This document provides information about anal fissures, anal fistulas, and hemorrhoids. It defines each condition, describes causes and risk factors, lists signs and symptoms, and outlines treatment options. Anal fissures are tears in the anal canal caused by hard bowel movements or high sphincter tension. Anal fistulas are abnormal passages from the anal canal to the skin surface, often due to abscesses. Hemorrhoids are swollen veins in the rectum or anus that can cause pain, itching and bleeding. Conservative treatments aim to soften stools and ease discomfort, while surgical procedures repair or remove tissue.

1. Anal Fissure and Fistula

2. Anal fissure
• An anal fissure is a narrow tear that extends from the muscles that
control the anus (sphincters) up into the anal canal. These tears usually
develop when anal tissue is damaged during a hard bowel movement
or when higher-than-normal tension develops in the anal sphincters.

4. Causes
• Passing large or hard stools.
• Constipation and straining during bowel movements.
• Long-lasting diarrhea.
• Anal intercourse.
• Childbirth.

5. Risk factors
• Factors that may increase your risk of developing an anal fissure include:
• Constipation. Straining during bowel movements and passing hard stools
increase the risk of tearing.
• Childbirth. Anal fissures are more common in women after they give birth.
• Crohn's disease. This inflammatory bowel disease causes chronic
inflammation of the intestinal tract. This may make the lining of the anal
canal more vulnerable to tearing.
• Anal intercourse.
• Age. Anal fissures can occur at any age, but are more common in infants
and middle-aged adults.

6. signs and symptoms
• Severe pain during bowel movements
• Lasting pain after bowel movements for several hours
• Bright red blood after bowel movements
• Lump or skin tag near anal fissure
• Pain during, and even hours after, a bowel movement
• Constipation
• Blood on the outside surface of the stool
• Blood on toilet tissue or wipes
• A visible crack or tear in the anus or anal canal
• Burning and itching that may be painful
• Discomfort when urinating, frequent urination, or inability to urinate
• Foul-smelling discharge

7. Complications
• complications of an anal fissure may include:
• Failure to heal. An anal fissure that fails to heal within eight weeks is
considered chronic and may need further treatment.
• Recurrence. Once you've experienced an anal fissure, you are prone to
having another one.
• A tear that extends to surrounding muscles. An anal fissure may extend
into the ring of muscle that holds your anus closed. This muscle is called the
internal anal sphincter. If this happens, it makes it more difficult for your
anal fissure to heal. An unhealed fissure may trigger a cycle of discomfort
that may require medicines or surgery to reduce the pain and to repair or
remove the fissure.

8. anal fissure diagnose
• Usually, your doctor can diagnose an anal fissure by visual
inspection of the anus or by gentle exam with the tip of the
finger.

9. How are anal fissures treated
• The goal of anal fissure treatment is to lower the pressure on the anal canal
by making stools soft and to ease discomfort and bleeding. Conservative
treatments are tried first and include one or more of the following:
• Preventing constipation through the use of stool softeners, drinking more
fluids while avoiding caffeine-containing products (which cause
dehydration), and dietary adjustments (increase in intake of high fiber
foods and fiber supplements);
• Soaking in a warm bath (also called a sitz bath), 10 to 20 minutes several
times a day, to help relax the anal muscles;
• Cleansing the anorectal area more gently;
• Avoiding straining or prolonged sitting on the toilet;
• Using petroleum jelly to help lubricate the anorectal area

10. surgery for an anal fissure
• A fissure may fail to heal because of scarring or muscle spasms of the
internal anal sphincter muscle. Surgery usually consists of making a
cut to a small portion of the internal anal sphincter muscle to reduce
pain and spasms and allow the fissure to heal.
• The surgery can usually be performed on an outpatient basis (the
patient goes home the same day). Pain is relieved after a few days and
complete healing takes place in a few weeks

11. Anal fistula
• An anal fistula is a tube-like passage (tract) from the anal canal
to a hole in the skin near the anus. This may occur after rectal
surgery, after an abscess in the rectal area, or as a complication
of bowel disease.

12. symptoms
• pain
• redness, and swelling around the anus.
• There can also be bleeding
• painful bowel movements
• fever
• skin irritation around the anus
• smelly discharge from near your anus
• swelling and redness around your anus and a high temperature if you also
have an abscess
• difficulty controlling bowel movements (bowel incontinence) in some cases

13. causes
• Anal fistulas occur when the fluid glands in your anus are blocked.
This leads to a bacteria buildup that may create pockets of
abscesses. Unless treated, abscesses may grow, finally moving outside
near the anus hole to drain out. In most cases, abscesses may turn into
fistulas. They may also be a result of conditions such as tuberculosis
and sexually transmitted diseases.

14. Treatments for an anal fistula
• anal fistulas usually require surgery as they rarely heal if left untreated.
• The main options include:
• a fistulotomy – is a procedure that involves cutting open the whole length of
the fistula so it heals into a flat scar
• seton procedures – where a piece of surgical thread called a seton is placed
in the fistula and left there for several weeks to help it heal before a further
procedure is carried out to treat it
• All the procedures have different benefits and risks. You can discuss this
with the surgeon.
• Many people do not need to stay in the hospital overnight after surgery,
although some may need to stay in the hospital for a few days.

15. diagnose anal fistulas
• Your doctor may be able to diagnose your anal fistula after a physical
exam. Some fistulas may be easy to diagnose, some may not. Your
doctor may check for oozing fluids or bleeding. They may also refer
you to specialists in the colon and rectal problems. You may have to
conduct some other tests such as X-rays or CT scans.

16. Hemorrhoids

17. Overview
• Hemorrhoids (HEM-uh-roids), also called piles, are swollen
veins in your anus and lower rectum, similar to varicose veins.
Hemorrhoids can develop inside the rectum (internal
hemorrhoids) or under the skin around the anus (external
hemorrhoids).

18. types of hemorrhoids
• External: Swollen veins form underneath the skin around your
anus. External hemorrhoids can be itchy and painful.
Occasionally, they bleed. Sometimes, they fill with blood that
can clot. This isn’t dangerous but can result in pain and
swelling.
• Internal: Swollen veins form inside your rectum. Internal
hemorrhoids may bleed, but they usually aren’t painful.
• Prolapsed: Both internal and external hemorrhoids can
prolapse, meaning they stretch and bulge outside of your anus.
These hemorrhoids may bleed or cause pain.

19. Symptoms
• Signs and symptoms of hemorrhoids usually depend on the
type of hemorrhoid.
• External hemorrhoids
• These are under the skin around your anus. Signs and
symptoms might include:
• Itching or irritation in your anal region
• Pain or discomfort
• Swelling around your anus
• Bleeding

20. Internal hemorrhoids
• Internal hemorrhoids lie inside the rectum. You usually can't see
or feel them, and they rarely cause discomfort. But straining or
irritation when passing stool can cause:
• Painless bleeding during bowel movements. You might notice
small amounts of bright red blood on your toilet tissue or in the
toilet.
• A hemorrhoid to push through the anal opening (prolapsed or
protruding hemorrhoid), resulting in pain and irritation.

21. causes
• Straining puts pressure on veins in your anus or rectum,
causing hemorrhoids. You might think of them as varicose
veins that affect your bottom.
• Any sort of straining that increases pressure on your belly or
lower extremities can cause anal and rectal veins to become
swollen and inflamed. Hemorrhoids may develop due to:
• Pelvic pressure from weight gain, especially during pregnancy.
• Pushing hard to have a bowel movement (poop) because of
constipation.
• Straining to lift heavy objects or weightlifting.

22. symptoms
• Signs of external hemorrhoids
include:
• Itchy anus.
• Hard lumps near your anus that
feel sore or tender.
• Pain or ache in your anus,
especially when you sit.
• Rectal bleeding.

23. diagnoses
• A healthcare provider diagnoses hemorrhoids based on symptoms
and a physical exam. You may also have:
• Digital rectal exam: Your provider inserts a gloved, lubricated finger
into your rectum to feel for swollen veins.
• Anoscopy: Your provider uses an anoscope (lighted tube) to view
the lining of your anus and rectum.
• Sigmoidoscopy: Your provider uses a sigmoidoscope (lighted tube
with a camera) to view inside the lower(sigmoid) part of your colon
and rectum. Procedure types include flexible
sigmoidoscopy and rigid sigmoidoscopy (proctoscopy).
• These tests may be uncomfortable but aren’t painful. They typically
take place in a doctor’s office or outpatient center
without anesthesia. You go home the same day.

24. complications
• Anemia.
• Blood clots in external hemorrhoids.
• Infection.
• Skin tags (flap of tissue that hangs off skin).
• Strangulated hemorrhoids (muscles in the anus cut off blood
flow to a prolapsed internal hemorrhoid).

25. Surgical treatment
• Hemorrhoidectomy: Surgery removes large external
hemorrhoids or prolapsed internal ones.
• Hemorrhoid stapling: A stapling instrument removes an
internal hemorrhoid. Or it pulls a prolapsed internal hemorrhoid
back inside of your anus and holds it there.
• External hemorrhoid thrombectomy
• If a painful blood clot (thrombosis) has formed within an external
hemorrhoid, your doctor can remove the hemorrhoid, which can
provide prompt relief. This procedure, done under local
anesthesia, is most effective if done within 72 hours of
developing a clot.

27. Conti…
• Rubber band ligation. Your doctor places one or two tiny
rubber bands around the base of the internal hemorrhoid to cut
off its circulation. The hemorrhoid withers and falls off within a
week.
• Hemorrhoid banding can be uncomfortable and cause bleeding,
which might begin two to four days after the procedure but is
rarely severe

29. Conti…
• Injection (sclerotherapy). Your doctor injects a chemical
solution into the hemorrhoid tissue to shrink it. While the
injection causes little or no pain, it might be less effective than
rubber band ligation.

30. Home remedies
• Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing
so softens the stool and increases its bulk, which will help you avoid the
straining that can worsen symptoms from existing hemorrhoids. Add fiber
to your diet slowly to avoid problems with gas.
• Use topical treatments. Apply an over-the-counter hemorrhoid cream or
suppository containing hydrocortisone, or use pads containing witch hazel
or a numbing agent.
• Soak regularly in a warm bath or sitz bath. Soak your anal area in plain
warm water for 10 to 15 minutes two to three times a day. A sitz bath fits
over the toilet.
• Take oral pain relievers. You can use acetaminophen (Tylenol, others),
aspirin or ibuprofen (Advil, Motrin IB, others) temporarily to help relieve
your discomfort.

31. Nursing Interventions
• Provide a “donut cushion” for the patient to sit on if needed.
• Administer topical medication as ordered.
• Administer stool softeners as ordered.
• Instruct patient and/or family regarding causes of hemorrhoids,
methods of avoiding hemorrhoids, and treatments that can be
performed
• Instruct patient and/or family regarding all procedures required

32. Conti…
• Avoid infection. Teach the caregivers to keep the area around the colostomy
clean with soap and water and to diaper the baby in the usual way; monitor
white blood cell (WBC) count; and wash hands and teach the patient and
SO to wash hands before contact with patients and between procedures with
the patient.
• Protect skin integrity. A protective ointment is useful to protect the skin
around the colostomy; monitor the site of impaired tissue integrity at least
once daily for color changes, redness, swelling, warmth, pain, or other signs
of infection; and keep a sterile dressing technique during wound care.
• Restore balanced fluid volume. Administer parenteral fluids as prescribed;
consider the need for an IV fluid challenge with an immediate infusion of
fluids for patients with abnormal vital signs; teach family members how to
monitor output in the home; instruct them to monitor both intake and
output.