#SENTINEL PILE SKIN#

If the fissure does not heal or if the pain does not diminish substantially over the next 2 to 3 weeks, a more aggressive approach is justified. Topical nitroglycerin (0.2% cream applied twice daily) has been used with success however, we have found that recurrence is common and patients often complain of headaches that accompany its use. We find that topical diltiazem (2% gel) may relieve the pain and spasm and promotes healing. Because ischemia has been implicated in the propagation of a chronic fissure, several topical smooth muscle relaxants have been shown to be effective, probably by both lowering resting anal pressure and promoting vasodilatation. Topical corticosteroids and suppositories are ineffective and should be avoided topical anesthetics are popular, but we do not routinely recommend their use to our patients. Warm sitz baths seem to provide comfort and may relax the anal spasm and provide gentle anal cleansing following bowel movements. Standard treatment includes stool softeners, such as methylcellulose or dietary fiber. For this reason, reassurance is beneficial-emphasize that most fissures heal spontaneously with nonoperative treatment. Your patient may well express some anxiety about the pain and bleeding associated with an acute anal fissure. Fissures that are not close to the midline suggest other processes that could result in anal or perianal ulceration, such as Crohn disease, syphilis, herpes, and carcinoma. Up to 10% of fissures occur in the anterior midline (particularly in women).

At this point, further examination of the anorectum with either a finger or instrument is unnecessary and can be quite painful for your patient. You can easily diagnose an anal fissure by carefully spreading the buttocks apart and observing the linear ulceration in the anal canal.

#SENTINEL PILE SKIN#

Thus, the classic triad of a chronic anal fissure is the fissure itself, accompanied above by a hypertrophied anal papilla and below by a sentinel skin tag. The anal papilla at the cephalad edge of the anal fissure may also become enlarged and hypertrophied as a result of the chronic inflammation. This swollen epithelial tag may resemble an external hemorrhoid. At this point, the adjacent perianal skin may be edematous, forming a 'sentinel pile'-the hallmark of a chronic fissure that will likely need surgical treatment. 1 Often by the time patients arrange an appointment, what started as a tear has become an ischemic ulceration. This syndrome is associated with relative ischemia of the posterior midline of the anal canal, an area with a relative paucity of blood vessels. The pain causes sphincter spasm and anal hypertonia, and thus begins a vicious circle of pain, spasm, and constipation. The linear injury is typically caused initially by the passage of a hard stool, resulting in pain with defecation that can be accompanied by bleeding. In men and most women, the tear, or ulcer, occurs very close to the posterior midline of the anal canal. FISSURE An anal fissure is simply a tear in the anoderm. In this article, we discuss the diagnosis and treatment of these conditions, as well as other, less common causes of anal pain.

In fact, 95% of patients who complain of anal pain have one of the following 3 conditions: anal fissure, thrombosed hemorrhoid, or anorectal abscess. While it is certainly understandable that our patients should make such an assumption, it is all the more important for us, as health care providers, to remember that anal pain frequently has a nonhemorrhoidal cause. They frequently phone and ask us to prescribe a medication for their 'painful hemorrhoids,' and they are often dismayed when we insist that they must come to the office for an examination before we can prescribe any treatment. Patients almost always believe that their anorectal problems are caused by hemorrhoids, regardless of the nature of their symptoms. Anorectal Complaints: Office Diagnosis and Treatment, Part 1Īnorectal Complaints: Office Diagnosis and Treatment, Part 2

Sentinel pile