Category Archives: Surgery

What is an Anal Fissure?

An anal fissure is a small ulcer just inside the anal canal. They usually occur in just one place, but heal and return over many months or years. The continuing irritation nearby causes the skin next to it to become lumpy, leaving a skin tag. That piece of skin is mistaken by many people for a haemorrhoid. Anal fissure can occur at any age, but I have often seen it in young adults. A fissure may appear for no apparent cause, or it can be caused by an abrupt change in bowel habits, like constipation (in this case, meaning hard stool) or diarrhoea.

It seems that the ulcer (fissure) is caused by the tight contraction of the cylindrical muscles around the anal canal – much tighter and longer than normal. This muscle cramp might stop fresh blood from bringing oxygen to the lining of the anus, resulting in the breakdown (or ulceration) of that lining. The pain is probably from the muscle cramp, rather than from the ulcer.

This picture of a slice through the anal canal shows the inner muscle layer (and an outer muscle layer, which is not affected) in brown. The little red fissure on the back wall of the anal canal might be caused by the inner muscle squeezing it too tight.

How do I know i have one? Typically, a fissure causes pain, most severe when triggered by passing a bowel motion, and sometimes bright bleeding can be seen on the toilet paper.

Most of the time, the fissure will heal by itself, and this can be helped by ensuring that the stools are formed, but soft. Prevent constipation by drinking plenty of water, and eating fruit and plenty of fibre. Regular exercise is also very helpful – walking seems to stimulate the bowels to work more effectively. Some people also find things at the pharmacist to soften the stool, but try to avoid the tablets that stimulate the bowel contractions. We don’t want to push the hard stools faster – we want them to be soft and easy.

The usual “haemorrhoid creams” contain local anaesthetic, and so they might help a little, but they won’t make it heal any faster. There are specific creams which might actually allow the fissure to heal more quickly. In Perth, Rectogesic can be bought over the counter in your local pharmacy. It contains GTN, which causes the smooth muscle to relax. The same type of muscle is also present in your blood vessels, so if you absorb much of it into your system, you can suffer a low blood pressure when you stand up, or develop headaches. It is a good idea to use a very small amount at first, to allow your body to adapt to the new medication gradually. You will want to cover the skin around the anus over a radius of about a centimetre, but you also need to get the cream to the inner surface of the muscle, by putting you (gloved!) finger inside and twisting – so that you get at least the tip right inside.

Other creams can be made by Compounding Pharmacies – these might include Diltiazem or Nifedipine. However, you will need a prescription for these. Studies suggest that they are just as effective as Rectogesic, but may cause fewer headaches.

If keeping the stools soft, using the muscle-relaxing creams is not effective after six weeks, it might be worth considering paralysis of the muscle. This is done with an injection of Botulinum toxin, a procedure usually done under a general anaesthetic. It often results in a temporary risk of incontinence, but there are reports of permanent reduction in the effectiveness of control of the anus.

The traditional surgical treatment for anal fissure is cutting the lowest one third of the muscle. This is permanent, and if too much muscle is cut, there can be permanent loss of control of gas, or liquid stool, or sometimes even solid stool.  Therefore, if surgical intervention is required for anal fissure, it is strongly recommended that a specialist colorectal surgeon is consulted.

Sue Taylor is not a colorectal surgeon.

What is a General Surgeon?

To look at it simply, a General Surgeon is a fully trained Surgeon (Fellow of the Royal Australasian College of Surgeons) who hasn’t taken up a subspecialty. At least, that’s how it worked in the old days…

Now, being a General Surgeon means that training was in the discipline of General Surgery. What does this include? The common things are hernias, gallstones, bowel surgery, simple liver surgery, haemorrhoids, ingrown toenails, vasectomy and various skin lumps and bumps.

But it isn’t that simple. (Was that simple, I hear you ask? No, I agree – it isn’t). Within General Surgery are some subspecialties – Colorectal Surgeons, Breast and Endocrine Surgeons, Upper Gastrointestinal Surgeons, Bariatric Surgeons are all types of General Surgeon. If you have a simple, common problem in one of those subspecialties, most general surgeons will be happy to help you. But if your problem is more involved, you will be best served by someone with extra training in the particular area.

There are other surgical specialties which are not covered by General Surgery at all anymore – Urology (prostates, bladders, continence problems), Plastic and Reconstructive Surgery, Ear Nose and Throat Surgery are all separate specialties with very little in common with a General Surgeon. Occasionally, individuals will cross over the borders (I know a General Surgeon who does some Cosmetic Surgery, but most of us don’t).

So, what kind of surgeon am I? 

My passion is for laparoscopic (keyhole) surgery. I love to take out gallbladders that have harboured irritating stones, repair hernias that ache or are growing, stop reflux and heartburn in their tracks, and help people to change their lifestyle to eat less food without feeling as if they are starving all the time. I also quite enjoy fixing ingrown toenails – because they give such pain when they are bad, and it is so rewarding when they are fixed. However, there are many other practitioners (family doctors and podiatrists) who do a good job with these, too.

Because I am a woman, I do see people (mostly women) who are worried that their haemorrhoids are dangerous, or are suffering with the pain of a chronic anal fissure. But this is not something I have any special skill for. Sometimes those women have been struggling along for decades with the problem because they don’t want to see a male surgeon. But if the problem is outside my training and ability, I refer them on to one of my trusted colleagues with more experience, and up-to-date knowledge.

There are plenty of good female breast surgeons in town, and because they see so many patients with similar problems, they have excellent support services all set up around them to get a diagnosis quickly, and treat it with the most up-to-date therapy. I don’t have those networks established, because this is not my main focus. If you have a breast lump you are worried about, please go and see a specialist breast surgeon.

Osborne Park Clinics

The outpatient Clinics at Osborne Park Hospital expanded this year, and are an outstanding success.
Public (or uninsured) patients will need a specific referral from their GP, but the waiting times are much less than the large tertiary teaching hospitals.
Sometimes, more complicated problems are referred on to the larger hospitals but most problems can be dealt with at the local level.

Of course, uninsured patients are also welcome in the rooms at Hollywood. Surgery can be booked at Osborne Park Hospital from either venue.

Twitter

I’m experimenting with a Twitter account to encourage my Weight Loss patients to keep their resolve strong.
Weight Loss surgery certainly helps keep hunger at bay, but for many people, hunger isn’t the primary reason for eating.

If you have any suggestions on how a Twitter feed might help you, please do let me know. If you have been following, you will know that I need some inspiration!

Web Presence

I’ve set up a Facebook account with a view to providing support for patients as required. If you think a chat group is what you need, contact me – there are a couple running already, but as we discuss personal matters, we need to meet you first….

Surgical Summaries

I’ve been working on some patient information essays recently.

They can be found at the Western Surgical website.

Hernia    Reflux    Anal fissure

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