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Anal Fissure

Anal Fissure

What is an anal fissure?

An anal fissure is a tear in the lining of the lower rectum (anal canal) that causes pain during bowel movements. Anal fissures don’t lead to more serious problems.

 

Most anal fissures heal with home treatment after a few days or weeks. These are called short-term (acute) anal fissures. If you have an anal fissure that hasn’t healed after 8 to 12 weeks, it is considered a long-term (chronic) fissure. A chronic fissure may need medical treatment.

Anal fissures are a common problem. They affect people of all ages, especially young and otherwise healthy people.

What causes an anal fissure?

Anal fissures are caused by injury or trauma to the anal canal. Injury can happen when:

An anal fissure is a tear in the lining of the lower rectum (anal canal) that causes pain during bowel movements. Anal fissures don’t lead to more serious problems.

  • You pass a large stool.
  • You are constipated and try to pass a hard stool.
  • You have repeated diarrhea.
  • You give birth. (Childbirth can cause trauma to the anal canal.)

Fissures can also be caused by a rectal exam, anal intercourse, or a foreign object. In some cases, a fissure may be caused by Crohn’s disease.

Many experts believe that extra tension in the two muscular rings (sphincters) controlling the anus may be a cause of fissures. The outer anal sphincter is under your conscious control. But the inner sphincter is not. This muscle is under pressure, or tension, all of the time. If the pressure increases too much, it can cause spasm and reduce blood flow to the anus, leading to a fissure. This pressure can also keep a fissure from healing.

What are the symptoms?

  • A sharp, stinging, or burning pain during bowel movements. Pain from a fissure may be quite severe. It can be brief or last for several hours after a bowel movement.
  • Itching.
  • Bleeding. You may see a small spot of bright red blood on toilet tissue or a few drops in the toilet bowl. The blood from a fissure is separate from the stool. (Very dark, tarry stools or dark red blood mixed with stool may be a sign of a more serious problem.) Tell your doctor if you have any bleeding with a bowel movement.

Sometimes an anal fissure may be a painless wound that won’t heal. It may bleed from time to time but cause no other symptoms.

How is an anal fissure diagnosed?

A doctor can diagnose an anal fissure based on your symptoms and a physical exam. The exam may include:

  • Looking at the fissure by gently separating the buttocks.
  • A digital rectal exam. The doctor inserts a gloved finger into the anal canal.
  • Anoscopy. This involves using a short, lighted scope to look into the anal canal.

The doctor may wait until the fissure has started to heal before doing a rectal exam or anoscopy. If an exam needs to be done right away, medicine can be used to numb the area.

 

Medications

Topical Anesthetics

A topical medication is one that you apply directly to the area needing treatment. Topical anesthetics work by numbing the skin, which can help alleviate the sharp, intense pain that often occurs with an anal fissure during bowel movements.

Lidocaine is the most frequently prescribed topical anesthetic, available as either a gel or ointment. Typically, it is used for only one to two weeks, as the fissure is expected to start healing within this period. Lidocaine is generally applied just before a bowel movement, but it’s important to follow the specific instructions provided with the medication.

Painkillers

If you experience prolonged, burning pain after bowel movements, your doctor may recommend an analgesic (pain reliever) like paracetamol or ibuprofen. Always follow the dosage instructions on the patient information leaflet or packaging.

Glyceryl Trinitrate (GTN)

If symptoms don’t improve after a week, a medicine called glyceryl trinitrate (GTN) may be prescribed. GTN works by dilating nearby blood vessels, increasing blood flow to the fissure, which helps promote faster healing.

GTN also reduces anal pressure, helping to ease the pain. It is available as an ointment and is typically applied to the anal area every 12 hours. GTN is not recommended for pregnant or breastfeeding women or for children. Headaches are a common side effect, affecting about 50% of users, and some may also feel dizzy or lightheaded.

GTN ointment is generally used for six to eight weeks or until the fissure has fully healed.

Calcium Channel Blockers

Calcium channel blockers are medications typically used to treat high blood pressure, but they can also be helpful for some people with anal fissures.

When applied topically, calcium channel blockers help by relaxing the sphincter muscle and increasing blood flow to the fissure, promoting healing.

Common side effects of topical calcium channel blockers may include:

  • Headache
  • Dizziness, especially when standing up from sitting or lying down
  • Itching or burning at the application site

These side effects usually subside after a few days as your body adjusts to the medication. Calcium channel blockers are generally used only when GTN is not an option, as they aren’t shown to be more effective than GTN.

Botulinum Toxin

Botulinum toxin is a newer option for treating anal fissures and is generally used if other treatments haven’t worked.

Botulinum toxin is a powerful substance that is safe in small doses. For anal fissures, an injection of botulinum toxin can temporarily paralyze the sphincter muscle, preventing muscle spasms and helping to reduce pain so the fissure can heal.

Botulinum toxin has been effective in the short to medium term, with about three-quarters of people remaining symptom-free for up to six months after treatment. However, as symptoms may recur within three years for about half of patients, further treatment may be necessary in the long term.

 

Follow-up

Your GP will typically schedule a follow-up appointment about eight weeks after beginning treatment. This allows them to check whether your fissure has healed or is showing sufficient improvement. If it hasn’t fully healed, they may suggest another follow-up in six to eight weeks.

For more severe fissures or cases that don’t respond to treatment within eight weeks, you may be referred to a proctologist—a specialist in rectal and anal conditions. In such cases, surgical treatment is often recommended.

Surgery

Several surgical techniques can be used to treat an anal fissure. One of these is described below:

Internal Sphincterotomy

An internal sphincterotomy involves removing a portion of the sphincter muscle. This procedure helps reduce muscle tension, preventing further spasms and promoting the healing of the anal fissure.

An internal sphincterotomy is a relatively simple procedure that can be performed under local anesthesia on an outpatient basis, meaning you won’t need to stay overnight in the hospital.

This treatment is highly effective, with about 95% of patients experiencing successful healing of their anal fissure.

However, around 1 in 10 people may experience some bowel incontinence following surgery due to potential damage to the anal muscles. This typically results in a mild loss of control over bowel movements, such as difficulty controlling the passing of gas or occasional mild soiling.

These symptoms usually improve within the first few months after the procedure and typically resolve within two months. In rare cases, approximately 1 in 200, the incontinence may become permanent.

 

Fissurectomy

A fissurectomy is a surgical procedure that involves removing the anal fissure along with the surrounding tissue.

Fissurectomies are less commonly used than internal sphincterotomies because they do not address the underlying causes of the fissure. As a result, a fissurectomy may not prevent the fissure from recurring in the future.

However, a fissurectomy may be a suitable treatment option for children, as removing a portion of the sphincter muscle at a young age could lead to permanent incontinence.

Advancement Anal Flaps

Advancement anal flaps involve taking healthy tissue from another part of the body to repair the fissure and improve blood flow to the affected area.

This technique is often recommended for treating chronic anal fissures, especially those resulting from pregnancy or other injuries to the anus.

During an examination, doctors may also investigate whether another condition could be contributing to the fissure. Multiple fissures or fissures in areas where they are not typically found can indicate more serious issues, such as inflammatory bowel disease or a weakened immune system.

Anal fissures are a common issue that affect people of all ages, particularly young, otherwise healthy individuals.

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