ANAL FISSURE

What is Anal Fissure?

An Anal Fissure is a painful medical condition, which occurs when the anal canal suffers a tear in its mucosal lining.

The condition can be extremely painful but very manageable with proper care.

As with all causes of rectal bleeding, other serious causes of blood loss must be ruled out with an examination of the bowel, usually a colonoscopy.

Who Does Anal Fissure Affect?

Anal Fissure most commonly affects young children and infants as they are more prone to experience constipation. Anal Fissures can occur at any age and affect both men and women.

How Does Anal Fissure Occur?

An Anal Fissure usually occurs when the mucosal lining of the anal canal experiences extreme stretching, pressure or dilation beyond it's normal limits or capacity.

After the canal is stretched the mucosal tissue experiences a tear in its continuity, leading to severe pain and bleeding.

The dilation can occur due to the:

• Passing of hard stool in any number of conditions that can cause constipation, or
• Insertion of a foreign object into the canal beyond its limit.

Causes Of Anal Fissure?

Anal Fissures can be caused by:

• Chronic constipation,
• Excessive straining due to hard stools and difficult bowel movements,
• Chronic diarrhea,
• Women bearing down during childbirth to deliver the baby,
• Inflammatory bowel disease such as Crohn’s disease,
• Anal intercourse, and
• Syphilis.

It most frequently occurs with the passage of hard or large stools.

Symptoms Of Anal Fissure?

As this lower anal region has a rich nerve and blood supply an Anal Tear can lead to intense anal pain and there is usually some minor blood loss. The symptoms for Anal Fissure include:

• Severe pain, often during bowel movements,
• Pain and tenderness that remains for hours after passing stool,
• Bleeding and bright red blood on toilet paper or stool,
• The patient often reports a fear of going to the bathroom to avoid the pain, and
• The sensation of a skin lump near the anal tear (fissure).

Stages Of Anal Fissure

The Anal Fissure severity is directly proportional to the extent of the tear in the mucosal tissue. The symptoms become more prominent as the fissure worsens.

Patients can have so much pain they become very apprehensive about going to the toilet, This in turn can lead to further constipation and then more damage to the tear when the stools become harder.

Advanced cases can result in spasm of the anal sphincter muscle which then reduces blood flow to the tear and holds the edges of the tear apart. Both of these factors impair healing and many acute anal fissures can go on to become a chronic problem.

How is Anal Fissure Diagnosed?

The diagnosis for Anal Fissure is made by

• Taking a complete history and
• A complete physical examination, which includes an examination of the anal region.

Usually, a diagnosis can be made on the basis of visual confirmation of the fissure. However, the doctor might perform additional tests to determine the cause of the fissure. These tests can include:

• Anoscopy,
• Flexible sigmoidoscopy,
• Colonoscopy.

How is Anal Fissure Treated?

Anal Fissures are very manageable and don’t require surgery if diagnosed very early. Treatment is directed at the factors which impair healing.

Home Management

It is very important to make the stools quite soft, usually aiming for a porridge consistency so that passage is fairly effortless. This most often requires laxatives for at least one month.

Anal Fissures can heal on their own during this period by:

• Increasing fibre intake, fluid intake which ensures softer bowel movements.
• Taking an osmotic laxative such as movicol, Epsom salts or lactulose is quite safe and will not result in any long term bowel problems.
• Anal Spasm in the anal sphincter can be relaxed with heat such as warm salt baths (30 minutes, per day) or using warm water for soaking during a warm shower after going to the toilet as regularly as required.

Non-Surgical Approaches

If the pain remains for extended periods, the doctor might decide to try the following non-surgical therapies:

• Topical analgesic creams such as Lidocaine
• Botox injections to cause sphincter paralysis and help in healing
• Oral nifedipine or diltiazem can also aid in sphincter relaxation, and promote healing

Anal Creams

Application of nitroglycerin externally or glyceryl trinitrate (GTN) to improve blood flow to the anal canal and relaxing the anal sphincter.

This can be applied three times a day but can be associated with a pounding headache due to relaxation of the blood vessels to the head.

It is best to have the first dose when not required to work or drive in case this occurs. Patients should try to minimise getting the cream onto normal external skin to avoid this side effect.

Chronic Anal Fissure Surgery

Most patients can achieve healing of the anal fissure with these steps but if this fails, other surgical treatments can be offered.

A persistent Anal Fissure or Chronic Anal Fissure typically runs for eight weeks or more, and despite treatment does not improve. These can require surgical intervention.

A procedure known as Lateral internal Sphincterotomy (LIS) is performed by a surgeon.

The surgery is designed to aid in the fissure’s healing, reduce local pain and spasms.

What If Anal Fissure Is Untreated?

If left untreated or improperly managed, an Anal Fissure can leave a patient in pain and hinder his daily routine.

Additionally, the patient can experience further occurrences of Anal Fissures and the tear can extend to nearby tissue, requiring additional surgery to provide pain relief and repair the fissure.