Anal fissure

An anal fissure is a small tear in the lining of the anal canal. This type of tear may develop in adults from passing hard or large stools during bowel movements. Anal fissure is also common in infants between 6 and 24 months. Anal fissures are less likely to develop in older children.

The main signs and symptoms of an anal fissure include:

Pain or burning during bowel movements that eases until the next bowel movement
Bright red blood on the outside of the stool or on toilet paper or wipes after a bowel movement
Itching or irritation around the anus
A visible crack in the skin around the anus

Causes of anal fissure include:

  1. Large or hard stool passing through the anal canal
  2. Constipation and straining during bowel movements
  3. Inflammation of the anorectal area, such as is caused by inflammatory bowel disease (IBD)
  4. Anal sex, less commonly

Factors that increase your risk of developing an anal fissure include:

Infancy. Many infants experience an anal fissure during their first year of life, although experts aren’t sure of the reason.
Old age. Older adults may develop an anal fissure partly because of slowed circulation, resulting in decreased blood flow to the rectal area.
Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
Childbirth. Anal fissures are more common in women after they give birth.
Crohn’s disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing.

Anal fissures rarely cause complications. If a fissure fails to heal, it may become chronic, which means it’s present for more than six weeks. Once an anal tear occurs, it may happen again, leading to repeated injury of the tissue. The tear occasionally may go into your internal anal sphincter, a ring of muscle that holds your anus closed except during bowel movements. A tear in the muscle usually causes the muscle to spasm, which widens the tear and hampers healing. An unhealed fissure can result in a cycle of discomfort that may require surgery to reduce the pain and repair or remove the fissure.

For Diagnosis doctor will ask you for your medical history and perform a physical exam, including inspection of the anal region. Often, the tear is visible. Doctor may refrain from performing a rectal exam, which involves inserting a gloved finger or a small instrument into your anal canal, because it may be too painful. However, after your anal fissure has healed and especially if you’ve had rectal bleeding, your doctor may recommend further testing, usually a sigmoidoscopy or colonoscopy, to be sure no underlying disorder such as Crohn’s disease or colorectal cancer caused your anal fissure. Both tests involve inserting a thin, flexible tube into your rectum. A tiny video camera allows your doctor to see inside your rectum and colon. To prepare for either test, you’ll need to clean your colon, which means you need to avoid solid or opaque foods for 24 hours before the test, and you’ll need to take laxatives or enemas as prescribed by your doctor. Most people also choose to have some form of anesthesia during these procedures. If you’re 50 or older, your doctor likely will recommend a colonoscopy, which allows viewing of the entire colon and also serves as a screen for colorectal cancer, another possible cause of rectal bleeding. If you’re younger than 50 and have no risk factors for intestinal diseases or colon cancer, your doctor may recommend the less invasive sigmoidoscopy, which allows viewing of only the bottom portion of the colon.

Anal fissures are fairly common and usually heal without treatment or with nonsurgical treatments. Signs and symptoms may go away within two weeks. If the tear doesn’t heal within six to eight weeks, however, you may need surgery.

For infants, the only intervention necessary may be changing the diaper regularly and keeping the anal area clean. Discuss with your pediatrician ways to avoid constipation and ensure regular bowel movements to prevent your baby from straining.

If lifestyle and self-care measures such as adding more fiber to your diet, drinking more water, getting regular exercise, and taking a stool softener or occasional laxative aren’t effective, your doctor may recommend the following nonsurgical treatments:

Medicated creams or suppositories. Your doctor may prescribe a rectal corticosteroid (Anusol, others) or recommend an over-the-counter cream or ointment containing hydrocortisone (Cortaid, Preparation H) to help reduce inflammation and ease discomfort.

Other nonsurgical therapies. Some doctors recommend applying nitroglycerine ointment to the anus, which widens blood vessels and increases blood flow to the tear, promoting healing. This therapy also helps reduce pressure in the anal sphincter, which eases the spasm and decreases pain, both of which promote healing. The dose of nitroglycerine is small to avoid dangerous side effects. Wash your hands thoroughly after applying the ointment to reduce the amount on your skin even further. Side effects such as headaches, low blood pressure and dizziness may occur. Your doctor may advise you to remain seated or lying down and to avoid exercise immediately after applying nitroglycerin to minimize these side effects. Men shouldn’t use nitroglycerine within 24 hours of taking erectile dysfunction medications such as sildenafil (Viagra), tadalafil (Cialis) and vardenafil (Levitra) because of the possibility of significantly lowered blood pressure.  Another fairly new treatment involves injecting a small dose of botulinum toxin type A (Botox) into the internal anal sphincter. Botox paralyzes the muscle for up to three months, causing the spasm to relax. A possible side effect is temporary, mild leakage of gas or stool (anal incontinence). Blood pressure medications nifedipine (Adalat) and diltiazem (Cardizem), taken orally or ground into a gel and applied to the tear, also have shown some promise.

If you have a chronic anal fissure that won’t heal on its own, doctor may recommend surgery. Surgery usually involves cutting a portion of the anal sphincter muscle to reduce spasm and pain and promote healing. Surgery may also include removal of the fissure and any scar tissue resulting from it.

Surgery is usually done on an outpatient basis. Rarely, cutting the anal sphincter results in loss of ability to control bowel movements.

Lifestyle changes may help relieve discomfort and promote healing of an anal fissure, as well as prevent recurrences:

Add fiber to your diet. You can increase your fiber intake by eating more fruits, vegetables, nuts and whole grains. The recommended amount of fiber is 20 to 35 grams of fiber daily. Most people don’t get that much, so you may want to take a fiber supplement. Bulk-forming laxatives, such as psyllium (Fiberall, Metamucil, others), soften stools and allow them to pass more easily. Adding fiber through either diet or supplementation may cause gas and bloating, so increase your fiber intake gradually.
Drink adequate fluids. Fluids also help prevent constipation, so it’s important to get enough. However, it may be difficult to determine how much is enough for you. If you’re rarely thirsty and your urine looks colorless or very light yellow, you’re probably drinking enough.
Exercise regularly. You can experience a host of benefits by walking or engaging in 30 minutes of another moderate activity most days of the week. Among those benefits are promoting regular bowel movements and increasing blood flow to all parts of your body, which may promote healing of an anal fissure.

Take a bath or a sitz bath. Soaking in warm water for 10 to 20 minutes one or more times a day, especially after bowel movements, will help ease pain and itching. Don’t use soap or bubble bath, as this may irritate the area. Also, avoid using medicated or perfumed wipes because these also may irritate the area.
Avoid straining during bowel movements. Straining creates pressure, which can open a healing tear or cause a new tear.