An anal fissure is a tear in the lining of the anal canal. Anal fissures normally occur when passing a very hard stool, but may occur with other conditions. Anal fissures typically cause anal pain and bleeding. They are one of the most commonly diagnosed anorectal conditions. Because of their overlapping symptoms with hemorrhoids, they are also frequently misdiagnosed. Timely evaluation and treatment by properly trained colon and rectal specialists often results in the healing of fissures without the need for surgery.
Causes of Anal Fissure
Anal fissures are caused by a combination of factors, generally beginning with excessive tension on the anal skin from a hard stool resulting in tearing. Sometimes, patients may have tight sphincter muscle tone predisposing to tearing. It is currently unclear to researchers whether the relationship between sphincter tone and fissures is cause and affect. What is known is that many patients exhibit increased tone with their fissures. Additionally, many therapies are aimed at decreasing the sphincter tone to achieve healing.
Some scenarios where anal fissures occur include:
- Patients experiencing constipation
- Women giving birth vaginally with or without episiotomy
- Patients with irritated perinatal skin
- Excessive spreading of the buttocks
- Excessive or vigorous wiping or cleaning of the anus
- Patients with other conditions such as Crohn’s disease, HIV, or dermatologic disorders
Anal Fissure Symptoms
While anal fissures may be caused by a variety of things and occur in a widely diverse variety of people, they’re typically marked by the same symptoms. Symptoms of anal fissure include:
- Fresh blood on toilet paper, on the stool, or in the toilet water
- Sharp or burning pain when passing stools, especially firm ones
- Soreness or aching following stools
- A feeling of tightness or spasm of the anus
- A feeling of the stool being too large to pass
- Itching or irritation of the anus
- A visible crack or ulceration in the skin around the anus
- A protruding tag, or small tag at the lower edge of the tear
Anal fissures can happen to anyone, and most anal fissures are short-lived and easily resolve with simple treatments, like stool softeners and increased fiber and fluid intake. Patients with fissures that fail to resolve may develop increasing pain and anal spasm. Fissures that have lasted beyond 6-8 weeks may exhibit a small anal skin tag. Generally speaking, the longer a fissure lasts, the more likely a surgical treatment becomes necessary. If left unresolved, anal fissures can develop complications like abscesses, fistulas, and chronic tightening of the anus (anal stenosis) and can become more difficult to heal and more likely to recur. It’s vital that a patient seek professional advice if an anal fissure is identified or suspected.
Diagnosing an Anal Fissure
The first step in confirming an anal fissure diagnosis is a visual examination. This can usually be confirmed with a simple and comfortable office examination. Depending on the patient’s history, a physician might or might not request special testing such as a colonoscopy or sigmoidoscopy, or measurement of the anal tone with manometry. Anal fissures are typically classified as acute when they resolve, or can be expected to resolve, within a few weeks. Chronic fissures are those that persist for longer than about six weeks with or without treatment.
Safe, Effective Treatment
Most anal fissures are acute and short-lived, and can be managed fairly easily with simple treatments. Warm soaks are nearly always recommended, which can both help prevent infection of the site and help to relax the sphincter muscles. Diet changes typically include increasing fiber intake and possibly prescription of laxatives or other stool softeners to prevent constipation.
Topical cream options like Nitroglycerin, Diltiazem and Nifedipine are often effective in treating anal fissures. They represent the first line and mainstay of non-operative management of fissures. Patients apply the cream to the anal canal. The medication is effective at lowering the anal tone to promote healing. Healing is observed in up to 60% of patients in 3-9 weeks. Nitroglycerine has been largely replaced by Diltiazem and Nifedipine because they are better tolerated without producing headaches. Recurrences may be common, especially if constipation remains an issue.
Botox injections under sedation have been used to relax the sphincter muscles, in order to increase blood flow and speed healing. This similarly results in 60-80% success by 3-9 weeks. However, recurrences, as well as the need for sedation, have tempered the use of Botox for this indication. A trip to the operating room is usually required to perform the treatment.
For chronic anal fissures, ones with large tags, or complicated cases, surgical intervention is typically the most effective option. Additionally, patients who do not tolerate cream application or have other conditions like hemorrhoids that require surgery are candidates. The most commonly used procedure for resolving chronic or recurring anal fissures is the lateral internal sphincterotomy, a procedure where the internal anal sphincter is loosened by being partially cut. This increases blood flow to the site of the fissure to speed healing and also decreases the resting amount of tension in the internal anal sphincter. The fissure site itself then heals once any scar tissue and tags are removed. Success for healing is expected in around 90-100% of cases. Recurrence is around 10%. Surgical complications may include an increase in the leakage of gas or liquid stool. This may be seen in up to 15% of patients. Many such cases improve on their own with time. Sphincterotomy is most appropriately applied to patients with increased tone.
Patients with fissures who do not have signs of increased tone, or who have had prior anorectal surgery or sphincter damage (from vaginal birth deliveries or surgery), may benefit from other surgical procedures. One such procedure involves bringing fresh tissue into the anal canal to create space and cover the fissure (anoplasty). Removal of the scar tissue around the fissure may be appropriate without sphincterotomy as well. Preoperative testing with manometry and a review of any prior anorectal surgical procedures may be appropriate in some cases.
Evaluation and consultation with a board certified colon and rectal surgeon experienced with each option is essential in choosing the treatment modality that maximizes the chances of healing, while minimizing recurrence and complications.
Your Comfort During Recovery
Acute anal fissures typically resolve fairly quickly, but communication with your physician about your comfort is vital, since pain and irritation need to be managed and can be indicators of a failure to heal or of recurrence. Often patients experience acute fissures with hemorrhoids, and office management of the hemorrhoids in addition to topicals for the acute fissures deliver fast and safe relief.
For chronic anal fissure patients who receive surgical intervention, cases are monitored closely by a proctology specialist to ensure the healing of the fissure site and for maximum control of any side effects. Surgery is an outpatient procedure, and long lasting local aesthetics (Exparel) are typically used. Patients can expect to recover over 4 to 8 weeks, and most are out of work for about 10 days.
An experienced approach to fissures realizes that each patient is unique and may require different care. We have found that office management of fissures as the initial line of therapy often minimizes the need for surgery. In cases that fail to heal, a conservative surgical approach in both patient and procedure selection yields optimal results and minimizes complications and recurrences.
The Great Outlook with Saleeby & Wessels Expert Treatment
When you want to ensure that a health issue is resolved as quickly and painlessly as possible, the best thing you can do is open a dialogue with a trusted professional right away. At Saleeby & Wessels, we know that the right way to practice medicine is to put the patient first, so we work hard to create a safe and comfortable environment for you and all of our proctology patients. Let us make sure that your case is handled safely, conveniently, and confidentially, by the best and most highly-qualified proctology professionals in the region. Give us a call at (919) 636-3803 to ask questions or schedule an appointment today.