Medical condition characterized by tear in the anoderm, sensitive lining of the anus or the anal canal is known as anal fissure. Fissures can develop in any one irrespective of age and sex. The posterior part of the anal canal that is less supported by the anal sphincters is at high risk of fissures. In women even the anterior region may develop fissures. If the fissures develop at other locations in the anal canal then it is an indication for the presence of even more serious conditions such as anal cancer, leukemia, Crohn’s disease or an infectious disease such as HIV, Syphilis or gonorrhea. Rectal bleeding observed during infancy primarily develops due to fissures.
Types of anal fissures
- Acute fissures: Fissures that heal within few days or weeks are known as acute fissures.
- Chronic fissures: Fissures that do not heal even after six weeks are considered as chronic fissures.
Causes for development of anal fissures
After knowing what is fissure, let us see the factors ripping the anoderm lining the anal canal.
- Passing hard stools repeatedly.
- Persistent diarrhea.
- Insertion of devices such as rectal thermometer, endoscope, ultrasound probe or a enema tip.
- Tearing of perineum during labor may extend into the anoderm.
- Traumatic labor.
- Anal intercourse.
Risk factors for development of anal fissures
- Lowered blood circulation observed in old people.
- Delivering the baby.
- Crohn’s disease.
Symptoms of anal fissures
- Severe long lasting pain that develops during defecation.
- Constipation may develop in patients who avoid emptying bowels out of fear of pain.
- Discomfort while urinating.
- Itching of the anus.
- Yellowish pus discharge from the fissures.
Acute fissure that is left untreated may become chronic. In few cases, fissures keep recurring or the unhealed fissure may extend to the surrounding healthy tissue that further delays the healing process. Fissures do not cause complications but cause severe pain while emptying the bowels and also do not heal fast.
Reasons for poor healing of fissures
- Spasm of the internal anal sphincter after bowel movement that further cuts the anal fissure.
- Comparatively low blood supply to the posterior part of anal canal.
- Poor blood supply: Spasm of the internal anal sphincter creates pressure in the anal canal compressing the blood vessels and thereby reducing the blood supply to the posterior anal canal.
Treatment of anal fissures
Knowing the history of symptoms and careful observation of the anus reveals presence of anal fissures. If the anal fissure cannot be identified by examining through the anus, then the anal canal is examined by endoscopy after giving a local anesthetic. Sigmoidoscopy, colonoscopy and anal manometry may be performed if the physician suspects of more serious condition in addition to anal fissures.
As the spasm of anal sphincter is preventing the healing of fissures, treatment mainly aims at relieving the anal sphincter to normal resting level. Surgical or non surgical treatment methods are chosen depending on the severity of the condition.
Non-surgical fissure treatment
Mild cases can often be treated by using a conventional treatment strategy within four to six weeks. 80% of the acute cases and about 40% of chronic cases get healed through this conventional treatment.
- Softening the stools: Mild cases can be treated by softening and increasing the bulk of the stools. For this stool softeners, fiber supplements and fiber rich foods such as fruits and vegetables should be taken. Patient is also recommended to increase the fluid intake and avoid foods that are hard to digest.
- Maintaining healthy bowel habits: Making a daily routine to pass the stools will help avoid irregularity. Do not rush to finish defecation process as it causes straining increasing the risk for fissures.
- Sitz baths: Taking sitz bath immediately after emptying the bowels helps relax the internal anal sphincter. This avoids further tearing of the anoderm from the pressure exerted by spasm of anal sphincter. Sitz baths also aid in increasing the blood supply to the anus.
- Topical anesthetics: Creams such as lidocaine, tetracine help reduce the pain after passing the stools. Steroids contained in these creams also aid in reducing inflammation. Do not use these steroid creams for more than two weeks as steroids result in thinning of the anoderm increasing the risk for further trauma.
- Nitroglycerin creams: Nitroglycerin present in these creams serves as a muscle relaxant and reduces the pressure exerted by anal sphincter. It also aids in improving the blood supply to the anal canal. Relaxation of the anal sphincter and improved blood supply together aid in faster healing of fissures.
- Calcium channel blocking drugs: Calcium channel blocking drugs such as nifedipine relax the spasms of anal sphincter and expand the blood vessels. This increases blood supply to anal canal and promotes faster recovery. These drugs also pose less risk for side effects.
- Botulinum toxin: This toxin serves as a muscle relaxant and eases the spasms of internal anal sphincter. Though the toxin gives desirable results it is associated with the risk of weakening the sphincter muscles and is also a very expensive procedure. A weakened anal sphincter causes considerable degree of incontinence of stools.
A specific non surgical procedure has to be chosen depending on the severity of the disease, cost of the treatment and risk of side effects associated with a specific treatment process.
Precautions to be followed for non-surgical treatments
Be cautious about the dosage of nitroglycerin cream being used. Nitroglycerin causes side effects such as lightheadedness and headache. Hence, very small amount of nitroglycerin cream should be used before going to bed to avoid the risk of falling due to lightheadedness. Avoid applying nitroglycerin cream for about thirty minutes after taking bath with warm water.
Surgical fissure treatment
Fissures that cannot be treated by non surgical procedures are treated surgically.
- Partial lateral internal sphincterotomy: This is the commonly used surgical procedure for treatment of fissures. In this procedure the anal sphincter is cut at the distal end close to the anus so as to reduce the pressure of sphincter. The cut is extended in to anal canal for a length equivalent to the anal fissure. It should be remembered that surgery does not heal the fissure but it only cuts the sphincter so as to aid in faster healing of the fissure. Fissure heals on its own even after surgery.
- Anal advancement flap: In this surgical procedure the damaged edges of the fissure are removed and the healthy tissue is sutured.
Surgery should be performed by experienced surgeon as extensive scarring at the end of the fissure results in anal stenosis, a condition that obstructs the passage of stools. Surgical treatment is reported to give high success rate and recurrence rate is also very low.
After undergoing the surgery few patients fail to control the passage of gas or stools for a certain period of time. The possibility of incontinence is observed only in 8% of the cases.