What is Anal Fissures?
An anal fissure is a minor tear in the skin near the end of the digestive tract, often resulting in emergency visits to the hospital. These fissures usually occur due to hard stools, constipation, or an injury. They are frequently seen in both adults and kids, particularly in people who often struggle with constipation.
An anal fissure can be acute, which means it lasts less than six weeks, or chronic, meaning it lasts more than six weeks. Most anal fissures happen at the midpoint on the backside of the anal canal. Occasionally, they can also occur at the front midpoint. Fissures in unusual locations are generally due to other medical conditions, which would require further examination.
Diagnosing an anal fissure is usually based on the symptoms and medical history. Various treatments are available for dealing with anal fissures, including medication management and surgical procedures.
What Causes Anal Fissures?
Anal fissures, or small tears in the lining of the anal canal, can occur due to a variety of reasons. Common causes include constipation, long-term diarrhea, sexually transmitted diseases, tuberculosis, diseases that cause inflammation in the bowels, HIV, anal cancer, childbirth, past anal surgeries, and anal intercourse.
Most times, an acute or sudden anal fissure is believed to happen when hard stool is passed, due to a sexually transmitted infection (STI), or because of an anal injury from penetration. These fissures can often become chronic or long-term, especially if the initial cause, such as passing hard stools, continues, or if the anal muscles remain constricted for a long time. When an anal fissure lasts for more than six weeks, it is referred to as chronic.
Conditions like inflammatory bowel disease, tuberculosis, HIV, anal cancer, or past anal surgeries, can make you more susceptible to having both acute and chronic atypical anal fissures. It’s important to note that around 40% of people who experience an acute anal fissure may later develop a chronic anal fissure.
Risk Factors and Frequency for Anal Fissures
Anal fissures can occur in people of all ages, but they are most commonly found in children and middle-aged adults. Both men and women can be affected equally. Each year, around 250,000 new cases are diagnosed in the United States.
Signs and Symptoms of Anal Fissures
Acute anal fissures cause anal pain that worsens during bowel movements and can sometimes involve bleeding, though usually not severe. The pain typically lasts for hours after defecation. It’s critical to differentiate acute anal fissures from hemorrhoids, which may have similar symptoms. Chronic anal fissures, on the other hand, involve long-term painful defecation, potentially with rectal bleeding. Often, these patients have a history of constipation and hard stools. In some cases, people with certain illnesses, such as Crohn’s disease, may experience intermittent rather than constant pain during defecation.
When a patient is examined for an anal fissure, the doctor will place them in the most comfortable position. While the optimal position is lying face down while being bent at the hips, this may not be feasible outside of an operating room. Therefore, having the patient bend over the exam table or lie on their side may be more practical. Health professionals should avoid unnecessary physical manipulation or the use of examination instruments during this process.
In the early stages, an anal fissure may appear as a superficial tear, which may or may not bleed. It can be sensitive to touch, especially in thin patients. In overweight patients, diagnosis may come from pain when gently putting pressure on the anus. In more chronic cases, the tear might be large and deep, exposing muscle fibers. The edges might raise over time due to repetitive damage and healing, and a thick bulge at the tear’s edges, known as a sentinel pile, may form.
Testing for Anal Fissures
If a patient suffers from recurring chronic anal fissures, a medical examination under anesthesia is usually recommended. This can help to identify and sometimes treat the underlying cause of the problem. The evaluation of both acute and chronic anal fissures requires determining if they are primary or secondary.
A primary, or typical, anal fissure is located at the front (anterior) or back (posterior) midline of the anus. An atypical, or secondary, anal fissure can be found at any other place. When a secondary anal fissure is found, it’s important to rule out conditions such as Crohn’s disease right away. However, it’s important to note that patients with Crohn’s disease or other underlying conditions might also develop anal fissures in the typical locations.
Treatment Options for Anal Fissures
Anal fissures are often initially treated using noninvasive methods. These can include regular sitz baths (soaking the affected area in warm water), pain relief medications, stool softeners, and a diet high in fiber. To avoid recurrence of anal fissures, it’s important to stay well-hydrated. If these methods don’t provide sufficient relief, there are other options such as creams or ointments that numb the area, reduce muscle tension, or increase blood flow to aid healing. Out of these, an ointment containing nifedipine is considered best as it not only promotes healing but also has fewer side effects compared to a similar treatment involving nitroglycerin, which often causes headaches and low blood pressure.
When it comes to chronic anal fissures, which are more difficult to treat because of their tendency to recur and other complications, botulinum toxin (Botox) tends to be more effective than nitrates and calcium channel blockers. However, in cases where non-surgical treatments haven’t succeeded, a surgical procedure known as lateral internal sphincterotomy (LIS) may be recommended. This procedure, which involves reducing tension in a specific internal muscle, was found to provide complete resolution for approximately 96% of patients in a study conducted between 1984 and 1996.
As with all surgical procedures, however, LIS comes with some risks. Initially, fecal incontinence (loss of bowel control) is experienced by about 45% of patients, though this generally improves over time. Within five years after the surgery, less than 10% of patients report this issue. Meanwhile, the recurrence of CAF occurs in about 5% of patients after LIS, and can often be managed effectively with drug treatments. Other risks associated with the surgery include excessive bleeding (which occurs more frequently with one type of LIS procedure over the other), and abscess development in approximately 1% of patients.
A long-term, though generally asymptomatic and well-tolerated, consequence of LIS surgery is the development of a deformity in the repair of posterior chronic anal fissures, known as a keyhole deformity. This issue is relatively uncommon, however, and was found to affect only 15 out of over 600 patients in a study. Importantly, it was not associated with anal incontinence, and those affected opted to receive a repair.
What else can Anal Fissures be?
An anal fissure is diagnosed primarily through a physical examination, performed to eliminate other potential sources of rectal discomfort. Hemorrhoids are usually the main cause of rectal pain. However, it’s important to note that only external hemorrhoids are painful, especially when they have blood clots in them.
Patients may also experience soreness due to perianal abscesses, which are pockets of infection that cause painful bowel movements and may bleed. These abscesses can sometimes develop into anal fistulas, or small channels, which can bleed or drain pus.
Conditions like sexually transmitted infections, inflammatory bowel disease or tuberculosis can result in ulcers around the anus. Moreover, there’s a rare condition known as solitary rectal ulcer syndrome (SRUS) – although its cause is unknown, it can also cause discomfort and is usually identified via sigmoidoscopy, a type of lower bowel examination, a few centimeters from the anus itself.
What to expect with Anal Fissures
Acute anal fissures generally improve through non-invasive treatments and usually heal within several days or weeks in patients without high-risk conditions. However, some patients may eventually develop chronic anal fissures (CAF), needing medication or surgical treatment. It’s worth mentioning that more than 90% of patients who go through surgery are completely healed within 3 to 4 weeks after the operation.
Possible Complications When Diagnosed with Anal Fissures
Anal fissures can lead to a variety of complications, these include:
- Bleeding
- Pain
- Infection
- Incontinence
- Fistula formation, which is the most serious complication
Preventing Anal Fissures
Those experiencing anal fissures should be informed about the importance of certain lifestyle modifications. These include maintaining a diet high in fiber, using stool softeners, and avoiding constipation. These measures can help manage symptoms and promote healing.
