Anal Fissures

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Dr Chong Choon Seng

MBBS | MRCS | Masters in Medicine (Surgery) | FRCS (Edinburgh)

An anal fissure is a small tear in the lining of the anal canal, often associated with pain and discomfort during and after bowel movements. These tears can also cause bleeding, spasms in the anal sphincter, and irritation. While most fissures occur due to trauma from passing hard or large stools, some may result from underlying medical conditions. Early recognition and appropriate management can help improve symptoms and prevent complications.

Symptoms of Anal Fissures Symptoms of Anal Fissures

Symptoms of Anal Fissures

The symptoms of anal fissures vary in intensity and can often be mistaken for other conditions. Recognising these specific signs may help identify the issue.

  • Pain during or after bowel movements: A sharp, burning, or tearing sensation typically occurs when passing stools and may last for hours afterwards.
  • Visible tear or soreness: A fissure may appear as a small cut near the anal opening, which can become inflamed or irritated.
  • Bleeding: Bright red blood on toilet paper, in the stool, or in the toilet bowl is a common sign.
  • Spasms in the anal sphincter: Persistent or intermittent muscle spasms in the anal region can exacerbate discomfort and delay healing.
  • Itching or discharge: Chronic fissures may lead to itching or mild discharge due to irritation or secondary infection.

Causes and Risk Factors

Anal fissures can develop due to trauma, underlying medical conditions, or lifestyle factors. Common causes include:

  • Constipation and straining: Frequent constipation and the passage of large, hard stools place significant pressure on the anal lining, increasing the likelihood of tears.
  • Chronic diarrhoea: Repeated loose stools irritate the anal tissue, weakening its integrity and making it prone to tearing.
  • Vaginal childbirth: The pressure and strain experienced during delivery can result in postpartum fissures, particularly in first-time births.
  • Medical conditions: Conditions such as Crohn’s disease, ulcerative colitis, or infections like syphilis or tuberculosis can reduce tissue elasticity and resilience, leading to fissures.
  • Injury or trauma: Anal injury from improper insertion of objects, certain medical procedures, or physical trauma can directly cause fissures.
  • Reduced blood flow to the anal area: Poor blood circulation, particularly in older adults, can delay tissue repair and increase vulnerability to fissures.

Types of Anal Fissures

Anal fissures can be classified based on their duration and underlying causes, each requiring tailored approaches for treatment:

Acute anal fissures

These are recent tears that occur suddenly and typically resolve within four to six weeks with conservative treatment. They are superficial and often result from a singular event, such as passing a hard stool.

Chronic anal fissures

Fissures lasting more than six weeks are considered chronic and may develop scar tissue or a sentinel skin tag (a small growth near the fissure). Chronic fissures often indicate repeated trauma or an underlying issue.

Primary fissures

These fissures arise due to common causes such as constipation or diarrhoea and generally respond well to conventional treatments.

Secondary fissures

Associated with medical conditions such as Crohn’s disease, infections, or malignancies, these fissures may require additional diagnostic evaluation and specialised treatment.

Diagnosis of Anal Fissures

Visual Inspection

The anal region is examined for visible tears, irritation, or associated signs such as sentinel skin tags. This procedure is typically quick and provides a clear indication of superficial fissures or other external abnormalities.

Digital Rectal Examination

A gloved finger is gently inserted into the anal canal to assess for tenderness, sphincter tightness, or structural abnormalities. This examination helps identify additional conditions that could mimic fissure symptoms, such as haemorrhoids or abscesses.

Diagnostic Tests for Underlying Conditions

In cases where fissures are atypical, recurrent, or associated with other symptoms, further diagnostic measures may be used. Blood tests can evaluate inflammation or infection, imaging studies can provide structural details, and biopsies may be performed to assess for conditions like Crohn’s disease, infections, or malignancies.

An MRI can be indicated to check and exclude other causes of pain in the anorectal junction. Colonoscopy is mainly indicated if the symptoms are not consistent with anal fissure, like if the blood in the stool is not fresh blood.

Anoscopy

This is usually not needed, as it is often painful to insert when a patient has an active fissure. However, an anoscope, a small, lighted instrument, can be used to inspect the anal canal and rectum to exclude other causes like haemorrhoids or when there is no obvious cause of pain at the external part of the anus.

Treatment Options

Management of anal fissures focuses on alleviating symptoms, promoting healing, and preventing recurrence. Treatment may include both non-surgical and surgical approaches, depending on the severity.

Non-Surgical Treatment

  • Dietary Modifications: A fibre-rich diet from fruits, vegetables, and whole grains softens stools, reducing strain during bowel movements. Hydration is equally necessary for maintaining stool consistency and preventing future tears.
  • Topical Medications: Nitroglycerin ointments and calcium channel blockers help relax the anal sphincter, reducing tension and improving blood flow to the affected area. Hydrocortisone creams may also be prescribed to address inflammation and irritation.
  • Warm Sitz Baths: Sitting in warm water for 10–20 minutes several times daily helps relax the anal muscles, soothe pain, and reduce inflammation. These baths are a simple and widely recommended home remedy.
  • Laxatives and Stool Softeners: Products such as polyethylene glycol or psyllium husk help maintain regular and comfortable bowel movements, easing the strain on the anal area.
  • Pain Management: Over-the-counter pain relievers like paracetamol or ibuprofen are commonly suggested for temporary relief of discomfort associated with fissures.

Surgical Treatment

  • Lateral Internal Sphincterotomy (LIS): This is the standard surgical procedure of care. It consists of a small incision made in the internal anal sphincter muscle to reduce tension and improve blood flow to the area. This reduction in sphincter pressure allows the fissure to heal more effectively while alleviating persistent pain and spasms. LIS is an effective option for treating chronic fissures that do not respond to non-surgical treatments.
  • Fissurectomy: This procedure involves the surgical removal of the fissure and any associated scar tissue or sentinel skin tags. By excising the damaged tissue, the fissurectomy promotes a fresh wound-healing process and reduces the likelihood of chronic inflammation or infection. It is generally considered for cases where other treatments, including LIS, have not provided satisfactory results. Fissurectomy can help improve healing outcomes and restore normal tissue function in the affected area.
  • Injection of Botulinum toxin (Botox Injection): Indeed, Botox can be used on the anus other than just on the face. It is given to create a release in the tension in the anus, much like the use of topical creams as mentioned above. Botox injections, which last 3 to 6 months, typically provide temporary relief of the anal fissure. It is primarily used in patients who are not suitable for general anaesthesia, as well as patients with acute symptoms that do not respond to creams or other medications.

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Prevention and Management

Preventing anal fissures involves maintaining good bowel habits, such as avoiding straining and ensuring stools remain soft through a fibre-rich diet and adequate hydration. Regular physical activity and prompt treatment of conditions like constipation or diarrhoea can also help minimise recurrence. If underlying conditions are present, they should be appropriately managed to reduce the risk of future fissures.

Frequently Asked Questions

Can anal fissures recur after treatment?

Recurrence is highly possible, particularly if the underlying causes like constipation or diarrhoea are not addressed. Long-term dietary changes, proper hydration, and regular bowel habits can significantly reduce the likelihood of recurrence. The relief is that recurrent anal fissures can still be treated with non-surgical interventions but the underlying causes have to be eliminated for a more effective and long-lasting strategy.

Are chronic fissures more difficult to treat than acute ones?

Chronic fissures often require more intensive treatment, such as surgery, as they may involve scar tissue formation or persistent spasms. Acute fissures are generally more responsive to non-surgical interventions.

Can fissures indicate a more serious condition?

Fissures linked to conditions such as inflammatory bowel disease or infections may signify an underlying health issue. A detailed evaluation can help identify these potential causes and ensure accurate diagnosis and appropriate treatment.

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Dr Chong Choon Seng

MBBS (NUS)

MRCS (Edinburgh)

Masters in Medicine (Surgery)(NUS)

FRCS (Edinburgh)

Dr Chong is the former Program Director of General Surgery Residency at NUHS, and has more than 10 years of experience as a colorectal and general surgeon.

As an esteemed professional in minimally invasive surgery, Dr. Chong remains committed to achieving optimal outcomes for all surgical conditions, from piles to cancer treatment.

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