What Is An Anal Fissure? What Causes An Anal Fissure?

An anal fissure is an anal tear, crack or ulcer in the lining of the anal canal - a cut or tear in the anus that extends into the anal canal. It is a common cause of red blood in the stool (feces) and toilet paper. According to rectal (colorectal) doctors, approximately one tenth of all their patient visits are for anal fissures. Patients commonly feel pain during and after a bowel movement.

Although most anal fissures are less than one centimeter across, the anus is an extremely sensitive part of the body, pain symptoms tend to be worse than one would expect from such a small tear.

Anal fissures can affect people of any age or sex equally. It is the most common cause of rectal bleeding in babies and children. Some children may find the sight of bright red blood in stools and toilet paper distressing.

In most cases, anal fissures resolve without the need for medical treatment or surgery. Topical creams and/or suppositories and OTC painkillers may help with symptoms. Some people, however, may experience chronic (long-term) problems if the lesion fails to heal properly.

According to Medilexicon's medical dictionary:

An anal fissure is a crack or slit in the mucous membrane of the anus, very painful and difficult to heal.

An anal fissure that lasts less than six weeks is called an acute anal fissure. A chronic anal fissure has symptoms for longer than six weeks. A primary anal fissure has not identifiable cause, while a secondary anal fissure does have an identifiable cause.

What are the signs and symptoms of an anal fissure?

The patient feels and describes a symptom, while other people, including the physician or nurse detect a sign. For example, headache may be a symptom while dilated pupils may be a sign.The main signs and symptoms of an anal fissure include:

• Pain - especially when going to the toilet (passing stools). During the passing of a stool the pain is sharp, and then afterwards there may be a longer deep burning sensation.
  
  Fear of pain may put some patients off going to the toilet, increasing their risk of having constipation. Unfortunately, after delaying going, when the person does go there is likely to be more pain and tearing because the stools will be harder and larger.
  
  Some people may experience a sharp pain when they clean themselves with toilet paper.
• Blood - because the blood is fresh, it will be bright red and may be noticed on the stools or the toilet paper. Anal fissures in infants commonly bleed. Children may be alarmed at the sight of bright-red blood in their stools or toilet paper.
• Itching - in the anal area. The sensation may be intermittent or persistent.
• Dysuria - discomfort when urinating (less common). Some patients may urinate more frequently.
• Pus - a malodorous (bad smelling) discharge of pus may come from the anal fissure.

What are the causes of anal fissure?

• Constipation - large, hard feces (stools) are more likely to cause lesions in the anal area during a bowel movement than soft and smaller ones.
• Muscle spasms - experts believe that anal sphincter muscle spasms may increase the risk of developing an anal fissure. A spasm is a brief, automatic jerking muscle movement, when the muscle can suddenly tighten. Muscle spasms may also undermine the healing process.
• Pregnancy and childbirth - pregnant women have a higher risk of developing an anal fissure towards the end of their pregnancy. The lining of the anus may also tear during childbirth.
• STIs (sexually-transmitted infections) - also known as STDs (sexually transmitted diseases) are linked to a higher risk of having anal fissures. Examples include syphilis, HPS (human papilloma virus), herpes and Chlamydia.
• Underlying conditions - some underlying conditions, such as Crohn's disease, ulcerative colitis and other inflammatory bowel diseases may cause ulcers to form in the anal area.
• Anal sex - can sometimes cause anal fissures (rare).

How is an anal fissure diagnosed?

A doctor, often a GP (general practitioner, primary care physician) will usually be able to diagnose an anal fissure after a physical examination of the anal area. If nothing is visible, gentle pressure onto the anal area will usually result in pain if there is an anal fissure.

Rectal exam - this involves inserting a gloved finger or small instrument into the rectum. Usually, however, the GP will not do this because it may cause too much pain. A specialist may apply anesthesia to the area before a rectal exam.

If the GP suspects there may be something more serious, the patient will be referred to a specialist.

Sigmoidoscopy or colonoscopy: a rigid or flexible viewing tube is used to inspect inside the anus and rectum. This diagnostic test may be ordered if the doctor wants to rule out a more serious disease of the anus.

What are the treatment options for an anal fissure?

In most cases an anal fissure will resolve within a few weeks. The doctor may recommend some medications to relieve symptoms of pain, burning or discomfort.

If the patient is suffering from constipation, a laxative may be prescribed. The individual will also be encouraged to increase his/her dietary fiber intake, which will help soften the stools. The National Health Service (NHS), UK says that adults should aim for at least 18 grams of fiber each day.

There is a risk of stomach cramps, wind, bloating and diarrhea if the fiber intake increase is rapid and too high. The increase should be done gradually.

The patient should make sure he/she is drinking plenty of fluids, preferably water.

Pain - the doctor may recommend a topical anesthetic. Topical means it is applied directly onto the skin. For the prolonged burning sensation after going to the toilet, Tylenol (paracetamol) or ibuprofen may help (ask your doctor or pharmacist). Some patients find that a warm (not too hot) bath helps relax the muscles and ease pain.

GTN (glyceryl trinitrate) - this medication helps speed up lesion healing by dilating the blood vessels in the area. The doctor may prescribe this medication if healing is slower than expected.

Calcium channel blockers - a medication originally designed to bring down high blood pressure; it also relaxes the sphincter muscle, as well as increasing the supply to blood to the affected area (which speeds up healing).

A steroid cream/ointment - will reduce inflammation around the lesion, which may help with symptoms of itching and pain.

Botulinum toxin (Botox) - used successfully for many disorders with muscle spasms.

Surgery - if the fissure is chronic (long-term) and does not heal, surgery may be an option.

A portion of the anal sphincter muscle is surgically removed, resulting in fewer and less severe spasms - this procedure is known as Internal sphincterotomy. According to the National Health Service (NHS), UK, about 95% of patients who undergo this procedure have good results.

A fissurectomy is the surgical removal of the fissure - this procedure is rare and may be used in children.

Preventing anal fissure

• Keep your stools soft - eat a well balanced diet with plenty of fiber. Make sure your fluid/liquid intake is adequate - remember that water is the best fluid.
• Don't delay going to the toilet - when you feel like going.. go! Don't put it off. If you do, the stools that eventually come through will be larger and harder.
• Babies - frequent diaper (UK: nappy) changes can reduce the risk of anal fissures developing in babies.
• Wiping - if you are susceptible, use moistened cloths or cotton pads to clean yourself after going to the toilet. Don't use rough and/or perfumed toilet paper.
• Exercise - regular exercise can reduce the risk of developing constipation, resulting in less risk of anal fissures. Make sure you are well hydrated during and after exercise (plenty of fluids).
• Straining - avoid straining and sitting in the toilet for a long time. If you like reading in the toilet and are susceptible to anal fissures, you may have to seriously consider not bringing any reading material with you to the toilet.