Last updated date: 08-Feb-2023
Medically Reviewed By
Medically reviewed by
Dr. Lavrinenko Oleg
Originally Written in English
All you need to know about Anal Fissures
What is Anal Fissure?
An anal fissure is a small cut or tear in the inner wall of the anus. During and after a bowel movement, the crack in the skin can cause severe pain and some bleeding. Sometimes the fissure can be deep enough to expose the underlying muscle tissue. Anal fissure is not usually serious. It can affect people of all ages and is common in infants and young children, because constipation is a common problem in these age groups.
In most cases, the tear will heal on its own within four to six weeks. In the case where the fissure persists for more than eight weeks, it is considered chronic.
Certain treatments can promote healing and help relieve discomfort, including stool softeners and topical pain relievers. If these treatments do not improve the anal fissure, you may need surgery. Or your doctor may need to look for other underlying diseases that may cause anal fissures.
What are the symptoms of Anal fissure?
An anal fissure may cause one or more of the following symptoms:
- A visible tear in the skin around the anus.
- A skin tag or small bump near the tear.
- Severe pain in the anal area during defecation.
- Blood on the stool or toilet paper after wiping.
- Burning or itching in the anal area.
What causes an Anal Fissure?
An anal fissure most often occurs after passing hard stool. Chronic constipation or frequent diarrhea can also tear the skin around the anus. Other common causes include:
- Straining during delivery or defecation.
- Inflammatory bowel disease (IBD), such as Crohn's disease.
- Reduced blood flow in the anorectal area.
- Hypertension or spasm of the anal sphincter.
In rare cases, fissures may develop due to one of the following reasons:
- Anal Cancer
Who is at Risk for an Anal fissure?
- Anal fissures are common in childhood. Due to the reduced blood flow in the anorectal area, the elderly is also prone to anal fissures.
- During and after childbirth, women are at risk of anal fissure due to stress during childbirth.
- People with IBD are also at increased risk of anal fissure. Inflammation in the lining of the intestine makes the tissues around the anus easier to tear.
- People with frequent constipation are at increased risk of anal fissure. Straining and passing large, hard stools are the most common causes of anal fissures.
How is an Anal Fissure diagnosed?
Doctors can usually diagnose anal fissure by examining the area around the anus. However, they may want to have a rectal exam to confirm the diagnosis. During this examination, the doctor may insert an anoscope into the rectum to make the tear easier to see. This medical device is a thin tube that allows a doctor to examine the anal canal.
Using an anoscope can also help your doctor find other causes of pain in the anus or rectum, such as hemorrhoids. In some cases of rectal pain, you may need an endoscopy to better evaluate your symptoms.
Is it an Anal fissure or Hemorrhoids?
Distinguishing between anal fissures and hemorrhoids can be difficult because most people have difficulty or unwillingness to see the affected area. But understanding the difference between the two is important for choosing the right treatment for anal fissure or hemorrhoids.
- Anal fissure.
If you have anal fissure, you will most likely know about it soon after you have this disease. Anal fissures are cuts or tears that occur around the anus. They are really painful, because they occur on a type of skin called andoderm. The andoderm does not have sweat glands or sebaceous glands, but it contains an abnormally large number of somatosensory nerves, which are particularly sensitive to touch and pain. Anal fissures are caused by trauma to the anus or anal canal, and the most common cause is heavy and strenuous exercise. Many patients can recall the exact time when the pain of anal fissure started. For anal fissures, you will often see a few drops of bright red blood in the toilet water, separated from the stool. Effective anal fissure treatments include home remedies, prescription drugs, and surgery.
Hemorrhoids are often accompanied by fissures and show many of the same symptoms. The difference between anal fissure and hemorrhoids is that they are both different types of injuries. Anal fissures are tissue tears, while hemorrhoids are caused by the weakening of the cushion of tissue in the lower rectum, causing the skin to swell and fill with blood like a small balloon (this applies only to thrombosed hemorrhoids). There are two types of hemorrhoids: external hemorrhoids and internal hemorrhoids. Rectal pain is usually related to external hemorrhoids and/or anal fissures. After cleaning, you can also see blood stains on the toilet paper. In the case of internal hemorrhoids, the most common symptom is rectal bleeding. After exercising, you may see bright red blood stains on toilet paper or bright red blood stains in the water. Treatments for hemorrhoids range from creams and home remedies to hemorrhoid banding and surgery.
For most people who have experienced one of these, the difference in symptoms between anal fissure and hemorrhoids is difficult to distinguish. Anyone experiencing what they think is anal fissure or hemorrhoids should seek a hemorrhoid doctor in their area. Experts in this field are most capable of providing accurate diagnosis and effective treatment for your condition, no matter what it may be.
What is the treatment for an Anal fissure – home remedies?
Most anal fissures do not require extensive treatment. However, certain home remedies can help promote healing and ease symptoms of discomfort. Without a good blood supply, cracks will not heal, unlike any other wound on the body. Unfortunately, the spasm caused by exposed muscles keeps blood away from the area, making it unlikely to heal. You can treat anal fissures at home in the following ways:
- Hot Bath. Take a hot bath, raise the water as high as possible in the bathtub, as it can relax the anal muscles and allow the blood to flow to the area. Most people don't know how to relax their muscles without contracting them first. So, when you're in the bathtub, contract the muscles you use to stop bowel movements or urination. Then focus on relaxing your muscles. When you are in the bathtub, do it every five minutes. Bathe 3 times a day; fissures will usually heal in 4 weeks.
- Fiber. If you have difficulty defecating during this period, your skin may crack again. Therefore, it is very important to increase the fiber content in the diet. You can do this by eating more raw fruits and vegetables and consuming extra fiber, such as the foods listed below. The soluble fiber found in prepared fiber supplements will soften your bowel movements and allow cracks to heal.
- Liquids. You should also drink enough liquids, up to eight glasses a day.
- Stool softeners. Use over-the-counter stool softeners. Laxatives are medicines that can help you pass your bowels more easily. Adults with anal fissures are usually prescribed laxative filling tablets or granules. These work by helping the stool retain liquid, making it softer and less likely to dry out. Children with anal fissures are usually prescribed osmotic laxatives. The action of this laxative is to increase the amount of fluid in the intestines and stimulate the body to defecate. Your GP may recommend starting treatment at a low dose and gradually increasing the dose every few days until you can pass loose stools every 1 to 2 days.
- Anti-inflammatories. If you experience prolonged burning after bowel movements, your doctor may recommend you to take common pain relievers, such as acetaminophen or ibuprofen, which you can buy in pharmacies or supermarkets. If you decide to take these drugs, be sure to follow the dosage instructions on the patient information pack or leaflet.
- Topical pain relievers. Use topical pain relievers (such as lidocaine) to relieve discomfort.
Surgery and other therapies that require medical attention
- Surgery. If your anal fissure has not healed within 4 weeks, or you have had it for a long time, you may need surgery. The surgeon will use a procedure called a sphincterotomy to open the fissure. This will hurt initially, but the crack will disappear and may not come back. This procedure is carried out in an outpatient clinic. A small number of people who have undergone this type of surgery may have air or stool leaks.
- Botulinum toxin. Another possible treatment is to inject botulinum toxin into the anal sphincter. The injection will prevent anal spasms by temporarily paralyzing the muscles. This allows the anal fissure to heal while preventing the formation of new fissures. Botulinum toxin is a relatively new treatment for anal fissures. If other medicines do not help, it is usually used. Botulinum toxin is a powerful poison and it is safe to use in small doses. The exact effect of botulinum toxin injections on anal fissures is not yet known, but studies have shown that they are helpful for more than half of patients with anal fissures. This is similar to treatment with GTN ointment and local calcium channel blockers. The effect of botulinum toxin injection lasts for about 2 to 3 months. This should usually allow enough time for the crack to heal.
- Calcium channel blocker ointment. Calcium channel blocker ointment can relax the sphincter and heal the anal fissure. Calcium channel blockers, such as diltiazem, are medications that are commonly used to treat high blood pressure (hypertension). However, local calcium channel blockers applied directly to the anus have also been shown to be helpful in treating some patients with anal fissures. Local calcium channel blockers work by relaxing the sphincter and increasing the blood supply to the fissures. Side effects may include headache, dizziness, itching, or a burning sensation in the area while using this medication. Once your body gets used to this medicine, the side effects should go away in a few days. Topical calcium channel blockers are considered to be as effective as GTN (glyceryl trinitrate) ointment for the treatment of anal fissures. If other drugs are not helpful, they may be recommended. Like GTN ointment, you should generally use calcium channel blockers for at least 6 weeks or until your fissures have fully healed.
- Glyceryl trinitrate ointments. Apply nitroglycerin ointment to promote blood flow to the area or hydrocortisone cream (such as cortisone 10). If your symptoms do not improve within a week or two, your GP may prescribe a medicine called glyceryl trinitrate (GTN), an ointment that is applied to the anal canal, usually twice a day. The role of GTN is to expand the blood vessels in and around the anus, increase the blood supply to the fissures, and help them heal faster. It can also help reduce pressure in the anal canal, thus relieving pain. Generally, you should use GTN ointment for at least 6 weeks or until your fissure is completely healed. Most acute fissures (appearing in less than 6 weeks) will heal with GTN therapy. If used correctly, about 7 out of 10 chronic anal fissures can be cured with GTN therapy. Headache is a very common side effect of the GTN ointment, affecting up to half of the people who use it. Some people also feel dizzy or lightheaded after using the ointment. GTN is not suitable for children and pregnant or lactating women should use it with caution, after discussing with their OB-GYN. If headaches are a problem, it will help to reduce the amount of ointment used for a few days. Using ointment 5 or 6 times a day is usually better than using a large amount of ointment twice a day.
You may be followed up a few weeks after starting treatment. This will allow your GP to check if your fissure has healed or if it shows sufficient signs of improvement. If the fissure has completely healed, your GP may recommend additional follow-up visits in a few weeks. If your anal fissure is particularly severe or does not respond to treatment after 8 weeks, you may need to be referred to a colorectal surgeon who specializes in diseases affecting the rectum and anus for special treatment. Usually this involves performing some type of surgery.
If your symptoms do not improve within two weeks of treatment, see your doctor for further evaluation. Your doctor can make sure you get the correct diagnosis and can recommend other treatments. If your anal fissure does not respond to other treatments, your doctor may recommend an anal sphincterotomy. This surgical procedure involves making a small incision in the anal sphincter to relax the muscle. Relaxing the muscles allows the anal fissure to heal.
Generally speaking, the average dietary fiber content of each food group is as follows:
- Fruits-1 to 2 grams.
- Nuts-6 to 8 grams.
- Beans or legumes-4 to 5 grams.
- Vegetables-2 to 3 grams of.
- Refined grains-2 to 3 grams of.
- Unrefined grains-label on the packaging.
Surgery for Anal Fissure
For patients who do not respond to conservative measures, surgery can be considered. Although the operation time varies from person to person, the literature generally recommends 4 to 12 weeks after starting conservative treatment (6 to 8 weeks may be the ideal time), taking into account the recommended duration of certain topical dosing regimens.
The gold standard surgical procedure for anal fissures is the medial and lateral sphincterotomy. This surgery usually involves separating the internal anal sphincter muscle from its distal end to the proximal end of the fissure or dentate line (whichever occurs first). The cure rate of lateral sphincterotomy is approximately 95%. Common complications include up to 6% of recurrences and up to 17% of patients with flatulence or fecal incontinence (usually transient).
When comparing the lateral internal sphincterotomy with the historical four-finger anal traction, the lateral internal sphincterotomy is superior regarding recurrence and mild incontinence. However, a more standardized method using balloon expansion shows a cure rate of 83%, which is close to the medial and lateral sphincterotomy, but the incidence of long-term incontinence is lower.
Comparing medial and lateral sphincterotomy with local glyceryl trinitrate calcium channel blocker and botulinum toxin injection, medial and lateral sphincterotomy is significantly superior in terms of cure rate. However, in some but not all studies, it has more complications. In recent years, there has been an increasing interest in surgical techniques, mainly fissurectomy alone or in combination with other techniques (for example, botulinum toxin injection or advancement flap). An observational study with good long-term follow-up reported that the cure rate of fissure resection alone was 88%, the recurrence rate was 11.6%, and the incontinence rate was 2.3%. Although internal and external sphincterotomy was not that successful or long-lasting, some people will argue that, given that the incontinence rate is much lower.
Advancement anal flaps involves removing healthy tissue from another part of the body and using it to repair fissures and improve blood supply to the fissure site. This procedure can be recommended to treat long-term (chronic) anal fissures caused by pregnancy or anal canal damage.
How to prepare for your appointment
If you have an anal fissure, you may be referred to a doctor (gastroenterologist) or colon and rectal surgeon who specializes in digestive diseases.
When you make an appointment, ask if you need to do anything in advance, such as fasting before taking a specific test. List the following:
- Your symptoms, even if they do not seem to be related to the reason for your visit.
- Key personal information, including major stress, recent life changes, and family medical history.
- All medicines, vitamins, or other supplements you take, including dosages.
- If possible, bring a family member or friend to help you remember things you may have forgotten.
Prepare questions to ask your doctor. Some basic questions to ask the doctor include:
- What can cause my symptoms?
- Are there other possible causes of my symptoms?
- Do I need any tests?
- Is my condition temporary (acute) or chronic?
- Are there any dietary recommendations I should follow?
- Are there any restrictions I should follow?
- What is the best practice?
- What is the alternative to the main method that you suggest?
- I have these other health conditions. How can I better manage them together?
- May I have brochures or other printed materials? Which websites do you recommend?
Please feel free to ask other questions during the consultation.
What do you expect from your doctor? Your doctor may ask:
- When did you start to show symptoms?
- Are your symptoms persistent or sporadic?
- How severe are your symptoms?
- Is there anything that can improve your symptoms?
- What, if anything, seems to make your symptoms worse?
- Do you have any other diseases, such as Crohn's disease?
- Do you have constipation?
What to do during this time?
While you wait to see a doctor, take steps to avoid constipation, such as drinking plenty of water, adding fiber to your diet, and exercising regularly. Also, avoid exerting force during bowel movements. The extra pressure can lengthen the cracks or create new ones.
How can you prevent an anal fissure?
Anal fissure cannot always be prevented, but you can reduce the risk of anal fissure by taking the following preventive measures:
- Keep the anal area dry.
- Clean the anal area gently with mild soap and warm water.
- Drink plenty of water, eat fiber-rich foods and exercise regularly to avoid constipation.
Not all anal fissures are a sign of a low-fiber diet and constipation. Poorly healed fissures or fissures located beyond the back and midline of the anus may indicate underlying disease. If you have any concerns about a crack that cannot heal despite trying some remedies, please contact your doctor to see if you need any additional tests.
Medically Reviewed By
Medically reviewed by
Dr. Lavrinenko Oleg