically episodic, occurring during defecation and lasting for one to two hours afterward.

This unique pain pattern distinguishes anal fissures from other causes of anal discomfort, such as thrombosed hemorrhoids, abscesses, or viral ulcers. While most anal fissures are considered “typical” or “benign,” there are instances of atypical fissures that may be multiple, off the midline, or large and irregular.

Causes of Atypical Anal Fissures

• Inflammatory bowel disease
• Local or systemic malignancy
• Venereal infections
• Trauma
• Tuberculosis
• Chemotherapy

The exact cause of typical anal fissures remains unclear, and there are no widely accepted methods for preventing their occurrence. This gap in our understanding presents a fertile area for future research in the field of colorectal health.

The Role of Sphincter Spasm in Anal Fissure Pain

One of the most consistent findings in typical anal fissures is the severe spasm of the internal anal sphincter. This spasm is so intense that it’s believed to be the primary source of pain associated with anal fissures. How does this work?

The intense contraction of the sphincter muscle leads to reduced blood flow to the area, essentially causing ischemia of the sphincter. This lack of blood supply not only contributes to the pain but also hinders the natural healing process of the fissure.

Interestingly, when this spasm is relieved, patients often experience a significant reduction in pain, and the fissure itself tends to heal without recurrence. This understanding has shaped many of the treatment approaches for anal fissures, with a focus on relaxing the sphincter muscle to promote healing and alleviate pain.

Traditional Surgical Approaches to Anal Fissure Treatment

Historically, the most common approach to treating chronic adult anal fissures has been surgical intervention. The primary goal of these procedures is to relieve the sphincter spasm, which in turn reduces pain and promotes healing of the fissure.

The most widely used surgical technique is known as lateral internal sphincterotomy. This procedure involves making a small incision in the internal anal sphincter muscle, which helps to release the tension and allow the fissure to heal.

While surgical treatments have been widely used and are generally considered effective, it’s important to note that there have been no placebo-controlled surgical trials conducted. This lack of controlled studies makes it challenging to accurately assess the true efficacy of these procedures compared to non-surgical interventions or no treatment at all.

Potential Risks of Surgical Treatment

For many years, the morbidity associated with operative procedures for anal fissures was thought to be extremely rare. However, more recent reports have highlighted some potential risks, particularly regarding post-operative incontinence.

• Incontinence to flatus (gas)
• Fecal incontinence (in rare cases)
• Wound infection
• Delayed healing
• Recurrence of the fissure

A systematic review of randomized surgical trials found that the overall risk of incontinence following sphincterotomy was about 10%. While this was primarily incontinence to flatus, the long-term implications of this side effect are not well-documented in the literature.

The Emergence of Non-Surgical Treatments for Anal Fissures

By the late 1990s, there was a growing interest in alternatives to surgical treatment for anal fissures. This shift was driven by several factors, including:

1. Cost considerations
2. Recovery time
3. Risk of incontinence associated with surgery

Rather than reverting to older treatments such as lubricants and numbing agents, researchers began investigating newer medications known to relax muscle spasm. These innovative approaches aimed to provide effective relief without the potential risks associated with surgical intervention.

Modern Non-Surgical Treatment Options

• Nitroglycerin ointment
• Botulinum toxin injections
• Calcium channel blockers (oral and topical)

Each of these treatments works by relaxing the internal anal sphincter, thereby reducing pain and promoting healing of the fissure. But how effective are these non-surgical options compared to traditional surgical approaches?

Comparing the Efficacy of Surgical and Non-Surgical Treatments

When evaluating the effectiveness of different treatment options for anal fissures, it’s crucial to consider both the success rates and the potential risks associated with each approach. Let’s break down the available data:

Surgical Treatment Efficacy

Surgical intervention, particularly lateral internal sphincterotomy, has long been considered the gold standard for treating chronic anal fissures. Studies have shown that surgery is highly efficacious, with cure rates often exceeding 90% of patients.

However, the potential risk of incontinence following surgery cannot be ignored. A systematic review of randomized surgical trials found that the overall risk of incontinence was about 10%. While this was mostly incontinence to flatus, the long-term implications and quality of life impact of this side effect are not well-documented in the literature.

Non-Surgical Treatment Efficacy

When evaluating the efficacy of non-surgical treatments, it’s important to consider the placebo effect. A systematic review combining analyses where a placebo was used as the comparison group found that the healing rate in the placebo group was approximately 35%. This placebo response rate was relatively consistent across studies, with a standard deviation of 12%.

In light of this placebo effect, the efficacy of medical treatments must be carefully assessed. The same systematic review found that:

• Nitroglycerin ointment had a healing rate of about 55%
• No significant difference in efficacy was found between nitroglycerin ointment, botulinum toxin injection, and calcium channel blockers
• Overall, nitroglycerin ointment was more effective than placebo, but this statistical significance disappeared in sensitivity analyses that excluded studies with unusually low placebo cure rates

While these non-surgical treatments show promise, their efficacy falls short of the high cure rates seen with surgery. However, they may offer a valuable alternative for patients who are not suitable candidates for surgery or prefer to avoid surgical intervention.

Side Effects and Limitations of Non-Surgical Treatments

While non-surgical treatments for anal fissures offer a less invasive alternative to surgery, they are not without their own set of challenges and potential side effects. Understanding these limitations is crucial for both healthcare providers and patients when making treatment decisions.

Nitroglycerin Ointment

Nitroglycerin ointment is one of the most widely studied non-surgical treatments for anal fissures. While it has shown efficacy in promoting healing, it is associated with a significant side effect profile:

• Headaches: Occurred in almost 40% of subjects in combined analyses
• Severity: Headaches were often severe enough to necessitate discontinuation of treatment
• Other potential side effects: Dizziness, low blood pressure

The high incidence of headaches associated with nitroglycerin ointment presents a significant barrier to patient compliance and overall treatment success.

Botulinum Toxin Injections

Botulinum toxin injections offer another non-surgical approach to treating anal fissures. While generally well-tolerated, they are not without potential drawbacks:

• Temporary incontinence: Due to the paralysis of the sphincter muscle
• Pain at the injection site
• Need for repeated treatments: The effects of botulinum toxin are temporary

Calcium Channel Blockers

Calcium channel blockers, particularly when applied topically, have shown promise in treating anal fissures with a potentially more favorable side effect profile:

• Fewer headaches compared to nitroglycerin ointment
• Possible systemic effects when taken orally, including dizziness and low blood pressure
• May be as efficacious as nitroglycerin ointment

The reduced incidence of headaches with topical calcium channel blockers makes them an attractive option for patients who cannot tolerate nitroglycerin ointment.

Tailoring Treatment Approaches for Different Patient Groups

When it comes to treating anal fissures and associated sphincter cramps, it’s important to recognize that a one-size-fits-all approach may not be appropriate. Different patient groups may require tailored treatment strategies to achieve the best outcomes. Let’s explore how treatment approaches might differ for various patient populations:

Chronic Anal Fissures in Adults

For adults with chronic anal fissures that have not responded to conservative measures, the treatment approach may involve:

1. Initial trial of medical therapy (e.g., topical calcium channel blockers or nitroglycerin ointment)
2. Consideration of botulinum toxin injections if topical treatments fail
3. Surgical intervention (lateral internal sphincterotomy) for refractory cases

The choice between these options should be based on factors such as the patient’s overall health, preferences, and the potential risks and benefits of each approach.

Acute Anal Fissures

For patients presenting with acute anal fissures, a more conservative approach is often warranted:

• Dietary modifications to soften stools
• Topical analgesics for pain relief
• Sitz baths to promote healing
• Short-term use of topical medications if symptoms persist

Many acute fissures will heal spontaneously with these conservative measures, avoiding the need for more invasive treatments.

Anal Fissures in Children

Treating anal fissures in pediatric patients requires special consideration:

• Conservative management is the mainstay of treatment
• Focus on stool softeners and dietary modifications
• Topical treatments may be used, but with caution due to potential systemic absorption
• Surgical intervention is rarely necessary and should be considered only in severe, refractory cases

The goal in pediatric patients is to promote healing while minimizing discomfort and avoiding invasive procedures whenever possible.

Anal Fissures in Pregnant Women

Pregnancy can predispose women to anal fissures, and treatment must take into account the safety of both mother and fetus:

• Conservative measures are the first line of treatment
• Careful consideration of topical medications, avoiding those with potential systemic effects
• Surgical intervention is generally deferred until after delivery unless absolutely necessary

The focus for pregnant women is on symptom management and preventing complications, with definitive treatment often delayed until the postpartum period.

Future Directions in Sphincter Cramp and Anal Fissure Management

As our understanding of anal fissures and sphincter cramps continues to evolve, there are several areas where future research and innovation could lead to improved treatment outcomes. Here are some potential directions for future developments in this field:

Improved Surgical Techniques

While lateral internal sphincterotomy is effective, the risk of incontinence remains a concern. Future research could focus on:

• Developing more precise surgical techniques to minimize the risk of incontinence
• Exploring minimally invasive approaches that offer the efficacy of surgery with reduced recovery time
• Investigating long-term outcomes of surgical patients to better understand and mitigate the risk of persistent incontinence

Advanced Medical Therapies

The development of new medications or delivery systems could enhance the efficacy of non-surgical treatments:

• Novel compounds that relax the internal anal sphincter with fewer systemic side effects
• Improved topical delivery systems to enhance local efficacy and reduce systemic absorption
• Combination therapies that target multiple aspects of fissure pathophysiology

Personalized Treatment Approaches

Advancements in our understanding of individual patient factors could lead to more tailored treatment strategies:

• Genetic or biomarker studies to predict treatment response and guide therapy selection
• Development of algorithms to help clinicians choose the most appropriate treatment based on patient-specific factors
• Integration of patient preferences and quality of life considerations into treatment decision-making

Prevention Strategies

Given the current lack of accepted methods for preventing anal fissures, research into preventive measures could have a significant impact:

• Identification of modifiable risk factors for fissure development
• Development of targeted interventions for high-risk individuals
• Exploration of the role of the microbiome in anal health and fissure prevention

Advanced Diagnostic Techniques

Improving our ability to accurately diagnose and characterize anal fissures could lead to more effective treatment:

• Development of non-invasive imaging techniques to assess sphincter function and fissure healing
• Exploration of biomarkers that could indicate fissure severity or predict treatment response
• Integration of artificial intelligence in diagnostic processes to enhance accuracy and guide treatment decisions

As research in these areas progresses, we can anticipate more effective, less invasive, and more personalized approaches to managing sphincter cramps and anal fissures. This ongoing work holds the promise of improved outcomes and quality of life for patients suffering from these challenging conditions.

Treatment of anal fissure

Anal fissure is one of the most common lesions to consider in the differential diagnosis of anal pain. This is an ulcer in the squamous epithelium of the anus located just distal to the mucocutaneous junction and usually in the posterior midline. It typically causes episodic pain that occurs during defecation and for one to two hours afterwards.¹ This feature uniquely distinguishes anal fissure from other causes of anal pain such as thrombosed haemorrhoids, abscess, viral ulcers, and others. Atypical fissures may be multiple or off the midline, or be large and irregular. These may be caused by inflammatory bowel disease, local or systemic malignancy, venereal infection, trauma, tuberculosis, or chemotherapy. The cause of the typical or benign fissure is not clear nor are there accepted methods for the prevention of fissures—both fertile areas for research.

The most consistent finding in typical fissures is spasm of the internal anal sphincter, which is so severe that the pain caused by the fissure is thought to be due to ischaemia of the sphincter.² Relief of the spasm has been associated with relief of pain and healing of the fissure without recurrence. Historically the most common approach for relieving the pain associated with spasm of chronic adult anal fissure is surgical, though no placebo controlled surgical trials have been undertaken. Morbidity from operative procedures, mainly incontinence, was once thought to be extremely rare³ but has been substantial in some recent reports.⁴ So by the late 1990s when alternatives to surgery were sought because of cost, time for recovery, and risk of incontinence, rather than turn back to older treatments, such as lubricants and numbing agents, newer medications were investigated—in each case a medication that was known to relax muscle spasm. These have included nitroglycerin ointment, injection of botulinum toxin, and calcium channel blockers either given as tablets or applied topically.

The choice of treatment remains difficult for the following reasons. Although surgery is highly efficacious and succeeds in curing the fissure in more than 90% of patients, in a systematic review of randomised surgical trials the overall risk of incontinence was about 10%.⁵ This was mostly incontinence to flatus, and there are no reports delineating the duration of this problem (is it permanent or transitory?) Publications describing treatment for incontinence after sphincterotomy for fissure are strikingly absent, implying a lack of need compared with other incontinent populations.

Regarding medical treatment, in a similar systematic review combining all analyses in which a placebo was used as the comparison group,⁶ the healing rate in the placebo group was found to be 35%. This was a level of response that was fairly uniform across studies (standard deviation 12%). The medications being tested in the meta-analysis (nitroglycerin ointment, botulinum toxin injection, and calcium channel blockers) must have their efficacy viewed in the context of this placebo effect and also in the context of a cure rate for surgery that often exceeds 95%.⁵ In the combined analyses, nitroglycerin ointment was found to have a healing rate of about 55%. In comparisons of nitroglycerin ointment to botulinum toxin injection or calcium channel blockers, no significant difference in efficacy was found between the three. Overall nitroglycerin ointment was more effective than placebo, but in sensitivity analyses that excluded studies with placebo cure rates below 10%—more than two standard deviations below the mean—statistical evidence of efficacy disappeared. In addition, with nitroglycerin ointment, the most investigated medical treatment, headache was common, occurring in almost 40% of subjects in the combined analyses and severe enough often to stop treatment.⁶

So it would be advantageous if the risk of incontinence could be reduced after surgery or the success rate of medical treatments increased to that found in surgery, but with less risk of headache. The Cochrane reviews provide some direction here but not a quick fix. Anal stretch was found to have a significantly higher risk of incontinence than controlled sphincterotomy in surgical trials and a higher risk of treatment failure. Stretch should probably be abandoned in favour of partial internal sphincterotomy until a better operation is described. Among the medical treatments, calcium channel blockers applied topically caused fewer headaches and may be as efficacious as nitroglycerin ointment.

Medical treatment for chronic anal fissure, acute fissure, and fissure in children may therefore be applied with a chance of cure that is only marginally better than placebo. The risk of using such treatments is not great: mainly headache during the use of nitroglycerin ointment, without apparent adverse effect in the long term. Medical treatments can therefore be used in individuals wanting to avoid surgical treatment, and surgery can be reserved for treatment failures in adults with chronic typical fissure. Topical application of calcium channel blockers may be as effective as nitroglycerin ointment in the treatment of anal fissure, without the risk of headache, which many patients find unacceptably painful. Too few studies exist to establish this efficacy.

Proctalgia fugax

CMAJ. 2013 Mar 19; 185(5): 417.

From the Department of Biosurgery and Surgical Technology, Imperial College, St. Mary’s Hospital, London, UK

Copyright © 1995-2013, Canadian Medical AssociationThis article has been cited by other articles in PMC.

Proctalgia fugax has many triggers

Proctalgia fugax or functional recurrent anorectal pain is part of a spectrum of functional gastrointestinal disorders defined by the Rome III diagnostic criteria as episodes of sharp fleeting pain that recur over weeks, are localized to the anus or lower rectum, and last from seconds to several minutes with no pain between episodes.¹ There is no diurnal variation. There are numerous precipitants including sexual activity, stress, constipation, defecation and menstruation, although the condition can occur without a trigger. It should be differentiated from chronic proctalgia, a functional anorectal pain disorder with a vague, dull ache or pressure sensation high in the rectum, often worse when sitting than when standing or lying down, and lasts at least 20 minutes.¹

Proctalgia fugax is common

The prevalence of proctalgia fugax in the general population may be as high as 8%–18%.² Many patients present to primary health care physicians and often do not require further consultation because the symptoms are fleeting.³ This condition is more common among women than among men,³ and usually affects patients between 30 and 60 years of age.⁴

Anal sphincter spasm may cause the pain in proctalgia fugax

Although the cause of proctalgia fugax is unclear, spasm of the anal sphincter is commonly implicated.⁵ The condition may be more likely to occur after sclerotherapy for hemorrhoids and vaginal hysterectomy. There are also associations with other functional pathologies, such as irritable bowel syndrome and anxiety.⁵

Proctalgia fugax is a diagnosis of exclusion

Other causes of anorectal pain (e.g., hemorrhoids, cryptitis, ischemia, abscess, fissure, rectocele and malignant disease) must be excluded before the diagnosis can be made.⁶

Treatments relax the anal sphincter spasm

Most treatments for proctalgia fugax (e.g., oral diltiazem, topical glyceryl nitrate, nerve blocks) act by relaxing the anal sphincter spasm, but the effectiveness of these treatments are supported only by case reports or case series, with the exception of a single randomized controlled trial of salbutamol,⁷ making the value of most treatment options, including salbutamol, difficult to judge. See Appendix 1 (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.101613/-/DC1) for a management pathway that may provide symptom relief.⁵ Reassurance of patients is paramount.

CMAJ invites submissions to “Five things to know about …” Submit manuscripts online at http://mc.manuscriptcentral.com/cmaj

Footnotes

Competing interests: None declared.

This article has been peer reviewed.

References

1. Bharucha AE, Wald A, Enck P, et al.
Functional anorectal disorders. Gastroenterology
2006;130: 1510–8 [PubMed] [Google Scholar]3. Boyce PM, Talley NJ, Burke C, et al.
Epidemiology of the functional gastrointestinal disorders diagnosed according to Rome II criteria: an Australian population-based study. Intern Med J
2006; 36:28–36 [PubMed] [Google Scholar]5. Jeyarajah S, Chow A, Ziprin P, et al.
Proctalgia fugax, an evidence-based management pathway. Int J Colorectal Dis
2010;25:1037–46 [PubMed] [Google Scholar]6. Wesselmann U, Burnett AL, Heinberg LJ.
The urogenital and rectal pain syndromes. Pain
1997;73: 269–94 [PubMed] [Google Scholar]7. Eckardt VF, Dodt O, Kanzler G, et al.
Treatment of proctalgia fugax with salbutamol inhalation. Am J Gastroenterol
1996;91:686–9 [PubMed] [Google Scholar]

New Protocol to Treat Anal Fissures

New protocol to treat anal fissures offers excellent results, without cutting the muscle.

Sometimes the most difficult thing about a problem is overcoming the fear of facing it. When people have painful conditions of the anus, they tend to be embarrassed to talk about that part of the body and even less enthusiastic about inviting a doctor to take a look. But anal pain is best treated sooner than later, and an earlier diagnosis can improve patients’ outcomes in the long run.

Reflecting their commitment to doing everything possible to ease patients’ suffering, the surgeons in the Division of Colorectal Surgery at NewYork-Presbyterian/Columbia have recently developed a new protocol to treat anal fissures, a painful condition frequently misdiagnosed as hemorrhoids. What’s more, the new protocol offers superb results without cutting the anal sphincter muscle.

What are anal fissures?

Anal fissures are small cuts or tears at the skin of the anal opening. They typically cause pain when a person has a bowel movement, and pain can be severe for hours afterwards. Some patients also experience bleeding. Many people assume that pain in that part of the body signifies hemorrhoids, so they self-treat with hemorrhoid remedies first, says Daniel L. Feingold, MD, an attending surgeon in the Division since 2004. Very often, it is only after suffering for a long time that people finally seek help from a gastroenterologist or colorectal specialist.

According to Dr. Feingold, anal fissures can happen to anyone: the majority of patients are healthy, and fissures do not appear to have anything to do with age, gender, diabetes, smoking, diet, sexual practices, or any other known factors. Although some anal fissures heal without treatment, some do not, and these go on to cause chronic pain problems. The fissure cycle goes like this: if the cut of the fissure stays open, pain causes spasms of the muscles around the anus, which prevents blood flow to the area, which prevents healing. This leads to more pain and more spasm.

Medical therapy, primarily a muscle relaxant cream applied around the anus, is effective in healing about 70% of anal fissures. By relaxing the muscle so that spasms resolve, blood flow to the area improves and healing can occur. Hot baths and stool softeners can help promote healing. About 30% of patients fail to heal with this approach, however. These patients traditionally have had two options, the first of which is injection of botox into the fissure. By paralyzing a portion of the muscle and relaxing the spasm, the hope is that the fissure will heal. This works only in about 30% of patients, however. The gold-standard approach is a surgical procedure called sphincterotomy, in which the surgeon cuts a piece of the anal sphincter. This relaxes the spasm, which relieves the pain and allows nearly all fissures to heal. The drawback to sphincterotomy is that some people develop function-related problems, meaning that they can have increased urgency or impaired control of bowel movements, gas, etc. Women, in particular, are at risk of having function-related problems after sphincterotomy.

Why Columbia?

When patients first meet Dr. Feingold, he reassures them of several important things. First, he acknowledges that it is normal to feel embarrassed and anxious. Second, he explains that they are in the right place, where he and his colleagues are experts in colorectal conditions like anal fissures. Third, he emphasizes that his exam will be pain free; when evaluating a patient with a fissure, he does no internal exam, just a visual examination of the external anus. In fact, he says, “Many of my patients are surprised and ask, ‘That was it? That’s the whole exam?'”

Beneath his ability to help his patients feel comfortable and even laugh, Dr. Feingold means every word. To the point, he was so determined to find a better option for his patients with anal fissures that he took it upon himself to develop a new protocol to improve upon available treatment options.

Wound care protocol

Dr. Feingold performs the procedure in the operating room because it has the best lighting and allows patients to have sedation during the procedure. It takes about 15 to 20 minutes, and patients go home after a few hours.

The procedure entails four steps.

1. Gently dilate the anus with special retractors
2. Clean out the fissure with curettage to stimulate healing
3. Cauterize the wound with electrocautery to seal the wound
4. Inject traimcinolone (generic Kenalog), a steroid, into the fissure.

Dr. Feingold says that he developed the idea for the Kenalog protocol by considering the best-known approaches to treating chronic wounds. He has treated 115 patients with the new method, and virtually all have had superb outcomes. He is in the process of publishing results from his first 100 patients, two thirds of whom were pain free within ten days. Among the other third of patients, it took as long as six weeks for their pain to disappear. None of the patients have had control-related complications. “Patients report they are very happy with this approach,” says Dr. Feingold.

Dr. Feingold explains, “This has a good record of fixing the problem and a low risk profile. The beauty is that it is muscle-sparing, so it does not cause control related problems. But it also doesn’t burn any bridges, so if it fails, it would still be possible to do a sphincterotomy, if need be.” Although he no longer performs sphincterotomies because of the success of this approach, other surgeons in the Division of Colorectal Surgery do, should it be needed.

For more information, visit columbiasurgery.org/colorectal or call 212.342.1155.

Anal Fissures | Johns Hopkins Medicine

Anal fissures are tears, or cracks, in your anus. Fissures are sometimes confused with hemorrhoids. These are inflamed blood vessels in, or just outside, the anus. Both fissures and hemorrhoids often result from passing hard stool.

Causes

Fissures result from the stretching of your anal mucosa beyond its normal capacity. This often happens when stools are hard due to constipation. Once the tear happens, it leads to repeated injury. The exposed internal sphincter muscle beneath the tear goes into spasm. This causes severe pain. The spasm also pulls the edges of the fissure apart, making it difficult for your wound to heal. The spasm then leads to further tearing of the mucosa when you have bowel movements. This cycle leads to the development of a chronic anal fissure in approximately 40% of patients.

Symptoms

You may have these symptoms with an anal fissure:

• Pain during and after a bowel movement
• Visible tear or cut in the area
• Bright red bleeding during or after a bowel movement

Risk factors

Certain factors raise the risk for anal fissures, including:

• Constipation with straining to pass hard stool
• Eating a low-fiber diet
• Intense diarrhea
• Recent weight loss surgery, because it leads to frequent diarrhea
• Vaginal childbirth
• Minor trauma, especially trauma caused by high-level mountain biking
• Any inflammatory condition of the anal area

Anal fissures may also result from inflammatory bowel disease, surgery, or other medical treatments that affect bowel movements or the anus.

Diagnosis

Your healthcare provider will make a diagnosis based on:

• Your personal health history
• Your description of symptoms
• Rectal exam

Because other conditions can cause symptoms similar to an anal fissure, your healthcare provider might also order tests to find out whether there is blood in your stool.

Treatment

An acute anal fissure typically heals within 6 weeks with conservative treatment. Some disappear when constipation is treated. Anal fissures that last for 6 weeks or more are called chronic anal fissures. These fail conservative treatment and need a more aggressive, surgical approach. 

People whose anal fissures don’t heal well may have an imbalance in anal pressure that prevents blood from circulating normally through the blood vessels around the anus. The reduced blood flow prevents healing. Medicine, Botox injections, and even some topical treatments that improve blood flow, may help anal fissures heal.

Other treatments include:

• Changing your diet to increase fiber and water, steps that will help regulate your bowel movements and reduce both diarrhea and constipation
• Taking warm baths for up to 20 minutes a day
• Taking stool softeners, such as fiber supplements, as needed
• Using topical medicines, such as nitrates or calcium blockers
• Having surgery, such as a lateral internal sphincterectomy. During the surgery, the pressure inside the anus is released. This allows more blood to flow through the area to heal and protect tissues.

The risks from Botox injections and medicines used to treat anal fissures are relatively mild. Complications from surgery include the risk for infection, bleeding, and persistent gas and fecal incontinence, or uncontrolled bowel movements.

Complications

Complications seen with anal fissures include:

• Pain and discomfort
• Reduced quality of life
• Difficulty with bowel movements. Many people even avoid going to the bathroom because of the pain and discomfort it causes
• Possible recurrence even after treatment
• Clotting
• Uncontrolled bowel movements and gas

Living with anal fissures

If you have an anal fissure, take these precautions to avoid making it worse and avoid recurrences:

• Take all medicines as prescribed.
• Get the recommended amount of fiber in your diet. Avoid constipation or large or hard bowel movements.
• Drink enough water to stay well hydrated.
• Maintain a routine bowel habit. Ask your healthcare provider about what this should be for you.
• Avoid spicy foods while you have an anal fissure, because they may make symptoms worse.

When to call the healthcare provider

Contact your healthcare provider if you notice blood in your stool or if your bowel movements are so painful that you are avoiding going to the bathroom.

Closed anal sphincter manipulation technique for chronic anal fissure

Introduction

Anal fissure is a common problem and is associated with severe pain and rectal bleeding. It is a longitudinal or elliptical ischemic ulcer in the anoderm, extending below the dentate line to the anal verge.1 One of the many suggested causes of anal fissure is high anal resting pressure, which in turn causes elevation of the tone of the internal anal sphincter and relief of this internal anal sphincter spasm has been demonstrated to achieve fissure healing.2 The various treatments designed to lower sphincter pressure includes sphincterotomy, anal dilatation and pharmacological manipulation of the sphincter.3, 4, 5

We innovated a new technique of finger fragmentation of the fibers of internal sphincter at the left lateral side of the anal canal and termed it “sphincterolysis”. A retrospective pilot study6 and another prospective trial7 to analyze the manometric and clinical results on this technique have already been published and this study is being presented with a longer follow-up of 24 months.

Patients and methods

Between February 2005 and August 2005, 312 patients of chronic anal fissure who were nonresponders to medical therapy [analgesics, stool softeners and nitroglycerine ointment] were treated with this procedure. Eleven patients were lost to follow-up and were excluded. The remaining 301 patients were enrolled in the study (194 men, 107 women; mean age 29 years, range 16-63 years).

The most common symptoms encountered in this series were pain (100%) and hematochezia (68%). Discomfort with bowel movements was reported in all cases while 148 patients suffered from constipation. The following data were recorded: patient’s age and sex, site of the fissure, symptoms and their duration, bowel habit, pre and postoperative anal manometry, duration of surgical procedure, postoperative continence index, minor and major complications and long-term outcome.

The consideration for selecting patients and labeling them having chronic anal fissure were presentation of anal fissure for more than 8 weeks duration or with clinical features like indurated edges, sentinel pile, hypertrophied anal papillae, or the presence of circular muscle fibers at the base of the cutaneous defect. Balloon manometry was performed in all patients preoperatively and 24 months postoperatively. Manometric assessments were carried out using an 8-lumen catheter perfused with sterile degassed water according to the technique described by Williams et al.8

The study protocol was performed according to the Declaration of Helsinki.

Table 1. Clinical data.

Procedure of sphincterolysis

All the patients were operated by the author. They were asked to consume 17 gms of polyethylene glycol on the night prior to the procedure. The patients were operated under a short-term general anesthesia.

With the patient in a lithotomy position, the right index finger was introduced in the anal canal to meticulously explore the sphincter complex. A Eisenhammer retractor was then introduced in the anal canal and its blades were opened in anteroposterior direction of the anus to make the sphincter fibers prominent and to sense their presence with the finger on left lateral wall of the anal canal. The point of the finger was placed within the anal canal corresponding to the intersphincteral groove.

Then by means of delicate but firm pressure over the stand out fibers of the internal sphincter just below the inter-sphincteric groove, the fibers were fractured and the finger was progressively retracted. This exerted a cautious, gentle but firm direct pressure on the mucosa to ease the fullthickness division of the sphincter fibers while carefully avoiding breaching the anal mucosa.

As the desired division was accomplished, a “give” on the sphincter could be clearly palpated. Patients were discharged on the same evening with prescription for a mild analgesic and instructions to consume a high-fiber diet.

Outcome measures and follow-up.

The primary outcome measure was healing of the fissure, defined as its complete reepitelization. Secondary outcome measures were pain control, reduction in anal resting pressure, and anal continence.

The patients were reviewed at 4 weeks, and then at 6 and 24 months.

Follow-up data were collected by personal interview and examination including symptom relief, early and late complications, and continence scores and healing of fissure and were analyzed by an independent and blinded observer, who was not from the operating team.

Healing of the fissure was scored as complete, incomplete, or none (persistent). The continence was graded according to the score of Jorge and Wexner.9

Early complications were defined as conditions developing within one month following the procedure, which resolved spontaneously or with intervention (i.e., ecchymoses, hematoma, abscess or hemorrhage).

Long-term complications were defined as conditions that occurred after 1 month of surgery that required some type of corrective procedure (i.e., recurrence of fissure, persistent prolapsed hemorrhoids and continence disturbances).

Results

Mean operative time was 3 minutes; there were no intra-operative complications. Mean resting pressure before sphincterotomy was 89.5 mmHg (median 91 mmHg). Six months after surgery it was recorded as 47.3 ± 4.3 mmHg (median 48 mmHg; Wilcoxon test p

Early complications included ecchymosis (n=7), and hematoma (n = 4). Pain control was achieved in 288 patients within 2 weeks. 11 patients complained of loss of continence to flatus or fecal soilage in the first 4 weeks. One patient developed abscess at the site of division of the fibers in the submucosal area, which needed drainage under anesthesia. The follow-up was uneventful in this patient with no further complaints at 2 years follow-up.

Complete continence was restored within 1 month in 97 percent of the cases, including three women with preoperative manometric findings of damage to the external sphincter. The difference between resting pressure at anal manometry in patients with and without continence problems did not reach statistical significance (43.3 vs. 47.7mmHg, p = 0.11). 284 patients achieved complete healing within 4 weeks. The remaining 17 needed 4 more weeks for the fissures to heal.

No recurrent fissures were observed during follow-up. Two of the patients had persisting complaint of incontinence to flatus.

Discussion

Chronic anal fissure is one of the most frequently reported proctologic diseases. Internal anal sphincter spasm has been recognized to play a key role in the pathogenesis of this disease, even if it is not always present.

The treatment is aimed at reducing the anal spasm when present, thereby allowing spontaneous healing of the fissure. This may be achieved by, anal stretch, pharmacological manipulation or surgical sphincterotomy.

Anal stretch causes sphincter lesions in more than 30% of patients, with incontinence in about half of them. The recurrence rate reported with this procedure is very high.10

Sectioning the internal sphincter to reduce the basal sphincter pressure is being widely practiced. While open posterior sphincterotomy is fraught with complications like abscess, delayed wound healing or key hole deformity.11 Lateral internal sphincterotomy has been found to be more effective and easy procedure with least incidences of complications and has been acknowledged as the treatment of choice in most part of the world.12 However, disturbed continence with this procedure ranging between 1.2 to 40% lead in generating interest in pharmacological approaches such as chemical sphincterotomy with topical nitrates and injection of botulinum toxin into the internal anal sphincter.13 However, these lack efficacy, are poorly tolerated and their long-term results are still not known.14

The procedure proposed by us could be termed as a combination of sphincterotomy and anal stretch, in the sense that the internal sphincter fibers are severed by way of fragmentation leading to a localized division of internal sphincter fibers like that achieved after sphincterotomy using fingers in place of surgical dissection or division. This in turn helps in minimizing the inherent complications accompanying both the procedures i.e., avoidance of surgical wound and its sequel like bleeding, suppuration or fistula formation15 and averting inadvertent injury to the sphincter fibers caused due to anal stretch.16

The antipathy to digital dilation of the anus for the treatment of chronic anal fissures is known as it has been found to cause disproportionate damage to both, the internal and external anal sphincters.17 However, there are many reports available which show that a controlled and gentle digital anal dilatation accomplishes a very high fissure healing rate and at the same time causes minimal disturbance of continence.18 It has been recommended as the first management choice in the treatment of chronic anal fissures.19

With regard to my technique, a question may be asked as to how much of the internal sphincter should be divided? I have observed that with the Eisenhamer retractor in the anal canal, the fibers of the internal sphincter which stand taught on palpation should be targeted to undergo lysis from the intersphincteric groove proximally to extend in the anal canal further up to the dentate line. This is because manipulations that are too limited or too extended are destined to suffer treatment failure or anal incontinence, respectively.20 The dentate line should be the reference while dividing the internal sphincter.

The digital detection of the proximal sphincter edge is a precise, yet simply achieved anatomical reference employed in the adopted technique. The near-total division of internal sphincter allows early healing, while the resultant intramuscular linear fibrosis prevents long-term incontinence.21

Furthermore, while the careful preservation of the mucosal lining minimizes the rate of local sep-tic complications, the goal of preserving the continuity of the intestinal lining is achieved easily.22

The procedure adopted here is simple if the surgeon has clear understanding of and adequate experience with the anal anatomy, which could be achieved with a short training. Success of the procedure can be measured by the fissure healing rate achieved, associated with negligible postoperative complications, and minimal disturbances of anal continence. As an independent observer carried out the measurements of the outcome, the possibility of a bias was eliminated in this study.

Conclusion

Because of the high degree of surgical success, patient satisfaction and the low rate of major morbidity, the procedure of manipulation of the internal sphincter may be considered as a straightforward, safe, and effective treatment for anal fissure.

Nevertheless, randomized and control trials comparing this procedure with the conventional approaches like open and closed sphincterotomy, botulinum toxin injections and nitroglycerine ointment are required before recommending this procedure as an alternative treatment approach for chronic anal fissure.

Consulting Proctologist. Gupta Nursing Home, D/9, Laxminagar, NAGPUR- 440022, INDIA. Phone:+49 712 2231047. Fax:+49 712 2547837.
Email: [email protected] – [email protected]

Fecha recibido: 1 noviembre 2007. Fecha aprobado: 26 marzo 2008

Don’t Ignore These Warning Signs of Anal Fissures : Betsy F. Clemens, M.D.: Board Certified Physician

Though often confused with hemorrhoids, an anal fissure is a tear in the sensitive tissue that lines the anus. In most cases, anal fissures heal with conservative care. 

However, ignoring the warning signs of an anal fissure may prolong the healing process or turn your acute problem into a chronic condition. 

At Midwest Hemorrhoid Treatment Center in Creve Coeur, Missouri, we specialize in diagnosing and treating rectal disorders like anal fissures. Our board-certified family physician, Dr. Betsy Clemens, offers effective treatments to heal the tear and alleviate symptoms. 

In this blog, we want to share some of the warning signs of anal fissures so you can get the help you need sooner rather than later. 

About anal fissures

Anal fissures are common and affect people of all ages. They occur when the anal tissue stretches beyond its limit, creating the tiny tear — or crack. Overstretching usually occurs when passing large, dry, hard stool.

The pain from the tear triggers the anal sphincter muscles to spasm and tighten, cutting off blood supply that may delay healing of the tear. This cycle of pain, muscle spasms, and lack of blood flow then occurs with every bowel movement. Treatment for an anal fissure centers around disrupting this pattern so the tear can heal.

With early diagnosis and treatment, most anal fissures heal within eight weeks. However, if you ignore the warning signs and put off getting the care you need, you may end up in a cycle that ultimately leads to a chronic anal fissure.

Warning signs of anal fissures

The most common warning sign of an anal fissure is severe pain during a bowel movement. The pain may last at that level for a few minutes or a few hours after your trip to the bathroom. 

Other signs of an anal fissure include:

• Blood in stool
• Visible tear
• Burning or itching sensation
• Discomfort when urinating

The severe pain you feel during and after a bowel movement may make you fearful of going. But holding stool in increases your risk of constipation and passing hard dry stools that may cause further damage — a Catch-22. 

Healing your anal fissure

Most anal fissures heal on their own with conservative treatments. For our patients, treatment focuses on softening stools and preventing constipation. In addition to recommending a stool softener, we also encourage drinking plenty of water and adding fiber-rich foods to your diet.

Soaking in warm water — a sitz bath — for 10 to 20 minutes several times a day may help relax your anal sphincter, prevent the muscle spasms, and promote healing of the tear.

If your anal fissure fails to heal within eight weeks, we may recommend more aggressive treatment such as surgery to stop the muscle spasms, thereby allowing the tear to heal.

Ignoring the warning signs of a rectal disorder like anal fissures won’t make them go away. Let us help. Call our office at 636-228-3136 to schedule your consultation with Dr. Clemens, or book online today.

Anal Fissures | Cedars-Sinai

Not what you’re looking for?

Overview

Several muscles encircle the anal canal and work together to control bowel movements. The inner muscle, just beneath the lining of the anal canal, is called the internal (involuntary) anal sphincter. This muscle is usually covered by skin. When a bowel movement occurs, the muscle relaxes to allow the stool to pass.

Tears that occur along the anal canal are called anal fissures. When a tear occurs, pain makes the muscle fibers contract, stopping the stool from passing. The fissure pulls apart when the muscle contracts (anal spasm). In turn, this affects the small blood vessels that carry nutrients and oxygen to the torn tissues. As a result, healing is slowed.

Symptoms

The pain and discomfort of an anal fissure usually gets worse when a person has a bowel movement. The pain tends to linger a long time afterward. There may be bleeding from the tear as well. Constipation may also occur as the condition gets worse.

Causes and Risk Factors

A fissure can occur from:

• Passing a hard stool or prolonged episode of diarrhea
• Lack of fiber in the diet and/or water with that fiber
• Food that creates a rough passage through the digestive system, such as popcorn, nuts or tortilla chips

Diagnosis

Diagnosis of this condition is usually done on the basis of the symptoms and a physical examination.

Treatment

Most fissures can heal by following good elimination habits.

• Take plenty of water and fiber
• Avoid foods such as popcorn, nuts or tortilla chips
• Avoid constipating foods

Additionally, the following measures can help:

• Warm baths (sitz baths)
• Use a topical anesthetic cream
• Avoid using hemorrhoid suppositories. These hard, bullet-like medications are painful to insert and sometimes tear the fissure even more.

If pain persists, consult a colorectal surgeon. In addition, the surgeon may prescribe medications (such as topical nitroglycerin ointment or diltiazem) that relax the anal spasm, improve blood supply to the anus and promote healing.

If medical treatments fail, an outpatient surgical procedure can relax the internal sphincter muscle to allow the fissure to heal.

© 2000-2021 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional’s instructions.

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Anal spasm (K59.4)> MedElement Disease Handbook> MedElement

Spasm of the anal sphincter is manifested by a sudden attack of acute pain in the rectal region. Patients describe the pain as sharp, stabbing, spastic, and sometimes burning. In some patients, pain is accompanied by the urge to defecate or a feeling of fullness in the rectum.

The duration of the pain is at least 3 seconds, but not more than a few minutes.Typically, patients describe the duration of pain as “no more than / about one minute.”

From a third to a half of patients experience pain attacks only at night, about a third – mainly during the day, the rest – at different times of the day.
In the intervals between attacks, there is no pain or disorder.

In 51% of patients, the average frequency of seizures is no more than 5 per year. Some authors describe the average frequency of seizures in a group of patients as 13 cases per year.

According to some observations, in men, spasm of the anal sphincter can be triggered by orgasm or cause an erection itself, probably due to stimulation of the autonomic nervous system. However, the reliability of these observations is questionable in terms of whether the diagnosis of functional fleeting rectal pain is consistent with the Rome III criteria.

Criteria for diagnosing disease include:

1. Recurrent episodes of pain localized in the anus or lower rectum.

2. Episodes of pain last from a few seconds to minutes.

3. Anorectal pain between attacks is absent.

In a number of patients, over time, the clinic is transformed or overlapped by signs of chronic proctalgia, which is characterized by an increase in the duration of pain attacks up to 20 minutes or more.

Physical examination shows no abnormalities.
Rectal examination does not reveal pain when pressing on the posterior part of the pubic-rectal muscle, which is an important part of the differential diagnosis with the so-called “levator syndrome” (chronic proctalgia).

FGBNU NTSPZ. ‹Chat General Psychiatry ››

Convulsive syndromes include paroxysmal arising and, as a rule, just as suddenly terminating states with convulsive phenomena, accompanied in most cases by confusion. The manifestation of seizure syndrome is extremely diverse: from a large deployed seizure to rudimentary retropulsive seizures, characterized by nystagmus-like twitching of the eyeballs and myoclonic cramps of the eyelids.A thorough study of each of the variants of convulsive syndrome is often decisive for the diagnosis of many organic diseases.

Epileptic seizure. Several phases are distinguished in the development of a large seizure. The seizure is often preceded by an aura, but it does not apply to the phases of a seizure (see chapter Epilepsy).

The tonic phase begins with a sudden, lightning-fast loss of consciousness and a sharp tonic convulsion, during which the patient falls as if knocked down with a distorted grimace of the face, and the fall is made most often prone, less often supine or to the side.During the fall, the patient emits a kind of sharp cry associated with a spasm of the muscles of the glottis. After a fall, the patient continues to be in a state of tonic convulsion, and due to increased muscle tone, the head is thrown back, arms bent at the elbows are pressed to the chest, hands are bent, fingers are clenched into a fist, the lower limbs are bent at the knees and hip joints and pressed to the stomach or pulled apart and bent at the knee joints. Sometimes during the tonic phase, a different position of the extremities is observed: the arms are extended forward, the spine bends backward in retroflection, the hands take the form of an “obstetrician’s hand”.In some positions of the limbs, a threat of fractures is created: for example, a sharp dilution towards the lower extremities can lead to a fracture of the femoral neck, retroflection of the spine – to a fracture of the lumbar or thoracic vertebrae, etc. Tongue bite, bite of the inner surface of the cheek is usually observed. Sometimes, with convulsive clenching of the jaws, traumatic amputation of the tip of the tongue can occur, especially if the tonic phase began during a conversation or if at the time of its development the tongue was protruded.In connection with the tonic spasm of the respiratory muscles, muscles of the chest, abdomen and diaphragm, breathing stops and after the initial pallor of the skin, a sharp cyanosis develops; cardiac activity ceases for a short time. During the tonic phase, due to the sharp tonic contraction of the muscles of the sphincters, there is never an involuntary urination and defecation; at the same time, men often have an erection and even ejaculation of the semen due to the tonic contraction of the corresponding muscles.There is total areflexia. Loss of consciousness is very pronounced, none of the strongest and most intense stimuli cause a response (coma). This explains the severe injuries, burns, injuries sustained by patients during a seizure. The duration of the tonic phase is up to 20-30 s.

The clonic phase follows the tonic phase. Rhythmic and symmetrical twitching begins in the eyelids and distal phalanges. Increasing in intensity, the cramps spread to the muscles of the limbs, trunk, neck, and head.After such generalization, the convulsions subside.

The amplitude of the flexion-extension movements of the upper limbs with such convulsions is quite large, the lower ones are more limited. The head rhythmically turns to the side, the eyes rotate, the tongue periodically protrudes, the lower jaw makes chewing movements, various grimaces appear on the face associated with clonic spasm of the chewing muscles. During the clonic phase, patients experience involuntary urination, defecation, as well as increased sweating, hypersecretion of saliva and discharge of the mucous membranes of the bronchi.The frothy liquid released from the mouth of patients is a mixture of saliva accumulated and strayed in the oral cavity with secretions from the bronchi, blood from the bite of the tongue or the mucous membrane of the cheek. By the end of the clonic phase, which lasts from 1 to 3 minutes, the frequency and amplitude of clonic twitchings decrease, respiration begins to recover, and cyanosis decreases. However, even after the end of the clonic phase, patients may experience a slight increase in muscle tone and breath holding, which is determined by biochemical shifts during the seizure.

The phase of the darkened consciousness (coming out of a coma). In some cases, a coma with areflexia, a sharp relaxation of the muscles and sweating, as well as impaired breathing is replaced by a state of deep stunning, which, in turn, through a state of dullness, goes into lucid consciousness or sleep, in others, stunning, which was preceded by a coma, is transformed into a twilight disorder of consciousness with a pronounced epileptiform excitement, which can be more or less prolonged, and in some cases it lasts up to several days.Following a complete recovery from a seizure, some patients have a feeling of relief, sometimes accompanied by some euphoria, while others, on the contrary, have a feeling of weakness, increased physical and mental fatigue. There may be a low mood with a touch of irritability, a feeling of extreme displeasure, sometimes anger.

Epileptic state ( st atus epilepticus ). This is a series of large epileptic seizures following one after the other. The frequency of seizures is often so high that patients do not come to their senses and are in a comatose, soporous or stunned state for a long time. The epileptic state can last from several hours to several days. During an epileptic state, a rise in temperature, an increase in heart rate, a drop in blood pressure, sudden sweating, weakness of cardiovascular activity, pulmonary and cerebral edema are often observed.The content of urea in blood serum and protein in urine increases. The appearance of these disorders is a prognostically unfavorable sign.

Adversive convulsive seizure. Like a classic epileptic seizure, an adversive seizure begins with a tonic phase, but in this case it develops more slowly and is usually not preceded by an aura. The turn of the body around the longitudinal axis is peculiar: at first, a violent turn of the eyeballs is observed, then the head and the whole body turn in the same direction, the patient falls.A clonic phase enters, which does not differ from that of a major epileptic seizure. The development of an adversive seizure is associated with organic damage to the frontal lobes of the brain, and with the left-sided localization of the process, a slower fall of the patient is observed than with the right-sided one.

Partial seizure (seizure of Bravais-Jackson). In such a seizure, the tonic and clonic phases are characterized by convulsions of a certain muscle group and only in some cases generalization of the seizure occurs.Partial seizures can be manifested by muscle cramps of only the upper or lower extremities, the muscles of the face. The dynamics of cramps in the limbs always has a proximal direction. So, if a seizure unfolds in the muscles of the arms, the tonic spasm passes from the hand to the forearm and shoulder, the arm rises and a violent turn of the head occurs in the direction of the raised arm. Further, the clonic phase of the seizure unfolds. If the seizure begins with cramps in the muscles of the leg, tonic cramps appear in the muscles of the foot, and a plantar bend occurs, then the cramps spread up to the lower leg and thigh, sometimes covering the muscles of the body on the corresponding side.And finally, if the seizure has a facial localization, the mouth twists in a tonic convulsion, then the latter extends to the entire facial muscles on the corresponding side. Possible generalization of seizures Bravais-Jackson: in these cases, they are extremely reminiscent of the usual convulsive seizure; their difference lies only in the fact that there is a predominance of the intensity of convulsive phenomena on one side of the body. Generalization of partial seizures is most often accompanied by loss of consciousness. Seizures of Bravais-Jackson often occur in series and can end in flaccid paralysis, usually when the organic process is localized in the anterior central gyrus.

Tonic postural seizures. Such seizures begin with a powerful tonic convulsion, resulting in opisthotonus, holding of breath with symptoms of cyanosis and the patient loses consciousness; this usually ends the seizure. There is no clonic phase in this variant of seizures. Tonic postural seizures develop when the brain stem is affected.

CUTLESS (SMALL) SEITS

Small seizures, unlike large seizures, are short-lived and are extremely diverse in clinical manifestations.

Abs. These are short-term “shutdowns” of consciousness (for 1-2 s). At the end of the absence, sometimes immediately, the patient’s usual activities are resumed. At the moment of “turning off” consciousness, the patient’s face turns pale, takes on an absent expression. There are no seizures. The attacks can be single or occur in a series.

Propulsive seizures. Despite the variety of conditions attributed to these seizures, they are characterized by an indispensable component of jerky forward movement – propulsion.They occur at the age of 1 to 4-5 years, usually in boys, mainly at night, without visible provoking factors. At a later age, along with propulsive seizures, large seizures often appear.

Salam seizures. The name reflects the peculiarity of these seizures, which outwardly resemble the movements performed with the usual oriental greeting. The seizure begins with a tonic contraction of the muscles of the trunk, as a result of which the body bends, the head drops, and the arms are extended forward.The patient usually does not fall.

Fulminated seizures differ from seizures only in a faster rate of their deployment. Their clinical picture is identical. However, due to the lightning-fast development of tonic convulsions and a sharp forward movement of the trunk, patients often fall prone.

Clonic propulsive seizures are characterized by clonic seizures with a sharp forward movement, and the propulsive movement is especially intense in the upper body, as a result of which the patient falls prone.

Retropulsive seizures. Despite the variety of conditions attributed to them, these seizures are inherent in an indispensable component of a jerky backward movement – a retropulsion. It occurs at the age of 4 to 12 years, but more often at 6-8 years (later propulsive), usually in girls, mainly in a state of awakening. Often provoked by hyperventilation and active stress. Never during sleep.

Clonic retropulsive seizures – Small clonic cramps of the muscles of the eyelids, eyes (lifting up), head (rolling back), arms (deviation back).The patient seems to want to reach something behind him. As a rule, no fall occurs. There is no reaction of the pupils to light, sweating and salivation are noted.

Rudimentary retropulsive seizures differ from clonic retropulsive seizures by non-deployment: only some protrusion and small nystagmoid twitching of the eyeballs occur, as well as myoclonic cramps of the eyelids.

Pycnolepsy – A series of retropulsive clonic or rudimentary retropulsive clonic seizures.

Impulsive seizures are characterized by a sudden, lightning-fast, impulsive throwing of the arms forward, spreading them to the sides or drawing closer, followed by a jerky movement of the trunk forward. The patient may fall on his back. After falling, the patient usually gets to his feet immediately. Seizures can occur at different ages, but more commonly between the ages of 14 and 18. Provoking factors: insufficient sleep, sudden awakening, alcoholic excesses.Impulsive seizures are, as a rule, in series, follow immediately one after the other, or at intervals of several hours.

90,000 Do you have difficulty urinating? The Coloplast company is ready to offer various solutions

This section will help you find answers to the most common questions. It should be remembered that if you have problems with urination, you should consult your doctor.

What is urinary incontinence?

Urinary incontinence is the inability to independently control the process of urination.

What is neurogenic bladder?

Neurogenic bladder – dysfunction of the lower urinary tract, due to malfunctioning of the nervous system.

What are the signs and symptoms of urinary incontinence?

Some characteristic signs and symptoms include:

• Involuntary urination that occurs unexpectedly or without urge to urinate
• Excretion of urine when sneezing, coughing, laughing or playing sports
• Intolerable urge to urinate, accompanied by a discharge of urine
• The need to get up to urinate two or more times during a night’s sleep (nocturia)

What causes urinary incontinence?

Possible causes include:

• Injury or weakness of the pelvic floor muscles (including due to pregnancy and childbirth)
• Problems with innervation of the muscles of the bladder (overactive bladder and decreased activity of the bladder)
• Neurological conditions leading to dysfunction of the lower urinary tract (eg, spinal cord injury, multiple sclerosis, or spinal hernia)
• Increase in the volume of the prostate gland
• Urinary tract infection
• Type 2 diabetes mellitus

Is urinary incontinence part of the physiological aging process?

Urinary incontinence occurs in people of different age groups, although older people are more likely to suffer.There are affordable and effective solutions to this problem that will allow you to lead a fulfilling and active life.

Can I continue to be active while I have urinary incontinence?

Urinary incontinence can be effectively controlled. Your doctor or nurse can help you find solutions to help you lead an active daily life.

Is urinary incontinence curable?

Most types of urinary incontinence can be treated or improved through lifestyle changes, pelvic floor exercises, bladder training, medication, or surgery.In the process of restoring or correcting the function of the lower urinary tract, care aids such as catheters, urocondoms (for men) or absorbent pads are very effective and convenient.

What is a catheter?

Catheters are used to empty the bladder. An intermittent catheter is a thin, flexible tube coated with a hydrophilic lubricant that is inserted into the bladder through the urethra to drain all urine.

Why is emptying the bladder so important?

Failure to empty your bladder regularly can cause urinary tract infections.A lower urinary tract infection can affect the kidneys and damage them. Even a small amount of urine left in the bladder for more than 4 hours can contribute to the development of an infection.

Should I drink less so I don’t have to empty my bladder so often?

No. It is very important that you drink enough fluids to maintain the physiological balance of the body, including the proper functioning of the urinary system. An adult should consume a total of about 3 liters of fluid per day, including 1500 ml of pure water.It is necessary to empty the bladder at least once every 4 hours while awake.

How do I know if I have a urinary tract infection?

Symptoms of a urinary tract infection may be substantial or subtle. These include:

• Discoloration of urine, addition of a strong odor
• Impurity of blood in urine
• Pathological impurities or turbid urine
• Increased body temperature / sweating
• Increased urinary excretion, or the addition of involuntary leakage of urine
• Leg cramps or other symptoms of deterioration in general well-being

If you develop any of these symptoms, tell your doctor right away.

Why do I often get urinary tract infections?

To answer this question, you need to consult your doctor. The likelihood of developing a urinary tract infection is high with the use of permanent bladder drains. The likelihood of developing a lower urinary tract infection exists with disposable catheters, but the risk is significantly lower than with other methods of urine diversion.

How can catheter-associated urinary tract infections be prevented?

There are ways to reduce the risk of urinary tract infections associated with the use of catheters:

• Wash hands well before catheterization
• Use disposable catheters – never reuse a catheter!
• Use only clean drinking water to activate catheters
• Drink enough fluids throughout the day for proper urinary tract function and normal urine concentration
• Empty the bladder completely each time catheterization is performed
• Discuss your catheterization regimen and procedure with your healthcare professional

More about urinary incontinence care

Clinical Study Sphincter of Oddi’s Dysfunction: Danshu Capsules, Pinaveria Bromide – Clinical Trials Registry

Esophageal spasm – causes, symptoms, diagnosis and treatment

Spasm of the esophagus – periodically arising discoordinated convulsive contractions of the muscular layer of the esophagus against the background of intact function and tone of the lower esophageal sphincter. It is one of the varieties of esophageal dyskinesia. Clinically manifested by chest pain, impaired swallowing, heartburn and regurgitation.Diagnosis of the disease includes X-ray of the esophagus with contrast, esophageal manometry; for differential diagnosis, EGDS, intraesophageal pH-metry are prescribed. The goals of treatment are to regulate the diet, prevent intra-abdominal pressure drops, and normalize the tone of the smooth muscles of the esophagus.

General information

Spasm of the esophagus – episodic functional disorders of esophageal peristalsis, accompanied by spasm of the walls of the esophagus.This pathology ranks first among all diseases of the esophagus. It is the most common cause of dysphagia with chest pain. Women aged 30-70 are more likely to get sick, with age, the incidence rate increases, and sex differences are smoothed out. Diffuse esophagospasm is detected in 3% of patients who undergo endoscopic examination in connection with the pathology of the digestive tract. However, the paucity of the clinical picture often leads to the fact that patients do not seek medical help.In addition, esophageal spasm is often mistaken for gastroesophageal reflux disease. Doctors-endoscopists, gastroenterologists, surgeons are engaged in the diagnosis and treatment of the disease.

Esophageal spasm

Causes

The exact causes of esophageal spasm are unknown. Primary esophageal spasm is an independent disease that develops against the background of mental (stress) and neurological (damage to the intermuscular nerve fibers of the esophagus) disorders. Damage to neurons can be caused by the effects of toxins, bacteria and viruses on both the nerve fibers in the esophagus and the brain (meningoencephalitis).Most often, spasm occurs in the most proximal and distal parts of the esophagus, since they have the richest innervation.

Some researchers in the field of gastroenterology suggest a connection between esophageal spasm and nitric oxide deficiency, which is needed for the transmission of information in neurosynapses. The pathogenesis of this disease is similar to achalasia of the cardia; moreover, with the progression of movement disorders, the transition of diffuse spasm to achalasia is possible (this pathology is characterized by an increase in the tone of the lower esophageal sphincter, which is accompanied by a violation of its relaxation).This is due to the fact that long-term functional spasms, especially those that are not subject to correction, lead to the formation of organic changes in tissues (degeneration of myocytes and nerve nodes, tissue fibrosis, etc.).

Secondary esophageal spasm develops against the background of another pathology (esophagitis, ulcer or esophageal cancer) due to reflex reactions of the mucous membrane, the sensitivity of which increases due to the fault of the pathological process. It is also possible the sudden development of esophageal spasm in a healthy person when swallowing too large portions of food, eating very hot, cold or dry food, strong alcoholic drinks, with hasty eating.

Spasms of the esophagus are divided into light, intermittent, acute or chronic, local (sphincters of the esophagus are affected) and diffuse (the entire muscular membrane is involved).

Symptoms of esophageal spasm

The clinical picture of esophageal spasm depends on the location and form of the pathological process. The most typical signs of any form of the disease are chest pain and swallowing problems. Patients most often associate pain with swallowing food and saliva, although it can occur spontaneously.Stress leads to increased pain. Possible irradiation of pain in the shoulder blades, shoulders, lower jaw, back. Most often, the attack lasts no more than an hour, although its longer duration is not excluded. Typically, patients describe their sensations as a feeling of pressure behind the breastbone. Against the background of taking antispasmodics, the pain weakens or disappears.

Dysphagia can develop with the intake of both solid and liquid food. Most often, it is fickle and occurs at the same time as pain. Heartburn worries every fifth patient, and regurgitation of food is noted only against the background of very strong spasms or a significant accumulation of food masses in the esophagus.

Spasm of the upper esophageal narrowing (the most common form of pathology) most often occurs in patients prone to hysteria, neuroses, mood swings. Clinically manifested by pressing pain behind the sternum, nausea, cough, facial flushing, fear and excitement. Esophageal spasm can occur acutely, or its manifestations increase gradually, interspersed with periods of remission. The intermittent nature of the pathology leads to the fact that the patient becomes restless, eats irregularly, is afraid of the return of symptoms, and this further aggravates the pathological manifestations of esophageal spasm.

Chronic spasm in the area of ​​the upper constriction most often develops in elderly patients with defects in the dentition, impaired chewing, prone to swallowing large, unchewed pieces of food; especially if there is a history of acute esophageal spasm. The clinical picture is dominated by unpleasant sensations behind the sternum, difficulty in passing solid food, the need to drink water every sip. Constant obstruction of the esophagus leads to the formation of its compensatory expansion over the spasmodic area.

Spasm of the lower esophagus and cardia can also be acute and chronic. Acute spasm is manifested by pain in the epigastrium and behind the sternum, a feeling of retention of food masses above the stomach; drinking food with water does not bring relief. Separately, a nonsphincteric spasm of the esophagus (Barshonya-Teschendorf syndrome) is considered, in which several parts of the organ are simultaneously affected throughout the entire length. Patients complain of episodic episodes of dysphagia (from a couple of minutes to several weeks), accompanied by chest pain, regurgitation of mucus.Pathology often occurs against the background of peptic ulcer, gallstone disease; it is characterized by increased appetite.

Diagnosis of esophageal spasm

The diagnosis of esophageal spasm requires the exclusion of organic and mechanical causes of the pathology. The most reliable diagnostic methods include x-ray of the esophagus, esophageal manometry and endoscopic examination.

In about half of patients, X-ray examination does not reveal signs of pathology.Esophagospasm is indicated by uncoordinated spastic contractions of the esophageal muscles, due to which the organ takes the form of a corkscrew, rosary, pseudodiverticula. Contrast esophagography with spasm of the upper esophageal stenosis demonstrates a delay in contrast at the level of the cricoid cartilage. In chronic spasm, the contrast accumulates in the area of ​​the suprastenotic expansion. The Barshony-Teschendorf syndrome is characterized by the identification of ring-shaped spasmodic areas throughout the esophagus. Spasm of the esophagus differs from achalasia of the cardia in the normal passage of contrast through the lower esophageal sphincter.

EGDS with esophageal spasm has less diagnostic value, is more often used for differential diagnosis. Esophagoscopy with spasm of the upper narrowing is difficult, usually it is possible to insert a fibroscope into the lumen of the esophagus only after thorough infiltrative anesthesia of the mucous membrane. In the presence of chronic spasm, the mucous membrane is hyperemic, it is possible to identify cicatricial strictures and deformities. With a spasm of the lower esophagus, conducting a fibroscope into the stomach is difficult due to accumulated food masses, the mucous membrane is not changed.

The result of esophageal manometry in some patients may not differ from the norm. In other patients, spastic undulating contractions of the esophageal muscles with an increase in pressure in it of more than 30 mm Hg may be found, interspersed with normal esophageal peristalsis. To differentiate from GERD, an intraesophageal pH meter may be prescribed.

Treatment of esophageal spasm

Treatment of esophageal spasm includes medication and non-medication methods. Compliance with a strict diet, drinking plenty of fluids is recommended.Too cold and hot foods, alcohol, coarse fiber, carbonated drinks should be excluded from the diet. To prevent an increase in the level of pressure in the abdominal cavity, the patient should avoid overeating, tilting the body, lifting weights.