Piles, Fissure & Fistula Treatment in Gandhinagar & Ahmedabad | Niraaya Hospital

An anal fissure is a small longitudinal tear or crack in the anoderm - the specialised skin lining the lower anal canal. Despite being a tiny lesion (usually less than 1 cm), anal fissures cause intense, disproportionate pain - a sharp, tearing sensation during defecation followed by a burning pain that can persist for minutes to hours after passing stool. Many patients dread defecation so much that they withhold stool, paradoxically worsening constipation and the fissure.

Acute fissures (less than 6 weeks duration): Usually caused by passing a large, hard stool that tears the anoderm. The skin is fresh, with no features of chronicity. Approximately 50% heal with conservative treatment - dietary fibre increase, adequate hydration, stool softeners, topical anaesthetic and anti-inflammatory creams, sitz baths, and topical nitrates or calcium channel blockers (which relax the internal anal sphincter, improving blood flow to the fissure and allowing healing).

Chronic fissures (more than 6 weeks duration): Characterised by a triad of: the fissure itself (usually at the posterior midline - 90% of fissures occur here), a skin tag at the distal end (sentinel pile), and a hypertrophied anal papilla at the proximal end. The chronic fissure is perpetuated by a cycle of pain causing internal anal sphincter spasm, which reduces blood flow to the posterior commissure of the anal canal (the most poorly vascularised part), preventing healing.

Medical treatment with topical GTN (glyceryl trinitrate), diltiazem, or botulinum toxin (Botox) injection into the internal sphincter relieves sphincter spasm and resolves approximately 50-70% of chronic fissures.

Lateral Internal Sphincterotomy (LIS): The definitive surgical treatment for chronic anal fissure - a precise incision through the lower portion of the internal anal sphincter (the involuntary muscle controlling baseline anal pressure), performed under anaesthesia (general or local with sedation) through a tiny lateral incision. LIS relieves the sphincter spasm permanently, allowing the fissure to heal. Success rate: over 95%. The tiny risk of minor incontinence (slight difficulty controlling flatus) is discussed with patients before surgery.

An anal fistula is an abnormal, tunnel-like connection between the inside of the anal canal (or rectum) and the skin surface near the anus. It is almost always the consequence of a previous perianal abscess - when the abscess drainage site does not heal completely, the abscess cavity becomes lined with granulation tissue and epithelium, forming a persistent fistulous tract that drains intermittently and refuses to close spontaneously.

Classification by Parks:

• Intersphincteric fistula (most common, 70%): The tract runs between the internal and external sphincter muscles - entirely through the intersphincteric plane, emerging at the anal verge. Safest to treat surgically as the external sphincter is not at risk.
• Transsphincteric fistula: The tract passes through both sphincters - requires careful surgery to avoid incontinence.
• Suprasphincteric fistula: Rare; the tract runs above the puborectalis muscle.
• Extrasphincteric fistula: Rare; the tract bypasses the sphincter complex entirely.

Symptoms: A persistent or recurrent discharge of pus, blood-stained fluid, or faecal material from an opening near the anus; intermittent pain and swelling (from recurrent abscess formation when the fistula opening blocks); and difficulty with hygiene.

Surgical treatment:

Fistulotomy: For simple (low, intersphincteric) fistulas - the tract is opened completely ("laid open") along its entire length and allowed to heal from the base. Highly effective (success rate 95%+) with minimal risk to continence when limited sphincter muscle is involved.

LIFT Procedure (Ligation of Intersphincteric Fistula Tract): A sphincter-preserving technique for transsphincteric fistulas - the fistula tract is identified in the intersphincteric plane, ligated, and divided without cutting sphincter muscle. Preserves continence while eliminating the fistula.

Seton Placement: A surgical thread (seton) is passed through the fistula tract and loosely tied. A loose seton allows drainage and resolution of sepsis while not cutting the muscle - used as a bridge to definitive repair or as definitive treatment for high or complex fistulas.

Video-Assisted Anal Fistula Treatment (VAAFT): A minimally invasive technique using a fistuloscope to visualise and treat the fistula tract endoscopically - ablating the internal opening and the tract under direct vision.

A perianal abscess is a painful collection of pus in the tissue around the anus. It is usually caused by infection of the anal glands (small glands in the anal crypts at the dentate line). Perianal abscesses present with throbbing perianal pain - severe, constant, and worsening - with a tender, red, fluctuant swelling near the anal verge. Fever and malaise develop as the infection spreads.

Perianal abscess is a surgical emergency - the abscess must be incised and drained urgently under local or general anaesthesia to relieve pressure, prevent further spread, and reduce the risk of fistula formation. Antibiotics alone are not adequate - they cannot penetrate the pus cavity and do not substitute for drainage. Delay in drainage increases the risk of the abscess tracking into deeper spaces (ischiorectal fossa, supralevator space) and forming a complex fistula after resolution.

A pilonidal sinus is a small pit or tunnel in the skin at the top of the natal cleft (between the buttocks) - caused by penetration of loose hair into the subcutaneous tissue, triggering a foreign body reaction and leading to sinus formation. It is most common in young, hair, hirsute males (the word "pilonidal" means "nest of hair").

Pilonidal sinuses may be asymptomatic (a simple pit), or present with recurrent pain, swelling, and discharge when the sinus becomes infected (pilonidal abscess). Recurrent or symptomatic pilonidal sinuses require surgical excision.

Surgical options:

Excision and primary closure: The sinus and associated tracts are completely excised, and the wound is closed primarily. Fast recovery but higher recurrence risk if off-midline closure principles are not followed.

Limberg flap (rhomboid flap) reconstruction: The sinus is excised and the defect closed with a rotational flap of adjacent tissue. Significantly lower recurrence rate than simple excision and primary closure - the preferred technique for recurrent or complex pilonidal disease at Niraaya Hospital.

Open wound healing (excision and healing by secondary intention): The sinus is excised and the wound left open to heal gradually from the base. Very low recurrence but slow healing (6-12 weeks). Used when primary closure is not appropriate (large excision, infected field).