Everything you wanted to know about Anal Fissure.
What is an Anal Fissure?
How do we get an Anal Fissure?
What are the Risk Factors for Anal Fissure?
What are the Types of Anal Fissure?
What are the Symptoms of Anal Fissure?
What are the Signs of Anal Fissure on physical examination?
What are the Treatment Options for Anal Fissure?
What are the Medical Treatment for Anal Fissure?
What are the Surgical Treatment for Anal Fissure?
What is the Post Operative Care following Surgery for Anal Fissure?
WHAT IS AN ANAL FISSURE?
An Anal Fissure, also known as Fissure-in-Ano, is a small tear or cut in the thin skin lining the external opening of the anal canal.
Initially it usually involve only epithelium, but if left untreated. involves the full thickness of anal mucosa.
Anal fissure develop with equal frequency in both sexes; tend to occur in younger and middle aged persons.
HOW DO WE GET AN ANAL FISSURE?
Common Cause of Anal Fissure:
Passing Hard Stools.
Passing large amount of stool.
Persistent watery stools or diarrhoea.
Less Common Causes of Anal Fissure:
Inflammatory Bowel Disease like Chron’s Disease.
WHAT ARE THE RISK FACTORS FOR ANAL FISSURE?
Injury to the anal mucosa can happen when:
- You pass a large and hard stool
- You are constipated and try to pass a hard stool
- You have repeated diarrhea
- You gave birth (childbirth can cause trauma to anal canal)
- Any foreign body entering into the anal canal
- In some cases, due to Crohn’s disease
TYPES OF ANAL FISSURE
Anal Fissure are usually of Two Types:
- Acute Anal Fissure: Anal Fissures of Recent Onset.
- Chronic Anal Fissure: Anal Fissures lasting for more than 8 to 12 weeks.
Location of Anal Fissure:
Most Anal Fissures, about 85%-90% are located in the Posterior Midline or 6 O’ clock position.
About 10%-15% are located in the Anterior Midline or 12 O’ clock position.
Few patients will have fissure in both 6 & 12 O’ clock position.
Fissures which are located off the midline, to the sides, should raise suspicion of some other underlying disease and should be investigated further.
WHAT ARE THE SYMPTOMS OF ANAL FISSURE?
Symptoms of anal fissure may include:
- Pain, sometime severe, during bowel movement. Pain from a fissure may be quite severe. It can be brief or last for several hours during a bowel movement.
- Burning or Itching sensation in the anal canal, which can sometimes last for quite sometime after passing stools.
- You may see a small spot of bright red blood on toilet paper or a few drops in the toiled bowel. The blood from the fissure is separate from the stool.
- A visible crack in the skin around the anus
- A small lump or skin tag on the skin near the anal fissure
- Sometime an anal fissure may be a painless wound that won’t heal. It may bleed from time to time but cause no other problem.
WHAT ARE THE SIGNS OF ANAL FISSURE ON PHYSICAL EXAMINATION?
A doctor can diagnose an anal fissure based on your symptoms and a physical examination. The examination may include:
- Looking at the fissure by gently separating the buttocks.
- A digital rectal examination, in which the doctor inserts a gloved finger into the anal canal.
- Initially, a fissure is just a tear in the anal mucosa and is defined as an acute anal fissure. If the fissure persist over time, it progresses to chronic fissure, and often, an enlarged anal skin tag is present in the anal canal proximal to the fissure and hypertrophied anal papillae are present in anal canal proximal to fissure.
- Most anal fissures occur in the posterior midline, with remainder occurring in the anterior midline. About 2% of the patients have anterior and posterior fissures.
- Fissures occurring off the midline should raise the possibility of other bowel conditions (for example Crohn's disease), infection (for example sexually transmitted diseases or AIDS), or cancer.
- Anoscopy: This involves using a short, lighted scope to look into the canal.
WHAT ARE THE TREATMENT OPTIONS FOR ANAL FISSURE?
Majority of the Anal Fissures will not need any surgical treatment.
Lifestyle modifications like High Fibre Diet, Stool Softeners, Increasing water intake to promote soft bowel movements, Warm Sitz Bath, Local application of appropriate ointments will usually promote the healing of the Anal Fissure.
Chronic Anal Fissures and very rarely certain Acute Anal Fissures not responding to medical therapy, will need surgical treatment.
WHAT ARE THE MEDICAL TREATMENT FOR ANAL FISSURE?
Initial therapy for an anal fissure is medical in nature and more than 80% of acute anal fissures resolve without further therapy. The goals of the treatment are to relieve the constipation and to break the cycle of hard bowel movement, associated pain, and worsening constipation. Softer bowel movements are easier and less painful for patient to pass.
First line of treatment consists of therapy with stool-bulking agents, such as fiber supplementation and stool softeners. Laxatives are used as needed. Mineral oil may be added to facilitate the passage of stool. Sitz baths after bowel movements and as needed to provide significant symptomatic relief.
Second line medical therapy consists of intra-anal application of 0.4% nitroglycerin (NTG; also called glycerol trinitrate) ointment directly to internal sphincter. NTG is approved by US food and drug administration (FDA) for moderate to severe pain associated with anal fissure and may be considered when conservative therapies have failed.
WHAT ARE THE SURGICAL TREATMENTS FOR ANAL FISSURE?
There are various Surgical Treatment options for Anal Fissure.
The most commonly performed surgery is a Lateral Internal Sphincterotomy.
Certain Chronic Fissure which may not heal completely with a Lateral Sphincterotomy, will need an Excision of the Fissure with cover of the defect by an Advancement Flap. This is done to ensure that the wound heals quickly and does not result in any narrowing of the anal canal opening.
LASERS IN THE TREATMENT OF ANAL FISSURE:
Lasers can be also used as a modality in the treatment of Anal Fissure.
WHAT IS THE POST OPERATIVE CARE FOLLOWING SURGERY FOR ANAL FISSURE?
- Try to avoid constipation
- Include fruit, vegetables, beans, and whole grains in your diet every day. These foods are higher in fiber.
- Drink plenty of fluids.
- Get some exercise every day.
- Take a fiber supplement, every day if needed.
- Do not strain when you have bowel movement and do not sit on toilet too long.
- Take Sitz baths 2 to 3 three times every day.
- Instead of using toilet paper, use baby wipes or medicated pads.