An anal fissure is a ulcer or tear in the longitudinal axis of lower anal canal. It is superficial, small and ends above dentate line. It occurs in midline posteriorly (common in male) but also occur in midline anteriorly (common in female).Acute fissure- deep tear in lower anal skin with severe sphincter spam, presents with severe pain and constipation.Chronic fissure-Fissure fails to heal, got inflamed forms linead indurated chronic ulcer, present with less painful pain.
Causes (Risk Factors)
- Straining during bowel movements due to constipation, hard stools or diarrhea can all tear the anal lining.
- Overly tight or spastic anal sphincter muscles.
- During infancy anal fissures are common, occur in approximately 80 percent of babies during the first year of life, but reasons are unknown.
- During and after childbirth, women are at risk because of the straining during delivery.
- Older adults are also prone to anal fissures due to decreased blood flow in the anorectal area.
- An inflammatory bowel disease ( Crohn’s disease, ulcerative collitis) due to the inflammation in the intestinal lining makes the tissue more prone to tearing.
- Sexually Transmitted Diseases, Tuberculosis
- Visual examination of rectal area- anal fissure can be diagnosed with just a visual exam.
- Anoscope- However there may be a need to insert an anoscope into rectum to see the tear.
With an anal fissure, you may experience one or more of the following symptoms
- A visual tear on the anus mostly on posteriorly but may be anteriorly.
- A skin tag (small lump of skin) next to the anal fissure
- extreme pain in the anal area during bowel movements
- Streaks of blood on stools or on tissue paper after wiping
- Burning or itching in the anal area
Although anal fissures cannot always be prevented, but risk can be reduced with the following guidelines:
- To prevent anal fissures in infants, change diapers frequently
- Keep the anal area dry
- Cleanse the anal area gently
- Avoid constipation by drinking plenty of fluids, eating plenty of fiber, and exercising regularly
- Treat diarrhea immediately
Anal fissures are usually most heal with medical treatment. However, those resistant to treatment may require surgery.Medical treatment:
- Dietary management- adding fiber supplements to diet
- Stool softeners- Lactulose to soften the stool to reduce the staning during defecation.
- Warm baths can relax the anal muscles, relieve irritation, and increase blood flow to the area.
- Topical pain relievers- Lidocaine, applied to the anus can help relieve the pain. There are also over-the-counter ointments, such as Anusol-HC, that can soothe some of the discomfort.
- Calcium channel blocker ointment- Diltiazam ointment that can relax the sphincter muscles and allow the anal fissure to heal.
- Topical nitroglycerin ointment applied to the anus widens the blood vessels in the anus, encouraging blood flow to the area, will also promote healing.
- Botox injections(Botulinum toxin 25 units) into the anal internal sphincter- This will prevent spasms in the anus by temporarily paralyzing the muscle to allow the anal fissure to heal and preventing new fissures toform.
Surgical treatment: Surgical therapy is usually reserved for acute anal fissures that remain symptomatic after 3-4 weeks of medical therapy and for chronic anal fissures which fails to heal and resistant to treatment.
- Lateral internal sphincterotomy: This procedure is either performed using a closed technique or under direct vision, under local or general anaesthesia. In this operation, a small cut is made in internal anal sphincter muscle to the length of the fissure. This procedure has the best healing rate and is the most widely used procedure for anal fissures.
- Fissurectomy: In this procedure anal fissure is removed completely, leaving an open wound to heal naturally. A fissurectomy may needed if patient have an anal fistula as well as an anal fissure.
- Advancement flaps: The advancement flap is a technique that involves replacing the broken tissue in the fissure with healthy tissue. This type of surgery is more complex and is usually only recommended when other surgical options have been unsuccessful.
All kind of surgical procedures are available at Devasya Superspeciality Kidney & Multispeciality Hospital.