Anal Fissure

An anal fissure is a small crack or tear in the moist lining of the anal canal.

Anal fissures may be acute or chronic, and cause pain during and after bowel movements.

Pain and rectal bleeding are the most common symptoms of anal fissures.

The lining may tear when large or hard stools pass through the anal canal. It is common in small children, but may develop at any age.

Anal fissures can be controlled by having a diet high in fiber.

Most cases of anal fissures resolve within six weeks. If anal fissures are not corrected with conventional or home remedies, medications and surgery are suggested. 

Anal fissure is a condition wherein a small cut or tear occurs in the anus. Since the anus is a sensitive organ, even a small cut or tear can lead to excessive pain and could even cause bleeding during or after passing bowels. Sometimes, the fissure is very deep and can expose the muscular tissues underneath the skin. There are various factors which could result in anal fissures, including childbirth; constipation, due to which one places excessive pressure on trying to pass motions; or passing excessive motions, as in the case of medical conditions like diarrhea. There are also certain chronic health conditions which could result in anal fissures, such as chronic inflammatory bowel disease, infection of the gut, or cancer.

Anal fissures can occur in anyone, irrespective of age, however, it is most commonly seen in infants and younger children. This age group is most susceptible to anal fissures, since constipation is a very common problem among this age bracket. Although anal fissures are not usually considered to be very serious, in some cases, complications may arise. Most of the time, anal fissures take about four to six weeks to heal on their own. However, any anal fissure that extends beyond eight weeks or so is considered a chronic health condition that needs medical attention, or else it may have a serious, long-term impact on the health of the patient.

There are various forms of treatments that can help heal anal fissures and ease the pain and discomfort caused by the condition. Stool softeners and painkillers are often administered to patients suffering from anal fissures. If the condition does not get better with the medications and treatments, surgery is often recommended. In certain cases, there could also be certain underlying health conditions which may be hampering improvement that have to be looked into by the treating doctor. 

Pain that worsens during and after a bowel movement is the most common symptom of anal fissures. The pain may last up to several hours in some cases.

Blood in the stool or on toilet paper indicates rectal bleeding.

A physical examination will reveal the presence of a visible tear around the anus.

Severe pain when passing motions all around the anal area is another symptom of a fissure.

Anal fissures are also characterized by itching or burning in the anal area. In most cases, skin tags are present near the fissure.

When the pain is severe, patients may be unwilling to have a bowel movement. This can lead to constipation or fecal impaction.

Pain may also affect urination, leading to discomfort or inability to urinate. Discharge of pus from the fissure causes malodorous discharge from the rectum. 

Trauma to the anal canal is the most common cause of anal fissure. Trauma is caused by passing hard, large stools.

Some other common causes of anal fissures are:

• Repeated diarrhea
• Constipation, or straining during bowel movements
• Inflammatory bowel disease
• Crohn’s disease
• Childbirth
• Insertion of rectal thermometers, enema tip, endoscope, or ultrasound probe

Anal cancer, HIV infection, tuberculosis, syphilis, and herpes are other possible causes of anal fissures.

The most common risk factors for developing anal fissures are age, constipation, childbirth, Crohn’s disease, and anal intercourse.

Many children develop fissures in their first year. Many older adults also develop tears in the anal canal due to reduced circulation to the area.

A physical examination is the tried and true way to diagnose anal fissures.

An anoscopy, a procedure in which a short tube called an anoscope is introduced into the anal canal and rectum, also helps locate the anal fissure. The location of the fissure will reveal the actual cause of the condition.

Crohn’s disease results in anal fissures on the sides of the anus. In patients younger than fifty, a sigmoidoscopy is suggested. In this method, the distal part of the colon is examined. For patients above fifty years and those who have a high risk of developing anal fissures, a full colonoscopy is recommended. 

In most cases, anal fissures do not require any specific treatment; the symptoms will resolve on their own within four to six weeks. Eating food rich in fiber and fluid helps make the stool soft. Sitting in warm water for about fifteen minutes several times a day promotes healing. Alternate treatment is suggested if symptoms persist.

There are also certain home remedies that can help treat anal fissures effectively. Some of these include:

• Over-the-counter medications for passing motions
• Drinking extra fluids
• Eating fibrous foods and supplements like fruits and vegetables
• Taking relaxing, warm baths to ease the anal muscles and relieve irritation, as it increases the blood flow to the anal region
• Using topical painkillers

Topical application of nitroglycerine increases blood flow to the anal canal region and improves healing of the lining. Topical anesthetic creams are suggested to relieve pain. Botox injections are used in some cases to alleviate spasms of the anal sphincter. These injections help manage the spasms by causing temporary paralysis to the anal muscles. This helps the healing process and also prevents the start of new fissures. Medications like nifedipine and diltiazem also help relax anal sphincters for the easy passage of stool.

Chronic anal fissures that do not respond to standard treatment methods may need surgery. Lateral internal sphincterotomy is a surgical procedure in which a small portion of the anal sphincter muscle is cut to reduce spasms. It also helps reduce pain during bowel movements.

Fissures caused by underlying diseases like tuberculosis, HIV, or rectal cancer may not heal with standard treatment methods. Treating the underlying condition is the best way to control symptoms.

Fissures are not necessarily a sign of a low-fiber diet or constipation. Whatever may be the cause of your fissures, it certainly requires medical attention for a proper solution to the problem, as there are always chances of a recurrence.

Surgery is often the last resort to treating anal fissures and is normally recommended only if the case is chronic or if all other treatments have failed to provide relief. The surgery often recommended for anal fissures is called a lateral internal sphincterotomy (LIS), which involves a small cut or incision being made in the anal sphincter muscle. Once the cut is made, it reduces the amount of pressure on the fissure, thereby giving the patient relief and allowing it to heal better.

The pain accompanying this surgery is bearable and not very severe. In fact, the pain is far less compared to the fissure itself. Post-surgery, the patient may have certain issues like being unable to control the passing of gas, mild leakage of stool, or some kind of post-surgical infection. However, surgery is often known to be a successful treatment process that allows the fissures to heal in about eight weeks.

One can reduce the risk of developing anal fissures by taking adequate preventive measures.

• In infants, changing diapers often helps prevent fissures and rectal bleeding.
• Drinking plenty of water and eating fibrous foods improves bowel movement.
• Regular exercise also promotes smooth bowel movements.
• Treating diarrhea immediately is also important for prevention. 

• Graphite is a common homeopathic remedy used to control symptoms of anal fissure like constipation and hard stools.
• Nitric acid is used to alleviate rectal bleeding after bowel movements.
• Ratanhia and phosphorous reduce pain, while paeonia prevents malodorous discharge.
• Olive oil, aloe vera, comfrey, coconut oil, and L-arginine gel are common home remedies used to reduce the impact of symptoms. 

There are different ways to adapt your lifestyle to cope with anal fissures.

Adding more fiber to one’s diet helps soften the stool and makes bowel movements less painful.

Drinking adequate fluid also helps prevent constipation, and exercising regularly improves bowel movements. 

Diet plays an important part in the healing process. Foods that can cause constipation are normally rich in fat and have a very poor fiber content. Those who are at a high risk of conditions like anal fissures should consume a high-fiber diet comprising whole grains, cereals, fresh fruits, and legumes rather than processed foods, fatty foods, fruit juices, and others falling in this category.

Healing anal fissures through exercise is most commonly recommended by doctors, as it is not only effective, but also helps prevent future recurrence. Yoga is known to be very helpful in managing this condition. Certain yoga poses like Dhanurasana help relieve constipation and also aid in better digestion. Practicing yoga everyday can help the body muscles work better, which eventually leads to better bowel movements. Thirty minutes of moderate exercise like walking or jogging also goes a long way in dealing with the condition. Exercising promotes healthy blood flow to the muscles, thereby resulting in better digestion of food. Contracting and relaxing the anal muscles during a warm bath is also very helpful. This gets the muscles working better and relaxes them. While exercise is an important part of managing this condition, it must be done only after consulting the doctor and under expert supervision. Especially for those who are recovering from anal fissure surgery, exercise must be done only in moderation, as it could cause extra strain on the anal muscles.

After surgery, one needs to pay extra attention to their diet and take appropriate amounts of rest as recommended by the doctor.

Chronic form of anal fissures is a possible complication.

There are chances of recurrence of anal fissures in some cases.

The tear in the lining of the anal canal may extend to the anal sphincters, causing trouble in healing.