Anal Fissure - Symptoms, Causes, Prevention, Treatment
Anal fissures, also known as fissure in ano, manifest as open sores or tears in the anal skin, primarily affecting the outer end of the digestive system. The condition is characterized by painful bleeding during bowel movements, distinguishing it from hemorrhoids, which typically cause painless bleeding. Contributing factors often include trauma during the passage of hard stools, chronic constipation, diarrhea, inflammatory bowel disease, or childbirth. Symptoms encompass sharp pain, described as tearing or burning, and the presence of bright red blood. While home treatments like dietary adjustments, hydration, and topical creams may alleviate milder cases, persistent or chronic fissures may necessitate medical attention. Diagnosis involves a physical examination, and treatment strategies range from lifestyle modifications to surgical interventions, with the goal of relieving pain, promoting healing, and preventing complications such as chronic fissures or infections. Timely intervention is crucial to addressing anal fissures effectively and improving the overall quality of life for individuals affected by this condition.
Fissure in Anal Region
These muscles facilitate the opening and closing of the anus during the passage of stool. Within the anus, there exists a complex network of blood vessels and nerve cells, contributing to its sensitivity and functionality.
Anal fissure, or fissure in ano, represents a specific condition in this region. It is characterized by the formation of an open sore or tear in the anal skin, leading to various discomforts. Unlike piles (hemorrhoids), anal fissures are associated with painful bleeding during bowel movements, adding an additional layer of distress to the individual.
The causes of anal fissures often involve factors such as trauma during bowel movements, chronic constipation, or conditions that affect the gastrointestinal system. The tearing or injury to the anal skin can result in persistent pain, especially during defecation, and may be accompanied by bright red blood.
While some cases of anal fissures can be managed with conservative home treatments, such as dietary modifications, increased water intake, and over-the-counter creams, persistent or severe fissures may require medical attention. Healthcare providers may recommend prescription medications, such as topical ointments containing nitroglycerin or calcium channel blockers, to promote healing and alleviate symptoms.
In cases where conservative measures prove insufficient, and the fissures do not settle, more invasive interventions like sphincterotomy—a surgical procedure involving the partial cutting of the anal sphincter muscles—may be considered. It is crucial for individuals experiencing symptoms of anal fissures to seek medical advice for a proper diagnosis and tailored treatment plan to address this condition effectively.
Reason for Fissure in Anal region
Causes
Certainly, here are more specific causes of anal fissures:
1. Constipation: Difficulty passing stools due to constipation is a common cause of anal fissures. Straining during bowel movements can lead to tears in the anal lining.
2. Hard Stools: Stools that are hard and difficult to pass can contribute to the development of anal fissures, especially when there’s increased pressure on the anus.
3. Diarrhea: Persistent diarrhea can irritate the anal area, making it more susceptible to fissures. The frequent passage of loose stools may lead to inflammation and damage.
4. Anal Trauma: Any trauma to the anal region, whether accidental or intentional, can cause fissures. This includes injuries during activities like cycling or certain sports.
5. Childbirth: Women may develop anal fissures as a result of the trauma experienced during childbirth. The stretching and pressure on the perineum during delivery can lead to tears.
6. Anal Intercourse: Engaging in anal sex, especially without proper lubrication or relaxation of the anal sphincter muscles, can cause trauma and increase the risk of fissures.
7. Inflammatory Bowel Disease (IBD): Chronic conditions like Crohn’s disease or ulcerative colitis, characterized by inflammation of the digestive tract, can contribute to the development of anal fissures.
8. Anal Stricture: A narrowing of the anal canal, known as anal stricture, can increase pressure during bowel movements, potentially leading to fissures.
9. Infections: Infections in the anal area, including sexually transmitted infections, can cause inflammation and damage to the anal tissues, increasing the likelihood of fissures.
10. Underlying Medical Conditions: Certain health conditions, such as HIV/AIDS or compromised immune systems, can weaken the body’s ability to heal and increase the risk of anal fissures.
It’s important to note that a combination of factors, rather than a single cause, may contribute to the development of anal fissures. Identifying and addressing these underlying causes is crucial for effective treatment and prevention of recurrence.
When to Seek Advice?
Absolutely, seeking advice from a healthcare professional, particularly a proctologist, is crucial if you experience symptoms of anal fissures. Here are some specific situations when it’s important to seek medical advice:
1. Persistent Pain: If you are experiencing persistent and severe pain during or after bowel movements, it’s essential to consult a healthcare provider. Chronic pain may indicate an ongoing issue that requires attention.
2. Recurrent Bleeding: If you notice recurrent bright red blood during or after bowel movements, it could be a sign of an unresolved anal fissure. Continuous bleeding warrants medical evaluation.
3. No Improvement with Home Remedies: If home treatments such as dietary changes, increased water intake, and over-the-counter creams are not providing relief or if symptoms persist, professional medical advice is necessary.
4. Frequent Recurrence: If you have a history of anal fissures and the condition keeps recurring, it’s important to consult a healthcare professional. Recurrent fissures may require a more comprehensive approach to prevent further occurrences.
5. Difficulty Healing: In cases where the anal fissure does not seem to be healing or if the symptoms worsen over time, medical intervention is crucial. Delayed healing may lead to complications.
6. Changes in Bowel Habits: Any significant changes in bowel habits, such as the onset of persistent constipation or diarrhea, should prompt a visit to a healthcare provider. These changes can contribute to the development or exacerbation of anal fissures.
7. Presence of Other Health Conditions: If you have underlying health conditions such as inflammatory bowel disease or compromised immune function, it’s important to consult with a healthcare professional to manage the anal fissure in the context of your overall health.
Remember that early intervention can often lead to more effective management and prevention of complications associated with anal fissures. A proctologist or another qualified healthcare provider can conduct a thorough examination, diagnose the underlying cause, and recommend an appropriate treatment plan tailored to your specific situation.
Anal Fissure Symptoms
Symptoms and Signs
Anal fissures are often associated with specific symptoms and signs. Here are some common indicators of anal fissures:
1. Pain During Bowel Movements: The most common symptom of anal fissures is sharp, stabbing pain during and after bowel movements. This pain is often described as intense and can persist for some time after defecation.
2. Bright Red Blood: Anal fissures can cause bright red blood to be seen on toilet paper, in the toilet bowl, or on the surface of stools. The bleeding is typically associated with the tearing of the anal tissues.
3. Itching or Irritation: The anal area may become itchy or irritated due to the presence of the fissure. This discomfort can contribute to a sense of overall anal discomfort.
4. Spasm of Anal Sphincter Muscles: The sphincter muscles surrounding the anus may go into spasm in response to the fissure, leading to additional pain and making it challenging for the tear to heal.
5. Tenderness or Swelling: The skin around the anal opening may become tender or swollen, adding to the discomfort associated with anal fissures.
6. Visible Tear or Sore: In some cases, especially upon close inspection, a visible tear or open sore may be observed in the anal area. However, fissures are not always visible without a thorough examination.
7. Discomfort Between Bowel Movements: Individuals with anal fissures may experience discomfort or pain between bowel movements, as the anal area is sensitive and prone to irritation.
It’s important to note that the severity of symptoms can vary, and not everyone with an anal fissure will experience all of these signs. Additionally, some symptoms, such as bright red blood, can be indicative of other conditions like hemorrhoids, so a proper medical evaluation is essential for an accurate diagnosis.
If you suspect you have an anal fissure or are experiencing any of these symptoms, it’s advisable to consult with a healthcare professional, such as a proctologist or a general practitioner, for a thorough examination and appropriate guidance on treatment and management.
Diagnosis of Anal Fissure
Diagnosis
Your proctologist will ask you about the kind of pain you are experiencing and your toilet habits. They need to perform a rectal examination to check for the presence of an anal fissure. Your proctologist will examine your anal region visually or by gently touching the anal region with the tip of the finger. If you have excruciating pain, please inform your surgeon, and they will not do a proctoscopy. A proctoscopy is done to assess anal disease and find the reason for anal bleeding
Treatment options for Anal Fissure
Treatment
The treatment of anal fissures focuses on reducing the pain and discomfort while passing stools and breaking the cycle of poor healing by increasing the blood flow to the fissure. Your proctologist will first recommend conservative treatments followed by medications. If these treatments do not work, the proctologist will suggest you undergo surgery.[4,9]
Home remedies
- The home remedies listed below would help you get rid of existing fissures and prevent any fissures in the future.
- Sitz bath: Soaking your anal region in a warm tub of water for 15 to 20 min at least twice a day with or without potassium permanganate (KMO4) or Epsom salts helps increase the blood supply to your anal region and relax your anal muscles. This provides pain relief to a great extent, and you must do this regularly to seek pain relief.
- It is important to have a fibre-rich diet. Aim to eat a minimum of 30 grams of fibre in a day, equal to almost two cups of boiled lentils. Consume vegetables, fruits, lentils, and wholegrain products to obtain sufficient fibre.[1,2,18]
- Drink a minimum of eight glasses of water to remain hydrated. Avoid caffeine as it can cause dehydration.
- Exercise regularly.
- Do not hold your stools when you want to go to the toilet. This causes drying or hardening of stools.
Medications
- If the conventional treatments do not work and the fissures recur or do not get treated, your proctologist would recommend the following:
- Over-the-counter medicines like paracetamol or ibuprofen to lessen the pain. These medications work by preventing the nerve cells from sending the pain signal to your brain. So, if your brain does not receive any pain signal, you will not feel the pain.
- Laxatives so that softer stools are formed that are easy to pass.
- Suppositories (medicines inserted into the anus) that will help to reduce any swelling due to fissures.
- Creams or ointments containing nitroglycerine and calcium channel blockers (e.g., diltiazem). These ointments help relax the anal sphincter muscles and increase the blood flow to the fissure region ultimately treating the fissures.
- An ointment containing a local anaesthetic such as lidocaine. This ointment helps to decrease the pain experienced while passing stools.
- Botox injection that contains botulinum toxin type A. When injected in the anal region, Botox injection temporarily paralyses the muscles in the anal area. This helps to reduce the pain and heal the fissure.
Your proctologist may recommend a follow-up after a few weeks of treatment. Depending on the improvement in the condition, your proctologist would take further steps.[
What does Ayurveda have to offer?
- The symptoms and signs of anal fissures mirror those of the Bhagandara condition described in the Ayurvedic literature. There are several Ayurvedic medicines or churns available to soften the stools and reduce constipation.
- Different ayurvedic formulations available to treat constipation are Avipatti churnam, Triphala churna, Pancha Sakar churna, Kalyan guide, and dashmula tail, hingvastaka churna, Sukumaran ghrita, etc.
- Medicinal plants like Isabgol Husk, Sonamukhi (Cassia Angustifolia vahl), and Haritaki (Terminalia Chebula Retz) help to have soft stools when consumed with warm water.[20]
- For managing chronic anal fissures, Ksharsutra therapy is recommended, which contains a mixture of Snuhi latex (Euphorbia nerifolia), Apamarga Kshara (Achyranthes Aspera) and Haridra Churna (Curcuma long). This therapy is considered a gold standard treatment as it is safe, cost-effective, and treats chronic fissures.
Surgery
- When conservative attempts fail, or the fissure is chronic, your proctologist may recommend surgery. The following types of surgeries are available to get rid of anal fissures:
- Anal dilation: In this surgery, the surgeon will manually stretch your anal sphincter muscle. This will help relieve pressure in your anal region and get rapid relief from pain.
- Lateral internal sphincterotomy: In this surgery, the surgeon will make several cuts in the anal sphincter muscles, which help reduce the pressure in the anal region. This facilitates the healing of anal fissures. This surgery is one of the most efficient treatments and causes complete relief within two to four weeks.
- Fissurectomy: In this surgery, the surgeon will remove the edges of fissures and skin tags. Fissurectomy has a high success rate and provides rapid relief from the discomfort due to fissures. Complete healing may take more time than lateral internal sphincterotomy.
- Damage to the anal sphincter muscle during lateral sphincterotomy can cause temporary loss of bowel control. But this is extremely rare, and you will be fully healed within a few weeks after the surgery.
What to Ask and Tell Your Doctors?
- You can ask your proctologist the following questions:
- What are the alternative treatment options for surgery?
- How would it feel after the surgery?
- How many days will it take to recover from the surgery?
- What medications or therapy to continue post-surgery?
- Are there any risks with anal fissure surgery?
- It is crucial that you inform your surgeon of the following before surgery:
- Prescription or non-prescription medicines that you are using
- Your current health issues other than a fissure
- Any history of illness or surgery
- Allergies to any medicine
- Problems that occurred in the previous surgery.
Surgery
Before surgery, the surgeon will administer spinal anaesthesia to you. Spinal anaesthesia helps to numb the anal region. After the surgery, the surgeon will apply a loose outer dressing to your anal area.
Benefits of Fissure in Ano treatment
- Relief from pain in the anal region
- Respite from blood loss, while passing stool
- Surgical procedure Like Lateral internal sphincterotomy– It helps reduce pressure inside the anus that can cause spasms and increases blood flow to the area to help the tissue heal.
- A Fissurectomy for the treatment of patients with an idiopathic noninfected fissure is associated with rapid pain relief and a high success rate even though complete healing may often be delayed
- Laser Sphincterotomy or LASER treatment opts when a patient suffers from a chronic fissure. The advantage of this surgical process is it is minimal -invasive, same day discharge from the hospital, shorter recovery with minimal blood loss
Risk And Delay in the treatment for Anal Fissures
- Delay in diagnosis may lead an acute fissure becoming a chronic one and, thus, becomes more difficult to treat.
- Misdiagnosis of an anal fissure may also allow other conditions to go undetected and untreated, such as serious infections or even cancer.
