Anal Fissure: Causes, Symptoms, Treatment & Prevention

Fissure is defined as a narrow opening or crack of considerable length and depth, usually occurring from some breaking or partying. An anal fissure is a small tear or open sore (ulcer) that develops in the lining of the large intestine near the anus. It is seen most commonly in young infants but can affect people of any age. Anal fissures are often caused due to constipation, passing hard stools frequently. It typically causes pain associated with bleeding while passing stools.

Causes of anal fissure:

Anal fissures are most commonly caused due to trauma to the inner lining of the anal canal. Some of the causes of anal fissures are listed below:

• Passing hard or large stools
• History of long-standing constipation and straining while passing stools
• During normal delivery
• Anal intercourse
• Crohn’s disease or other inflammatory diseases
• Anal cancer
• Prolonged diarrhea
• Scarring in the anorectal area
• Sexually transmitted infections include- HIV, syphilis, gonorrhea, and chlamydia.

Risk factors of anal fissure

The risk factors which can increase the incidence of anal fissures are listed below:

• Normal delivery (childbirth) or during pregnancy
• Constipation or straining while passing stools
• Age- it can be seen at any age, but it is most commonly seen in young infants or young adults
• Anal intercourse
• Crohn’s disease or other inflammatory disease.

Symptoms of anal fissure

The signs and symptoms of anal fissure include:

• Severe pain during and after passing stools
• Bleeding per rectum
• Constipation
• Burning and irritation are present around the perianal area
• A tear or crack felt in the anus or anal canal
• Bright red blood found on the stool or on toilet paper after passing stools
• In a few cases, a small skin tag may be noticed.

Diagnosis of anal fissure

Whenever the patient approaches the doctor for consultation, the doctor initially will take the medical history of the patient, which includes the medication lists that they take on a daily basis, and their surgical history (undergoing any surgeries in the past). In order to diagnose and confirm the condition, the doctor will advise the patient to undergo a few tests. They are listed below:

• Physical examination- During the physical examination, the doctor will examine the patient completely. The doctor will examine the perianal area region thoroughly. Initially, they will first inspect the perianal region, to look for any signs of abnormalities such as a tear in the anal region, skin tag, sphincter tone, any discharge present in the perianal area, etc.
• Digital rectal examination (DR exam)- During the examination, the doctor will place two gloved fingers (index and middle finger) into the per anal region and asses the sphincter tone, feel for any tear or crack in the perianal area or look for any signs of bleeding.
• Anoscopy- An anoscope is a tubular device inserted into the anus which will provide to see the rectum and anus region.
• Flexible sigmoidoscopy- A sigmoidoscope is a thin, flexible tube along with a camera at the tip is inserted into the sigmoid colon, which will help us to visualize the entire sigmoid colon to look for any signs of abnormality present or not. It is usually done in patients who are younger than 45 years of age and have no risk factors for intestinal diseases or colon cancer.
• Colonoscopy- The purpose of colonoscopy is the same as that of the sigmoidoscopy, with the difference being that colonoscopy will help us to visualize the entire colon. It is usually done in adults who are older than 45 years or have an increased risk for colon cancer, or symptoms associated with stomach pain or diarrhea.

Treatment for anal fissure

The treatment plan for anal fissures depends upon the age of the patient, the severity of the condition, and the overall condition of the patient. The treatment options available are listed below:

• Non-Surgical Treatment

a) Diet modification- making changes in the diet, such as adding lot of fiber to the diet, in order to make stools softer will help in improving the condition of the patient.

b) Taking plenty of liquids daily.

c) Sitz bath- during this procedure, the patient is advised to take a tub of warm water and is advised to sit in the tub for about 10-20 minutes, for about 3-4 times a day. This will help in the healing process of the wound, and also help in relaxing the anal sphincter muscles.

d) Stool softeners

d) Medications- topical medications such as lidocaine can be applied around the perianal region in order to get relief from pain. Other topical ointments such as diltiazem, nifedipine, or nitro-glycerine can also be used to give relief to the patient from pain and help in the healing process.

e) Oral medications- the doctor may advise the patient to take painkillers such as paracetamol or ibuprofen in order to give relief to the patient from pain.

f) Botulinum toxic injections- it is relatively a new treatment option available for anal fissures.

• Surgical Treatment

Surgical management is generally suggested for patients who were unresponsive to other treatment modalities. It is considered to be the most effective treatment for anal fissures and the recurrence is usually very low. There are a number of surgical treatment options available to treat anal fissures. They include:

a) Lateral Sphincterotomy- During this procedure, a small incision (cut) is made in the anal of the muscle surrounding the anal sphincter in order to reduce the tension in the anal canal. This procedure is done under spinal anesthesia or local anesthesia. Lateral sphincterotomy is one of the most effective treatments modalities used to treat anal fissures. The patient can get back to their usual routine activities within 2-4 weeks.

b) Advancement anal flaps- This procedure is considered to be a treatment of choice for patients who are suffering from chronic (long-term) anal fissure caused due to injury to the anal canal, or caused by pregnancy. During this procedure, a flap which is involving healthy tissue is taken from the other part of the body is used to repair to anal fissure. By doing this procedure, it will improve the blood supply to the site of the fissure and heels it.

c) Laser Surgery- During this procedure, a thin laser probe is used to heal the anal fissure and remove sentile pile if present.

Complications of Anal fissure

The complications associated with anal fissures are listed below:

• Recurrence
• Scarring
• Failure to heal
• Pain and discomfort
• Fecal incontinence
• Difficulty in bowel movements
• Blood clots

Prevention of anal fissure

Anal fissures can be prevented by following the below-mentioned measures. They are:

• Improve the quality of life
• Intake of a high-fiber diet and an adequate amount of liquid in a day
• Exercise regularly
• Using stool softeners in case of passing hard stools
• Sitz bath at regular intervals
• Keeping the anal area clean and dry
• Treating diarrhea

Reference

1. https://www.nhs.uk/conditions/anal-fissure/
2. https://my.clevelandclinic.org/health/diseases/13177-anal-fissures
3. https://www.mayoclinic.org/diseases-conditions/anal-fissure/symptoms-causes/syc-20351424
4. https://www.healthline.com/health/anal-fissure#symptoms
5. https://www.mayoclinic.org/diseases-conditions/anal-fissure/diagnosis-treatment/drc-20351430
6. https://fascrs.org/patients/diseases-and-conditions/a-z/anal-fissure
7. https://www.nhs.uk/conditions/anal-fissure/treatment/
8. https://www.nhs.uk/conditions/anal-fissure/treatment/
9. https://www.hopkinsmedicine.org/health/conditions-and-diseases/anal-fissures