What Is an Anal Fissure?

What is an anal fissure?

The anal canal is a short tube surrounded by muscle at the end of the rectum. An anal fissure is a small crack, tear, or rip in the anal canal lining. Anal fissure is often very small, but can cause you severe pain. The pain gets worse after passing stool and normally last for an hour. You may also notice blood after passing stool. The blood is often bright red and can be noticed on the stool coating or on the toilet paper used. Fissures are common but often confused with other anal conditions. They can affect people of any age but are very common in young infants.

The most common cause of anal fissures is constipation. There is pain during the passage of a hard bowel movement and also a sharp pain that continues afterward. Sitting, too, can be painful. A few drops of blood can be seen in the toilet bowel or upon wiping. The sphincter muscles surrounding the anus prevent stool leakage. In anal fissures, these sphincter muscles can go into spasm and cause long-lasting anal fissures.  

A history of the symptoms and an inspection of the anus are used for diagnosis. Usually, no other tests are needed.    

In many people, the fissure will heal within one to two weeks, just like any cut on the skin. Other fissures take more time to heal. A fissure that will last more than six weeks is termed as chronic. Chronic anal fissures are rare, but treatment may be effective. Treatment includes drinking lots of fluids and consuming a diet rich in fiber. Laxatives, stool softeners, and fiber supplements may be prescribed by the doctor.  When medicines and diet modifications fail, surgery is then considered.

What causes an anal fissure?

The anal canal is very short, approximately 1 to 2 inches long. It is the last part of the colon or large intestine, and has two circular muscles that help to control the passage of bowel movements. Trauma to the anus or anal canal that has occurred during a bowel movement because of constipation or other stretching of the anal canal may cause anal fissure. It can be due to a hard, dry bowel movement or frequent loose bowel movements. Anal fissure can be acute or chronic. Acute anal fissure is a tear in the superficial layer of the skin. If the superficial tear does not heal, then it may develop into chronic anal fissure. The tear deepens into the mucosa or tissue lining of the muscle of the internal anal sphincter.

Passing hard stools can stretch and tear your back passage rim. This skin injury heals fast without any problems in many people. In others, more pressure than normal is experienced in the tissues surrounding the anus. The tissue is tighter than usual. The increased pressure is thought to minimize blood supply and slow down the skin’s healing process in the anus. This anal tear may develop into an anal fissure. Once the fissure develops, pain while passing stool may place further pressure on the anal fissure. This causes symptoms and more pain, creating a vicious cycle. Less common causes include inflammatory bowel disease, anal infections, and tumors.

Constipation is the most likely cause of an anal fissure. One in ten cases of fissure occurs during childbirth. Bad diarrhea sometimes causes anal fissure as well.   

Fissures may develop as part of a different condition, though in rare cases, e.g., as a complication of Crohn's disease or an infection from anal herpes. In these cases, one would experience other symptoms and issues as well.  

What are the symptoms of anal fissure?

Anal fissure signs and symptoms are:

• Pain that sometimes worsens during a bowel movement.
• Pain after a bowel movement that may last for several hours.
• Blood on toilet paper or stool that is bright red in color after any bowel movement.
• Irritation or itching in the area surrounding the anus.
• A noticeable crack or tear around the anal skin.
• A small skin tag or lump near the anal tear.
• A vicious cycle of constipation causing pain. This causes the anal sphincter muscles to go into spasm. This may cause more pain, which makes bowel movement even more difficult. Even sitting down becomes painful.

When to call a doctor?

Anal fissure usually causes minimal bleeding. Only a few drops are seen in the toilet bowel or upon wiping. This blood does not mix with the stool. If the bleeding is significantly high or if the person complains of shortness of breath, abdominal pain, or lightheadedness, call the doctor right away. The pain of an anal fissure can be severe, and hence a doctor should be contacted for the proper diagnosis and options for pain relief.

Causes

Common causes of anal fissure:

• Passing hard or large stools
• Straining and constipation during any bowel movement.
• Childbirth
• Anorectal area swelling caused by various inflammatory bowel ailments, including Crohn's disease
• Chronic diarrhea

Less common causes of anal fissures:

• HIV
• Syphilis
• Tuberculosis
• Herpes
• Anal cancer

Diagnosis

First, the doctor obtains a history of the patient’s complaint. The doctor then performs a physical examination, which includes an inspection of the anus to look for cracks or tears in the skin surrounding the anus.

The doctor may perform a digital rectal exam. In this, the doctor inserts a gloved finger into the anal canal. Or the doctor may use an anoscope to inspect the anal canal. If either is too painful, the doctor may diagnose the condition purely by observation. A chronic anal tear has two skin tags: one internal (sentinel pile) and one external (hypertrophied papilla).

The doctor may suggest further tests, such as the following, to discover the underlying condition:

Flexible sigmoidoscopy - In this, the doctor inserts a thin, flexible tube into the bottom portion of the colon. The tube has a tiny video camera. If a person is younger than 50 and has no risk factors for colon cancer or intestinal diseases, then this test is done. In order to make the person feel less uncomfortable, lidocaine ointment is used as an anesthetic.

Colonoscopy - In this, the doctor inserts a flexible tube into the rectum to inspect the entire colon. This test is done in people who are older than 50 years, are at risk for colon cancer, or have other signs and symptoms such as abdominal pain or diarrhea.

Blood tests and x-rays are normally not needed.

If the anal fissure is midline, it may be due to constipation.

If the fissure occurs at the side rather than on the back or front, it is more likely to be a sign of a different disorder, such as Crohn’s disease, cancer, or HIV infection.

Risk Factors

These are factors that may increase the risk of anal fissure development:

• Infancy - Many infants experience anal fissure in their first year after being born. No explanation from experts has been found regarding this.
• Aging - Older adults can develop anal fissure especially because of slowed blood circulation, resulting in a decreased flow into the rectal section.
• Constipation - Straining during a bowel movement and passing of hard stools increases the danger of tearing.
• Childbirth – Anal fissures are likely to occur in women after giving birth.
• Crohn's disease – This is an inflammatory bowel ailment that causes chronic swelling in the intestinal tract and can make the anal lining susceptible to tearing.
• Anal intercourse – This form of sexual intercourse can cause anal fissure development.

Complications of Anal Fissure

These are possible complications of anal fissure:

• Failure to heal – If anal fissure fails to heal within 6 weeks, it is considered chronic and may require further treatment.
• Recurrence – It is possible to have another fissure if you have experienced one.
• A tear that extends to nearby tissue – Sometimes, the fissure can extend into the surrounding tissue holding your anus together. This makes the anal fissure healing process difficult. If the anal fissure doesn’t heal, it will bring about discomfort and require surgery or medication to minimize the pain and eliminate or repair the fissure.

Treatment

Non-surgical treatment

The doctor may recommend these:

1. Externally applied nitroglycerin (Rectiv) - This is applied to increase the blood flow in the area of the fissure. Nitroglycerin promotes healing and also helps the sphincter muscles to relax. Usually, this medicine is considered when other measures have failed. Side effects include severe headache.
2. Topical anesthetic cream- Lidocaine hydrochloride (xylocaine) may help in relieving pain.
3. Blood pressure medications - These medications help relax the anal sphincter. They include oral nifedipine (Procardia) or diltiazem (Cardizem). They can be taken by mouth or applied externally. They can be used when nitroglycerin is causing some side effects or is ineffective.
4. Over-the-counter stool softener - This is to make it easy to pass stool.
5. Warm tub baths – 10-20 minutes a few times a day is to be done, especially after bowel movements. The warm soak soothes the area and relaxes the anal sphincter muscles and helps the healing process.

Surgery

You doctor may recommend surgery if your symptoms are severe or if you have chronic anal fissure that is resistant to other treatments.

This is performed by a procedure called lateral internal sphincterotomy (LIS). A small portion of the anal sphincter muscle is cut. This reduces spasm and pain and promotes healing.

Botulinum toxin type A (botox) injection - This paralyzes the sphincter muscles and also relaxes the spasm.

Studies have shown that surgery is more effective for chronic anal fissure. However, it can cause incontinence.

Post-treatment prognosis

Most patients can resume work and carry on with their daily activities a few days after the surgery. Complete healing will take 6 to 10 days for both medical and surgical treatment. It is important to maintain good bowel habits and eat a high-fiber diet even after pain and bleeding have lessened. If bowel movements are hard or loose, there is scarring or spasm of the anal muscle, and healing can get delayed.

In 50 to 80 per cent of patients with chronic canal fissure, botox injections have been effective in healing.

In more than 90 per cent of patients, sphincterotomy has been successful

If fissures do not improve with treatment, they should be evaluated for other possible conditions. Fissures can also recur. A fissure that is completely healed can come back after a hard bowel movement or trauma.

More than 80 per cent of the time, medical therapy works in treating and preventing future anal fissures. The success rate is often more than 95 per cent in preventing recurrences.

Complications

No serious disease is associated with anal fissure, although anal cancer may mimic anal fissure. Some of the complications are as follows:

• Chronic anal fissure - It may develop when the tear fails to heal. Over a period of time at the site of the fissure, it may cause extensive scar tissue.
• Anal fistulas - The anal canal is joined to surrounding organs (usually other parts of the bowel) by abnormal tunnels.
• Anal stenosis- This is the abnormal narrowing of the anal canal due to spasm of the anal sphincter muscles or contraction of the resultant scar tissue.

Self-Management

Home Remedies and Lifestyle

A number of lifestyle changes can help relieve unease and aid in the healing of anal fissure, plus prevent recurrences:

• Adding fiber to the diet - Eat about 25 to 30 grams of fiber daily for softer stools and help in fissure healing. Fiber-rich diets include vegetables, fruits, whole grains, and nuts. You may also take fiber supplements. Gradually, increase your fiber intake as it can cause bloating and gas if taken or consumed in large quantities.
• Drink enough fluids - Fluids assist in preventing constipation.
• Exercise regularly - Engage in a minimum of 30 minutes of adequate physical activity like walking often during the week. Exercise helps in consistent bowel movements and increasing the blood flow in all parts of the body. This promotes anal fissure healing.
• Don’t strain during any bowel movement - Straining creates tone that can result in a tear or open one that’s healing.
• Change diapers regularly - If your baby is suffering from a fissure, clean the area well and gently, and discuss the issue with the child’s doctor.

Relieving soreness and discomfort

• Warm baths – They are soothing and can assist your back passage to relax, reducing the pain.
• An ointment or cream that has an anesthetic, i.e., lidocaine - This can assist in easing your pain. It should be used for a short period (5 to 7 days). Anesthetic can sensitize or irritate your skin surrounding the anus, if used for long. You can get a prescription of these ointments and creams. You may also purchase most of these treatment products from pharmacies, without any prescription. Always apply the cream before visiting the toilet. 
• An ointment or cream that has steroid medication – This can be prescribed by your doctor when the inflammation in the fissure region is too much. Steroids assist in minimizing any inflammation in the area surrounding the fissure, along with easing the pain and itch. This should not be used for over a week continuously.
• Clean the anus cautiously with water – Always do this after visiting the toilet and avoid using soap while the tear is still sore, because it can cause irritation.
• Painkillers – Ibuprofen and paracetamol are recommended as they can assist in relieving pain.

Keeping the stool soft and avoiding constipation

• Eat enough fibre – Fibre-rich foods include cereals, fruits, whole-meal bread, and vegetables.
• Drink plenty of fluids – Aim to drink two liters (10 to 12 glasses) of fluid daily.  A considerable amount of this fluid passes as urine. Some will go to the gut and soften the stool. Avoid alcohol as it dehydrates.
• Laxatives and fibre supplements – When high-fibre diets don’t help, you can use fibre supplements, i.e., methylcellulose, ispaghula, sterculia, or bran. Methylcellulose assists in softening stool directly, making it easier to pass. You can get a prescription for these or buy them at pharmacies. Laxatives, i.e., macrogol or lactulose, can be suggested sometimes.   
• Going to the toilet – Never ignore the feeling of needing to pass stool. Some individuals suppress and put off this urge. This can result in harder and bigger stools forming, which makes them more difficult to pass afterwards. 
• Don’t take painkillers that contain codeine – Painkillers most often cause constipation, e.g., co-codamol. Paracetamol is mostly preferred for easing the discomfort of fissures.

Prevention

• Eat a diet rich in fiber.
• Drink plenty of water. This will help to soften your stools.
• If needed, consider using a fiber supplement such as Metamucil.
• Wipe gently after going to the toilet.

Anal fissure can be prevented by preventing constipation and the passage of hard bowel movements.