Anal fissures

Symptoms: Pain during bowel movements, pain after bowel movements that can last up to several hours, bright red blood on the stool or toilet paper after a bowel movement, a visible crack in the skin around the anus, and a small lump or skin tag on the skin near the anal fissure.

Causes: Chronic constipation, passing a dry, hard stool, rough or excessive wiping of the anus after passing a motion, diarrhoea, inflammation of the anus and rectum, Crohn’s disease, scratching (as a reaction to pinworm infection, for example), anal injury, pregnancy, childbirth, cancer of the rectum.

Risk factors: Anal fissures are more common in people who have had anal surgery in the past, a low-fibre diet, a history of trauma, constipation or hard stools.

Prevalence: The yearly incidence varied greatly by age, ranging from 0.05% in patients aged 6–17 to 0.18% in patients aged 25–34. The incidence was 0.11% (1.1 cases per 1000 person-years). The incidence differed according to gender as well, with males 55–64 years old and females 12–24 years old having substantially higher incidences. 

Severity: Mild to severe

Which doctor to consult: Gastroenterologist

Overview: 

A tiny wound or rupture in the anal lining is called an anal fissure. During and after bowel movements, the skin crack causes excruciating pain and some bright red bleeding. The fissure may occasionally be deep enough to reveal the muscle beneath. Certain treatments, such as topical pain relievers and stool softeners, can aid in the healing process and ease discomfort.

The tear heals on its own most of the time. If the crack doesn't go away after six weeks, it's deemed chronic. You might require surgery to treat an anal fissure if these remedies are ineffective. Alternatively, your physician might need to investigate other underlying conditions that can lead to anal fissures.

Types of anal fissures:

Anal fissures can be classified based on their duration and underlying causes:

Acute Anal Fissures: These are recent fissures that appear as small tears, similar to paper cuts. They typically heal within a few weeks with proper care and are often caused by the passage of hard stools or excessive straining during bowel movements.
Chronic Anal Fissures: These fissures last longer than six weeks and may have a deeper tear. They can also present with internal or external fleshy growths, known as skin tags. Chronic fissures may require medical intervention for healing.

Additionally, fissures can be categorized as:

Primary Fissures: These are common and often result from trauma to the anal canal, such as the passage of hard stools, chronic diarrhoea, childbirth, or anal intercourse.
Secondary Fissures: These are less common and may be associated with other conditions like previous surgeries, inflammatory bowel disease, infections, or cancer.
Proper diagnosis and treatment are essential for managing anal fissures, and a healthcare provider can offer the best guidance based on the type and severity of the fissure.

Symptoms:

The symptoms of an anal fissure typically include:

Pain during bowel movements: This is often the primary symptom, described as a sharp pain that starts with the passage of stool.
Bleeding: Bright red blood may be visible on the stool or toilet paper after a bowel movement.
Visible tear: A crack in the skin around the anus can sometimes be seen.
Skin tag: A small lump or skin tag may appear near the fissure.
Itching or irritation: The area around the anus may feel itchy or irritated.
Pain after bowel movements: Discomfort can last minutes to several hours following the movement.

Causes: 

Anal fissures are typically caused by trauma to the lining of the anus or anal canal. The most common causes include:

Constipation: Passing large or hard stools can tear the lining of the anus.
Straining during bowel movements: Excessive straining can cause fissures.
Chronic diarrhoea: Persistent diarrhoea can irritate and tear the anal lining.
Inflammation: Inflammation of the anorectal area, often due to underlying conditions, can lead to fissures.
Childbirth: The process of childbirth can stretch and tear the anal mucosa.
Anal intercourse: This can cause physical trauma to the anal canal.

Preventing constipation by eating a high-fibre diet, staying hydrated, and exercising regularly can help reduce the risk of developing anal fissures. If you’re experiencing symptoms of an anal fissure, it’s important to consult a healthcare provider for proper diagnosis and treatment.

Risk factors:

Anal fissure risk is increased by a few factors, such as:

• Having trouble passing hard stool due to constipation
• Consuming little to no fibre
• severe diarrhoea
• Recent bariatric surgery, as it causes frequent diarrhea
• Vaginal birthing Minimal trauma, particularly trauma from extreme mountain biking
• Any inflammation that affects the anal region
• Additionally, surgery, inflammatory bowel disease, and other medical treatments that impact the anus or bowel movements can cause anal fissures.

Possible complications:

If anal fissures are not treated for an extended length of time, complications may include:

• Anal fissures that don't heal are known as chronic fissures, and they can bleed and hurt continuously.
• Inability to control bowel movements, which can result in gas or stool leakage, is known as bowel incontinence.
• Fissures can recur even after healing, particularly if the underlying causes—like constipation—are not treated.

Constipation can be avoided by modifying one's diet to include more fibre, drinking plenty of water, and exercising frequently. Additionally, it's critical to maintain proper anal hygiene and to consult a doctor if symptoms worsen or persist.

Prevention:

Prolonged constipation is the root cause of many cases of anal fissures. Some recommendations are as follows:

• Consume a lot of fibre
• Drink a lot of water to help soften stools
• Think about taking a fibre supplement (like Metamucil)
• Ensure that you gently wipe after using the restroom

When to see a doctor?

With home therapy, the majority of anal fissures heal in a few days or weeks. They are known as acute, short-term anal fissures. Anal fissures that do not heal within 8 to 12 weeks are classified as long-term (chronic) fissures. Treatment for a chronic fissure may be necessary.

Diagnosis:

In addition to reviewing your medical history, your doctor will probably do a physical examination that includes a careful examination of your anal region. The tear is frequently apparent. This examination is typically sufficient to diagnose an anal fissure.

A more recent, sharp anal fissure resembles a recently torn piece of paper. A deeper tear is probably present in a persistent anal fissure, also known as a chronic one. It might also have fleshy growths on the inside or outside. If a fissure persists for over eight weeks, it is deemed chronic.

The location of the fissure provides hints regarding its cause. If the fissure appears on the side of the anal opening instead of the front or back, it is more likely to be a sign of another illness, like Crohn's disease. To determine whether you have an underlying condition, your provider might advise additional testing. Tests could consist of:

Anoscopy: A tubular instrument called an anoscope is placed into the anus to aid your physician in viewing the rectum and anus.

Flexible sigmoidoscopy: Your healthcare provider inserts a thin, flexible tube with a tiny video into the bottom part of your colon. If you are under 45 and do not have any risk factors for colon cancer or intestinal diseases, you may be able to have this test.

Colonoscopy: To examine your entire colon, a flexible tube is inserted into your rectum during this test. A colonoscopy could be performed if you: 

• are over 45 years old
• have colon cancer risk factors
• possess signs of additional illnesses.
• possess additional symptoms, like diarrhea or stomach pain.

Treatment: 

The treatment of anal fissures typically involves a combination of home remedies, medication, and in some cases, surgery. Here’s a summary of the treatment options:

Home Remedies and lifestyle changes:

A few lifestyle adjustments can ease pain, encourage healing, stop recurrences, and relieve anal fissures. Modifications consist of:

• Sitz Baths: Soaking in warm water for 10 to 20 minutes several times a day, especially after bowel movements, can help relax the anal muscles and increase blood flow to promote healing.
• Including more fibre in your diet: Consuming 25 to 35 grams of fibre daily can help maintain soft stools and promote the healing of fissures. Whole grains, fruits, vegetables, and nuts are examples of foods high in fibre. Additionally, you can take a fibre supplement. Increase your fibre consumption gradually, as adding more may result in bloating and gas.
• Consuming enough water: Drinking fluids can help avoid constipation.
• Do not strain when having a bowel movement: Pressure from straining can cause a new tear or cause an existing tear to heal.

Change diapers often and gently wash the area if your baby has an anal fissure. Make sure you also talk about the issue with your child's physician.

Medications:
The medication for anal fissures typically includes:

Topical Anesthetics: To reduce pain during bowel movements. Example: Lidocaine hydrochloride.
Steroids: To reduce inflammation. Example: Hydrocortisone.
Laxatives: To soften stools and relieve constipation. Example: Bisacodyl.
Blood Pressure Medications: To relax the anal sphincter muscles. Examples include nifedipine or diltiazem, which can be applied topically.
Nitroglycerin: A topical ointment that helps to relax the anal sphincter muscles and improve blood flow to the area, aiding in healing.
Botulinum Toxin A (Botox): Injections can paralyze the anal sphincter muscle temporarily to prevent spasms and allow the fissure to heal.

Surgery:
Lateral Internal Sphincterotomy: A procedure involving a small incision in the anal sphincter to relax the muscle and promote healing.
It’s important to consult with a healthcare provider to determine the most appropriate treatment based on the severity and persistence of the anal fissure. If you’re experiencing new, severe, or persistent symptoms, contact a healthcare provider immediately.

Additional information:

Additional information about anal fissures includes:
Misdiagnosis: Anal fissures can sometimes be confused with hemorrhoids, as both can produce similar symptoms like pain and bleeding. Proper diagnosis is crucial for effective treatment.
Healing Signs: A decrease in pain during bowel movements, less bleeding, and the disappearance of a visible tear or lump near the anus can indicate that a fissure is healing.
Self-Care: Over-the-counter creams and ointments, such as those containing zinc oxide or petroleum jelly, can protect the skin in the anal area and promote healing.
Remember, while anal fissures are common and often heal on their own, persistent or severe symptoms warrant medical attention to prevent complications and ensure proper healing. If you have concerns about anal fissures, it’s best to consult a healthcare provider.