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Anal Fissure

Humza Khizer

Overview

An anal fissure is an <a href="https://merisehat.pk/disease/peptic-ulcer">ulcer</a> (open sore) or a tear in the tissue lining the anal canal. 
&nbsp;

The anus has a sphincter or a ring of muscle, which opens during a bowel movement to allow feces or stool to pass through. A fissure occurs when the anal tissue stretches too much, possibly during a hard bowel movement, causing spasms, pain, or bleeding.

While it can affect everyone irrespective of their age and gender, it mostly presents in infants and middle-aged populations. Nearly half of the cases of anal fissures occur before the individual turns 40, and around 8 out of 10 babies have it<a href="#accordion">[1][2]</a>. Around 250,000 new cases are diagnosed annually in the US<a href="#accordion">[3]</a>.

It&rsquo;s usually a treatable condition. However, an anal fissure that doesn&rsquo;t heal or recur is a cause for concern. 
&nbsp;

Since both anal fissures and hemorrhoids have similar symptoms and fissures often leave behind a skin tag at the anal opening, the two are often confused to be referring to the same condition. However, they are two different issues.

Hemorrhoids are inflamed vessels inside or just outside the anus, but the anal fissure is a common type of benign condition of the rectum and anus. Also, hemorrhoids don&rsquo;t necessarily result in pain, while 90% of the fissures do<a href="#accordion">[1]</a>. Moreover, pain due to hemorrhoids occurs constantly while pain from fissures occurs in episodes. 
&nbsp;

Anal fissures can either be:

<ul>
	<li>Acute &ndash; Lasting less than 6 weeks</li>
	<li>Chronic &ndash; Lasting more than 6 weeks 
	&nbsp;</li>
</ul>

Depending on their location, they are also classified as:

<ul>
	<li>Primary Or Typical &ndash; Occurs in the anterior or posterior midline</li>
	<li>Secondary Or Atypical &ndash; Occurs in any other location 
	&nbsp;</li>
</ul>

The majority of anal fissures occur at the anterior or posterior midline. 90% of all anal fissures in women are found in the anterior midline compared to 99% of occurrences in men<a href="#accordion">[4]</a>.

Fissures that occur off the midline are typically linked to secondary causes and systemic diseases, like Crohn&rsquo;s disease, <a href="https://merisehat.pk/disease/aids">AIDS</a>, cancer, or previous surgery. 
&nbsp;

Signs and Symptoms

These include:

<ul>
	<li>A visible cut or tear in the affected region</li>
	<li>Sharp pain during and after a bowel movement (can last for several hours)</li>
	<li>Burning or itching in the area during and after a bowel movement</li>
	<li>Bleeding during or after a bowel movement, either in the stool or on the toilet paper 
	&nbsp;</li>
</ul>

Some people may also experience:

<ul>
	<li>A small lump or skin tag near the tear</li>
	<li>Anal muscle spasms</li>
	<li>Pain radiating to their butts, upper thighs, and lower back</li>
	<li>Dysuria, which is discomfort when urinating</li>
	<li>Frequent urination 
	&nbsp;</li>
</ul>

Note: If you notice any of the aforementioned symptoms, it&rsquo;s important to seek medical advice immediately. 
&nbsp;

Causes

The anus constitutes two muscular rings &ndash; an outer ring that is consciously controlled and an inner ring that is under constant pressure. When the pressure increases too much, it causes the inner sphincter to spasm, reducing the blood flow to the area and increasing the risk of fissure.

1 in 10 people is affected at some point in their lifetime and 40% of these patients with acute anal fissures will have a chronic anal fissure<a href="#accordion">[3][5]</a>. The cycle begins when the anal mucosa is usually stretched due to constipation and hard stools, leading to frequent injury causing the internal sphincter to spasm. The spasm further pulls the fissure and makes it difficult for it to heal. 
&nbsp;

Some anal fissures are idiopathic or have no known cause. Other suspected causes may occur because of:

<ul>
	<li>Constipation and straining during bowel movements</li>
	<li>Passing large or hard stool</li>
	<li>Rough or excessive wiping of the anus</li>
	<li>Inflammation of the anus and rectum</li>
	<li>Chronic diarrhea</li>
	<li>Foreign body insertion</li>
	<li>Scratching as in a reaction to pinworm or other infection</li>
	<li>Muscle spasms</li>
	<li>Pregnancy and childbirth 
	&nbsp;</li>
</ul>

Atypical fissures may be caused by:

<ul>
	<li>Sexually transmitted infections, like genital herpes and HIV</li>
	<li>Inflammatory bowel disease, like Crohn&rsquo;s disease or ulcerative colitis</li>
	<li>Tuberculosis</li>
	<li>Leukemia</li>
	<li>Rectal or anal cancer</li>
	<li>Syphilis</li>
	<li>Skin condition, like psoriasis</li>
	<li>Medications like opioid painkillers or having chemotherapy</li>
	<li>Trauma through previous anal surgery 
	&nbsp;</li>
</ul>

Other causes may include overly tight or spastic anal sphincter muscles and decreased blood flow to the anorectal area.

Diagnosis

The doctor will begin by asking about the patient&rsquo;s symptoms and health history. A rectal exam or anoscopy can help locate the signs of a tear or other symptoms of an anal fissure. The fissure and, at times the entire anal sphincter, will be extremely sensitive to touch.

For a patient with a chronic anal fissure, the doctor may be able to see a large tear that is deep enough to expose the muscular fibers of the anal sphincter. Since repeated injury also delays the healing cycle, the doctor may also note raised edges and sentinel piles or thick tissue at the distal ends of the tears. 
&nbsp;

In obese patients, it may not be easily identifiable so the doctor may gently press on the posterior or anterior sphincter to reproduce the pain and diagnose the condition.

Generally, fissures at the sides of the anus are caused by underlying disorders, which may require more testing to rule out conditions such as Crohn&rsquo;s disease. However, some of these underlying conditions can present as primary anal fissures. Therefore, an examination under anesthesia is recommended to diagnose the exact cause of chronic recurrent anal fissures. 
&nbsp;

Furthermore, the doctor may order:

<ul>
	<li>Fecal Occult Blood Test</li>
</ul>

This helps check for blood in the stool.

<ul>
	<li>Colonoscopy Or Sigmoidoscopy</li>
</ul>

These are screening tests for colorectal cancer. A colonoscopy is usually preferred in patients aged 50 or above. 
&nbsp;

Treatment

These include: 
&nbsp;

<ul>
	<li>
	<h5>Lifestyle And Home Remedies</h5>
	</li>
</ul>

Some lifestyle changes can help relieve discomfort. For instance, fiber-rich foods, like vegetables, fruits, whole grains, and nuts, encourage fissure healing. They also act as stool softeners, helping avoid recurrences. However, fiber intake should be increased gradually as it can cause bloating and gas.

Additionally, the individual should drink adequate fluids to avoid straining during bowel movements. Also, the area should be washed gently and kept dry to avoid inflammation. 
&nbsp;

<ul>
	<li>
	<h5>Medication</h5>
	</li>
</ul>

The first line of treatment for anal fissures is usually home remedies. If that doesn&rsquo;t work, medications may be prescribed to relieve the symptoms and/or speed up the healing. 
 
These may include<a href="#accordion">[1][6][7]</a>:

<ol>
	<li>Painkillers, like ibuprofen and Tylenol, to relieve inflammation</li>
	<li>Topical Anesthetics like lidocaine to numb the anus before going to the loo</li>
	<li>Laxatives to soften feces, making it less likely to dry and helping avoid constipation</li>
	<li>Oral Solution or osmotic laxative for children to stimulate a bowel movement</li>
	<li>Topical Nitroglycerin Ointment or hydrocortisone cream like Cortizone 10 to promote blood flow to the area and speed the healing of the lesions</li>
	<li>Calcium Channel Blockers like diltiazem speed up healing by bringing down high blood pressure and relaxing the sphincter muscle</li>
	<li>Botox Injections for muscle spasms. 
	&nbsp;</li>
</ol>

<ul>
	<li>
	<h5>Surgery</h5>
	</li>
</ul>

The majority of anal fissures don&rsquo;t require any surgical interventions. They will heal naturally given the area around the wound is kept clean and dry. However, doctors may recommend surgery if the anal fissure persists despite treatment or if a severe anal fissure needs to be corrected surgically. 
&nbsp;

These procedures include:

<ol>
	<li>Lateral Internal Sphincterotomy to remove a portion of the anal sphincter and release the pressure inside the anus</li>
	<li>Fissurectomy, used rarely, is to remove the fissure in patients with a high risk of incontinence like the elderly</li>
	<li>Advancement Flap Surgery to repair the fissure using healthy tissue from another part of the body; usually recommended in case of chronic anal fissures due to injury to the anal canal or pregnancy 
	&nbsp;</li>
</ol>

While surgery is effective, with 9 out of 10 people experiencing long-term benefits, it can lead to complications, like bowel incontinence, risk of infection, persistent gas incontinence, and bleeding5.

Note: Anal fissures may recur even after treatment. Talk to your doctor about it. 
&nbsp;

An acute anal fissure will heal within six weeks of conservative treatment, particularly when constipation is treated. However, treatment may be delayed or avoided because a lot of people feel shame and discomfort talking about their condition. 
 
This causes complications, including:

<ul>
	<li>Difficulty with bowel movements</li>
	<li>Clotting</li>
	<li>Chronic anal fissure, i.e., the tear fails to heal or recur frequently, leading to extensive scare tissue (sentinel pile) over time at the site of the fissure</li>
	<li>Anal stenosis, i.e., abnormally narrow anal canal due to contraction of the resultant scar tissue or spasm of anal sphincter</li>
	<li>Anal fistulas or abnormal fistulas join or extend the anal canal to surrounding organs</li>
	<li>Reduced quality of life 
	&nbsp;</li>
</ul>

These include: 
&nbsp;

<ul>
	<li>A Low-Fiber Diet&nbsp;Recurrence rate is 30-70% if the patient stops consuming a high-fiber diet after healing of a previous fissure4</li>
	<li>Age&nbsp;It&rsquo;s more common in infants and middle-aged adults than otherwise</li>
	<li>Recent Weight Loss Surgery&nbsp;May lead to frequent diarrhea</li>
	<li>Inflammatory Conditions affecting the anal area</li>
	<li>Frequent Constipation&nbsp;straining during bowel movements, or passing hard stools</li>
	<li>Intense Diarrhea</li>
	<li>Vaginal Childbirth</li>
	<li>Crohn&rsquo;s Disease&nbsp;can make the lining of the anal canal more vulnerable to tears</li>
	<li>Trauma By Physical Activities like high-level mountain biking 
	&nbsp;</li>
</ul>

Following are some ways to reduce the risk of new or recurring fissures: 
&nbsp;

<ul>
	<li>Drink Plenty Of Fluids. Drink enough water to stay hydrated.</li>
	<li>Exercise Regularly to avoid constipation.</li>
	<li>Treat Diarrhea immediately.</li>
	<li>Use Anti-Inflammatory Ointments. Take all medicines as prescribed by a professional doctor.</li>
	<li>Avoid Spicy Foods because they aggravate the symptoms of an anal fissure.</li>
	<li>Take Sitz Baths. Warm baths for about 20 minutes a day help relieve discomfort.</li>
	<li>Maintain A&nbsp;Routine Bowel Habit. Work out a time of day when it&rsquo;s possible to go to the toilet and not delay it.</li>
	<li>Keep The Anal Area Dry. Avoid using wet wipes dabbed in alcohol or fragrance. Opt for a soft brand of toilet paper and avoid wiping too hard.</li>
	<li>Change The Infant&rsquo;s Diapers Frequently, especially if they have the condition. Clean the anal area with warm water and mild soap, and soak the bottom in a warm bath, especially after a bowel movement.</li>
	<li>A High-Fiber Diet. According to the NHS, adults should consume at least 18 g of fiber every day. If the fiber intake is too high or too rapid for the body to adjust, it may cause gas, stomach cramps, diarrhea, and bloating. Fiber supplements or other stool softeners may also help. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>An anal fissure is a tear in the lining of the anal canal.</li>
	<li>Anal fissures are usually less than 1 cm across. Even a small tear can cause severe pain because the region is highly sensitive.</li>
	<li>Signs and symptoms of anal fissure include pain, blood, itching, and discomfort in the anal area.</li>
	<li>Damage to the lining may occur due to constipation, straining or passing hard stool, chronic diarrhea, STIs, muscle spasms, underlying conditions like ulcerative colitis, and pregnancy and childbirth.</li>
	<li>A rectal exam can help diagnose an anal fissure.</li>
	<li>Treatment includes topical creams, OTC painkillers, and occasionally surgery.</li>
	<li>Sometimes people delay going to the loo due to pain or distress because of bleeding, increasing their risk of constipation and, thereby, of repeated injury.</li>
	<li>The condition is common in young infants but can affect people of any age.</li>
	<li>Self-help measures, like exercising regularly and eating a high-fiber diet, can help prevent constipation. 
	&nbsp;</li>
</ul>