Anal Fissure: Symptoms, Diagnosis and Treatment

An anal fissure is a small cut or tears in the tissue which lines the anal canal. The anal canal is a hollow tube through which stool passes before coming out of the anus. Patients typically complain of pain and bleeding during bowel movements. It can occur due to several reasons ranging from constipation to even cancer. It can occur at any age group but infants and older adults are more affected because constipation and diarrhea are common problems in these age groups. Most of the anal fissure heal on their own but some require additional treatment. About every 1 out of 350 adults get anal fissure and approximately 235000 new cases of anal fissure occur annually in the US.

Sign and symptoms of Anal Fissure

Following signs and symptoms are associated with the anal fissure

• Sharp pain – severe pain occurs during defecation and can last up to many hours after it
• Bright red blood can be seen on the toilet paper or stools
• Long-standing anal fissures can develop a visible skin lump (skin tag) near it
• Visible skin crack is also visible in some cases.

Causes of Anal Fissure

Fissures occur due to any condition that causes harm to the mucosa of the anal canal. The mucosa is the inner soft tissue which comes directly in contact with the stools

More common causes are

• Passing hard stools, require excessive straining
• Long episodes of constipation and diarrhea
• Inflammatory bowel diseases like Crohn’s and Ulcerative colitis
• To a mother during childbirth
• Injury or trauma around the anus

Less common causes are

• HIV
• Tuberculosis
• Herpes
• Syphilis
• Anal cancer

Risk factors of Anal Fissure

Not all people develop anal fissures but some people do because of the following factors

• Age: infants and older adults are more likely to have an anal fissure
• Constipation: Constipation leads to excesses straining which increases the risk
• Poor feeding habits:  Low fiber diet.
• Anal intercourse

Complications of Anal Fissure

If you are not serious about your anal fissure and don’t seek your doctor’s advice, then the following complications can arise

• Becomes chronic: An anal fissure which fails to heals in 6 weeks is considered to be chronic and doesn’t get easily treated by supportive care.
• Recurrence: once a fissure has occurred, there is always higher chances of another anal fissure.
• Extension: The crack can extend to deeper layers and consists of muscle which further complicates healing.

Diagnosis of Anal Fissure

your doctor will ask you some questions related to your medical history, conduct a physical exam and medical test to find the cause of the anal fissure

• Medical history: Your doctor will ask you many questions related to Your bowel habits: frequency, the color of stools, consistency, time of onset of problem, pain or blood during passing stools.
• Your Physical activity
• Perform rectal exam:  To see the fissure your doctor can use an anoscope which is a metallic hollow short tube inserted in the anal canal. The location of the fissure sometimes helps to find out the cause of anal fissure
• Endoscopy: endoscopy techniques like sigmoidoscopy or colonoscopy can be used if your doctor is suspecting inflammatory bowel diseases like Crohn’s or Ulcerative colitis.

Treatment of Anal Fissure

Most of the anal fissures don’t require medication and heals within a week it you follow some home remedies like

• Increasing intake of fibers in the food by eating raw fruits and vegetables
• Using over the counter stool softeners
• Taking sitz bath – it is a special bath for your anal area. You should sit in the warm water for 10 to 20 minutes about 3 to 4 times a day. It helps you by relaxing anal muscles

If the symptoms still persist then you need further treatment

Your doctor will recommend the following treatment

Non-surgical treatment

• Nitroglycerin ointment externally applied to the anal region. It is a blood vessel dilator, promotes blood flow in the region and helps in faster healing. It can also relax anal sphincter muscles.
• Topical pain reliever these are topical anesthetics such as lignocaine gel

Surgical treatment

It is advised by a doctor when non-surgical treatments are not effective. The surgeon usually performs an anal sphincterotomy which involves cutting small parts of the anal sphincter muscle to relax it thus reducing spasm and pain. It promotes healing.

Not all fissures are due to low fiber intake or underlying constipation. If your doctor suspects other causing conditions like an infection or inflammatory bowel disease, then the additional tests may be required and their treatment is also specific.

Prevention of Anal Fissure

With the help of some lifestyle changes, you can easily prevent the occurrence of anal fissure

• Take fiber-rich diet
• Exercise regularly
• Adequate fluid intake
• Avoid straining during defecation.

Reference

• Schlichtemeier, S., & Engel, A. (2016, February). Anal fissure. Australian Prescriber, 39(1), 14-17
• American College of Gastroenterology.