Anal Fissures

Anal Fissures

An anal fissure is a tear in the skin surrounding the anus (passage that passes out the stool). Anal fissures are uncomfortable and painful which gets worse during or after defecation. At times, the anal fissure may bleed a bit. These fissures may occur in adults or in children.
Anal fissures most often heal by themselves within a few weeks.
 
What causes anal fissures?

An anal fissure may occur due to many reasons:
  • Irregular bowel habits and straining at stools
  • Frequent diarrhoea
  • Severe constipation
  • Straining during child birth
  • Over tight anal sphincter muscles
  • Injury to the anal canal
 
The rare causes for anal fissure include:
  • HIV
  • Syphilis
  • Anal cancer
  • Tuberculosis
  • Herpes infection 

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What are the signs and symptoms?
  • Pain around the anus during and after bowel movements
  • A small lump / tag near the torn skin
  • A visible tear around the anus
  • Burning or itching sensation in the anal region
  • Blood marks on outside of stool or tissue paper
  • Spasm of the anal muscles and difficulty in passing stools

What are the treatment options?
 
Preventing constipation will help anal fissures heal and prevent them recurring in the future.

  • Increase your daily intake of fibre with foods such as fruit, vegetables and whole grains
  • Avoid dehydration by drinking plenty of water
  • Exercise regularly
  • Have regular toilet habits and do not delay going to the toilet when you feel the urge
  • Use toilet paper that is soft and does not have alcohol  
  • Soak your bottom in a warm bath (Sitz bath) to relax the muscles in your anus
  • Use stool softeners that are available over the counter in the pharmacy 

Medications

There are a number of different medications your doctor may recommend to help with your symptoms and allow the fissure to heal.

Laxatives: Bulk-forming laxative tablets or granules work by helping your stools retain fluid, making them softer and less likely to dry out.

Painkillers: Painkillers will be prescribed if you experience prolonged burning pain after passing stools.  

Glyceryl trinitrate: For symptoms that do not settle, glyceryl trinitrate (GTN) ointment can be applied directly to the anal area, usually twice a day. GTN works by expanding blood vessels in and around the anus, which helps to increase the blood supply to the fissure, helping it heal faster. It can also help reduce the pressure in your anal canal, which should help ease the pain.
Headaches are a common side effect of this type of ointment and some people may feel dizzy or lightheaded after using GTN. It should be used with caution in women who are pregnant or breastfeeding.

Topical anaesthetics: Topical anaesthetics will help with severe anal pain to numb your anus before passing stools.
Lidocaine is the most commonly prescribed topical anaesthetic for anal fissures. It comes in the form of either a gel or an ointment.

Calcium channel blockers: Calcium channel blockers, such as diltiazem applied topically to the anus have proved useful in treating some people with anal fissures. It works by relaxing the sphincter muscle and increasing blood supply to the fissure.

Botulinum toxin injections: Botulinum toxin is a relatively new treatment for anal fissures that is used if other medications do not help. An injection of the toxin will paralyze your sphincter muscle which prevents the muscle going into a painful spasm. This reduces pain and allows the fissure to heal.

The effect of an injection lasts for around two months, during which time the fissure will heal.

When will you be advised surgery?

Surgery will be advised when nonsurgical treatment treatments fail to heal the condition. The types of surgery are:
  
Lateral sphincterotomy

A lateral sphincterotomy involves making a small cut in the ring of muscle surrounding the anal canal (sphincter) to help reduce the tension in your anal canal. This allows the anal fissure to heal and reduces your chances of developing any more fissures. The procedure is simple and carried out under general anaesthesia on a day care basis.

Side effects (seen in 5%) is a temporary loss of bowel control as a result of damage to the anal muscles. The person is unable to prevent passing wind but this usually lasts only a few weeks.

Advancement anal flaps

This is used to treat chronic anal fissures caused by injury to the anal canal or caused during pregnancy. Healthy tissue from another part of your body is used to repair the fissure and improves the blood supply to the site of the fissure.

What can you expect post-surgery?

After the surgery, one may experience some pain and discomfort that can be controlled with analgesics and will reduce rapidly. Inform your doctor if there is
  • Increasing pain, redness, discharge or swelling
  • A persistent fever of greater than 101°F with chills
  • Nausea or vomiting
  • Constipation for more than 3 days even after using a laxative
  • Severe bleeding
  • Difficulty in passing urine

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