I was in England recently and I had constipation because of the cold weather. This caused me to strain in the toilet. Suddenly, and very alarmingly, I felt something pop out. I believe it was a pile. I came home and went to a surgeon who told me I not only had piles, but also anal fissures. What is the difference?
Piles are also called haemorrhoids. They are masses or pieces of tissue inside your anal canal that contain blood vessels. The surrounding tissue is made up of supportive tissue, muscles and fibres.
If you are unsure about what constitutes your anal canal, it starts from the anus, which is the hole or opening outside that is present between your buttocks, and extends up to four centimetres all the way to the rectum.
Haemorrhoids are present in every single person. It's only when they are enlarged that they are considered abnormal.
An anal fissure is, as its name suggests, a tear occurring in your anus that can extend up to your anal canal. They are very common, and can happen at all ages, including in infants.
My goodness, this sounds painful. How will I know if I have anal fissures?
People with anal fissures experience pain, which becomes worse with bowel movement. You don't experience pain all the time, but certainly, when you sit on the toilet to pass motion, there will be pain, ranging from mild discomfort to severe pain, especially when your stools are hard.
This pain may be brief, or it can last for a long time after your bowel movement. Some people who experience severe pain are almost afraid to go to the toilet.
Sometimes, this pain can also affect your urination by causing frequent urination, pain during urination, or even the inability to urinate.
Anal fissures can also cause bleeding in small amounts and anal itching. If infected, there can be a smelly discharge of pus.
Anal fissures can be divided into acute fissures and chronic fissures.
An acute fissure will look like a longitudinal tear to the surgeon. A chronic fissure is usually associated with skin tags at the edge of your anus, which are called sentinel piles, and thickened edges at the fissure.
How is this different from piles?
Haemorrhoids are divided into internal and external haemorrhoids. Internal haemorrhoids are usually painless because the nerve fibres that supply them belong to the nerve supply of the intestine, which cannot be felt.
An enlarged internal haemorrhoid may pull down the surrounding tissue and protrude from the anus.
Haemorrhoids can bleed, especially when hard stools injure the lining of the anal canal. Sometimes, they can also prolapse, meaning they protrude from your anus.
There is a grading system for haemorrhoids:
First degree: These bleed, but do not prolapse.
Second degree: These prolapse, usually after defecation, but retract on their own back into the anal canal.
Third degree: These prolapse, but cannot retract on their own. They must be pushed back with a finger, but will stay inside after being pushed back.
Fourth degree: These prolapse and cannot be pushed back inside.
External haemorrhoids are different though. They can be felt as bulges at your anus. They are easily prey to blood clots, which can make them very painful. Sometimes, they may heal and leave a tag of skin protruding from the anus.
What causes anal fissures?
They are caused by any sort of injury to the anus or anal canal. This usually comes from constipation, which gives rise to hard stools. Many people can remember the exact bowel movement that triggered the pain.
However, diarrhoea can also give rise to anal fissures, especially after repeated episodes.
Sometimes, the injury comes from the insertion of an instrument, like a thermometer, proctoscope, colonoscope or ultrasound probe, to examine the prostate. Needless to say, if you have anal sex, this can also be a cause.
Sometimes, a tear can also come after childbirth. Most anal fissures that result from injury occur in the midline, either in the front or the back (facing the spine).
Fissures that occur in any other position should be investigated for an underlying sinister cause like infections, tuberculosis, or even, anal cancer.
How do I get my anal fissures treated?
The majority of acute anal fissures heal. But chronic fissures don't heal that easily.
Treatment includes adding 'bulk' and 'fibre' to the stools. You should increase your liquid intake, avoid 'sharp' foods like popcorn, nuts etc, or take stool softeners.
You can take sitz baths after defecation as they are very relaxing and cleansing.
You may be given anaesthetic creams or steroids by the doctor to apply before defecation. If all else fails, you can opt for a simple surgery.