About Anal Fissure

An anal fissure is a small tear in the lining of the anal canal, usually caused by passing hard, dry stools or repeated straining during bowel movements. It leads to sharp, stabbing pain, particularly while passing stools, and is often accompanied by bleeding. Although it’s a common and generally non-threatening issue, delayed treatment may cause the fissure to become chronic, leading to prolonged discomfort and additional complications.

This condition can affect individuals of all ages, including infants, adults with constipation, and postpartum women. Anal fissures are classified into two types—acute (healing within 6 weeks) and chronic (lasting longer), with chronic fissures often revealing the underlying muscle and requiring advanced medical attention.

Anal Fissure : Signs and Symptoms

• Intense pain during or after passing stool
• Bright red blood on stool or toilet tissue
• A visible tear or slit around the anal opening
• Constant irritation or a burning sensation near the anus
• Skin tag formation near chronic fissures
• Spasms in the anal muscle, making bowel movements difficult
• Fear of defecation due to anticipated pain

Causes of Anal Fissure

Chronic Constipation

• Mechanism: Hard stools stretch the anal mucosa.
• Effect: Creates micro-injuries, especially at the posterior midline.

Repeated Diarrhea

• Mechanism: Continuous bowel movements irritate the area.
• Effect: Prevents healing, making fissures more likely.

Postpartum Trauma

• Mechanism: Vaginal childbirth stresses the anal area.
• Effect: Increases the risk of tearing, especially in constipated women.

Anal Penetration or Foreign Objects

• Mechanism: Trauma to the anal lining.
• Effect: Sudden tearing and acute fissure formation.

Underlying Health Disorders

• Examples: IBD, STIs, tuberculosis, HIV.
• Effect: Reduced healing due to compromised blood flow or immunity.

Anal Fissure Risk Factors

• Frequent constipation or hard stools
• Low dietary fiber intake
• Sedentary lifestyle
• Dehydration
• Childbirth-related stress
• Bowel diseases like Crohn’s or colitis
• Prior rectal injuries or surgeries
• Weakened immune system

Anal Fissure Complications

• Chronic Fissure: Symptoms linger or worsen over time
• Sentinel Tag: Tissue thickening near the persistent tear
• Muscle Spasm: Prolonged tightness hampers healing
• Infection: In rare cases, abscesses may form
• Fistula: Long-term fissures might develop abnormal tracts
• Iron Deficiency Anemia: Due to continuous blood loss

Anal Fissure Diagnosis

1. Clinical Examination

Doctors gently inspect the anal area for visible tears. For severe pain, digital rectal exams might be deferred or performed under anesthesia.

2. Anoscopy

A thin, tubular device helps examine the anal canal closely to determine the fissure’s depth and rule out hemorrhoids or other issues.

3. Additional Testing

• Sigmoidoscopy/Colonoscopy: Recommended when the fissure has atypical features or location
• Biopsy: Rarely needed unless healing fails or an underlying disease is suspected

Anal Fissure Treatment Options

Treatment varies depending on whether the fissure is acute or chronic. Most acute cases respond to conservative management, while chronic fissures may need procedural intervention.

1. Conservative Management - Lifestyle Modifications

• Increase intake of fiber-rich foods like fruits, vegetables, and whole grains
• Drink adequate water
• Avoid straining or prolonged sitting on the toilet
• Take warm sitz baths 2–3 times daily to ease discomfort

2. Medications

• Topical Ointments (Nitroglycerin or Diltiazem): Help relax the anal muscle
• Stool Softeners or Laxatives: Reduce strain during bowel movements
• Pain-Numbing Creams (e.g., Lidocaine): Provide temporary pain relief
• Botulinum Toxin (Botox): Used in select chronic cases to relieve muscle tightness

3. Surgical Options

For cases that don’t improve with conservative measures, surgical treatment is considered:

• Lateral Internal Sphincterotomy : A highly effective procedure that involves a small cut in the internal anal sphincter to reduce pressure and promote healing.
• Fissurectomy : Surgical removal of the fissure and fibrotic tissue, sometimes done with sphincterotomy.
• Advancement Flap Surgery : Utilized in complicated or non-healing cases, this technique involves covering the fissure with healthy tissue to improve blood flow and recovery.