Introduction & Need of the Study:

It is an ulcer in the longitudinal axis of the lower anal canal. Commonly it occurs in the midline, posteriorly (more common in males), but can also occur in the midline anteriorly (more common in females). Ninety-five per cent of anal fissures in men are posterior; 5% are anterior. Eighty per cent of anal fissures in females are posterior; 20% are anterior. Anterior anal fissure is common in females. It is superficial, small but distressing lesion. Fissure ends above at the dentate line.1 Because of the curvature of the sacrum and rectum, hard faecal matter while passing down causes a tear in the anal valve leading to posterior anal fissure. Anterior anal fissure is common in females due to lack of support to pelvic floor. Hard stool; diarrhoea; increased sphincter tone; local ischaemia; trauma; sexually transmitted diseases. Other causes are haemorrhoidectomy, Crohn’s disease, venereal disease, ulcerative colitis, and tuberculosis.1 Fissure in Ano is the most common painful and troublesome anorectal condition that covers a great majority of the population worldwide.2 It is one of the general pathological diseases and a well-known traditional surgical entity that constitutes 70% of the general surgery OPD.2 The incidence of anal fissure is around 1 in 350 adults Globally.3 It effects more than 10% of patient attending proctology clinics and its incidence is growing day by day due to sedentary lifestyle, low fibrous diet and junk foods etc. In India prevalence of anal fissures among patients with anorectal complaints are around 18%.4 An observational study showed that in Bangalore (Karnataka) out of 416 patients with anorectal ailments 65 (15.62%) patients were suffering from anal fissure.4

It can be classified as acute and chronic.5 Acute anal fissure usually heals with conservative treatment which includes oral analgesics, stool softener, local anaesthetic agents, high fibrous diet, using plenty of fluids6 and warm sit bath.7 In certain group of patients due to lack of adherence to life style and diet modification or due to their occupational need of prolong sitting which hamper the local circulation of blood. fissure in Ano persist of longer duration for which is conventional system of medicine there are other conservative management like injection botulinum toxin, topical application of calcium channel blocker (Diltiazem gel 2%) local vasodilator (topical nitrates)1 etc. are available but these drugs have some drawback like local irritation short duration of action. Side effect and adverse effect may be due to excessive systemic absorption. When conservative treatment fail for more than six weeks then surgical treatment is required like lords dilatation Fissurectomy or internal sphincterotomy but these having certain drawbacks like high cost of treatment, prolong hospital stay usually performed in secondary and tertiary hospital and complication like haemorrhage, haematoma, bruising, and perianal abscess and the most important complication is incontinence of stool of a variable nature and severity which may affect up to 30% of patient.8 In view of common prevalence, drawbacks and non-availability of affordable and safe treatment or anal fissures in conventional system, this study is being designed to manage the anal fissure by local application of zaroor-e-Aelwa. As Aelwa is purported to have healing properties and it does not produce local irritation in deep wounds. By the use of zaroor-e-Aelwa locally as fine powder over wound approximates the edge of the wound.10,30 Zakariya Rhazi mentioned in his book Kitab-ul-Hawi that the use Aelwa as topical application in treatment of fissure in Ano very much beneficial.9Review of Literature:

According to Unani system of medicine anal fissure is known as Shiqa ̄q-ul-Maq‘ad 11 which occurs due to sue mizaj Har Yabis (hot & dry temperament) of anus with shadeed Qabz (passing of dry hard stool)12,13,14,15,other causes include passing of Akkaal-khilt (corrosive humours),dietary habits of eating too much khusk (Dry), tursh (sour), Qābid ̣ (astringent) items, tafarruq wa ittesal (Trauma), external barudat (cold) and as a complication of bawaseer (Pile) and nasoor (fistula)14,15

Fissure is derived from a Latin word “Fissura” which means a groove, natural division, cleft, furrow, ulcer or crack like sore.8 Recamier in 1829 first described anal fissure as a painful linear tear at the muco-cutaneous junction of the lower anal canal which extends from anal verge proximally towards dentate line, but not beyond it.16 The cause of an anal fissure is not completely understood but certain etiologic factors such as trauma caused by the strained evacuation of a hard stool, less commonly from diarrhoea, has been proposed to cause anal fissure.8

Anal fissure is classified into:

1. Acute (within 6 weeks duration).

2. Chronic (more than 6-8 weeks of duration).

In Unani system of medicine, the Usool-e-Ilaj (principle of treatment) of fissure in ano in classical text is given as, use of high fibrous diet and laxatives15,22 avoidance of Tursh (sour), Qābiz ̣ (astringent) and Khushk (dry) items.15,23 along with a lot of formulations containing several Unani single drugs having properties of Muhallil- warm (Anti-inflammatory), Mundamil (healing agent), Muzliq (lubricant),

Mujaffif (desiccant) and Muskkin alam (analgesic) which are indicated in the treatment of anal fissures.24,25,26,27

According to different Unani literature, Roghan-e-Gandum, Roghan-e-Aas, fine powder of silkworms, Shib-e-Yamani biryan, fine powder of Gule Surkh, Dam-ul-Akhwain, Gogul, Rasout, Egg yolk, Usara-e-Kasni, Usara-e-Makoh, Zaroor-e-Anzaroot, Marham-e-Safedab, Marham-e-Shadanj, Marham-e-Shiqaq, Zaroor-e-Aelwa, Gil-e-Qaimoolia, Kakanaj, Roghan-e-Gul are some different Unani drugs mentioned as local application for treatment of anal fissures.