An anal fissure (or fissure-in-ano) is a small tear in the anal canal lining that causes pain and bleeding with bowel movements. Fissures are common in the general population, but are often confused with other anal conditions, such as hemorrhoids.
Anal fissures typically cause sharp pain during a bowel movement that may last from several minutes to few hours. Patients may also notice bright red blood with bowel movements. Some patients with anal fissures may have little to no pain between bowel movements. Many patients are fearful of having a bowel movement and may try to avoid it because of pain.
Fissures are usually caused by trauma to the inner lining of the anus from a bowel movement or other stretching of the anal canal. A hard, dry bowel movement is typically responsible, but loose stools and diarrhea can also cause fissure. Patients with tight anal sphincter muscles are more likely to develop anal fissures. Increased tightness of the anal sphincter muscle is thought to limit blood flow to the site of the injury and impair healing of the wound. Treatments of anal fissures are aimed at softening stools and relaxing the anal sphincter muscle to promote healing. Other, less common causes of fissures include inflammatory conditions and certain anal infections or tumors. Anal fissures may be acute or chronic (present for a long perior of time). Chronic fissures may be more difficult to treat. Chronic fissures are more likely to have an external skin tag, as well as extra tissue just inside the anal canal (hypertrophied papilla).
The majority of anal fissures do not require surgery. The most common treatment for an acute anal fissure consists of making the stool more soft, formed, and bulky with a high-fiber diet and over-the-counter fiber supplement (totaling 25-35 grams of fiber / day). Stool softeners and increasing water intake may be necessary to promote soft bowel movements and aid in the healing process. Topical medicines for pain and warm tub baths (sitz baths) for 10 to 20 minutes several times a day (especially after bowel movements) are soothing and promote relaxation of the anal muscles, which may help the healing process. Other medications (e.g., nitroglycerin, nifedipene, diltiazem) may be prescribed to allow for relaxation of the anal sphincter muscles. These are typically creams that require a specialized (compounding) pharmacy to make. Your surgeon will go over the benefits and side effects of each of these with you. Narcotic pain medications are not recommended for anal fissures because they promote constipation. Chronic fissures are generally more difficult to treat, and your surgeon may advise surgical treatment.
Fissures can recur easily, and it is quite common for a fully healed fissure to recur after a hard bowel movement or other trauma. Even when the pain and bleeding have subsided, it is very important to continue good bowel habits and a diet high in fiber as a lifestyle change. If the problem returns without an obvious cause, further assessment by a physician is warranted.
A fissure that does not improve with dietary and medical measures should be re-examined. Persistent hard or loose bowel movements, scarring, or spasm of the internal anal muscle all contribute to delayed healing. Other medical problems such as inflammatory bowel disease (Crohn's disease), infections, or anal tumors can rarely cause symptoms similar to anal fissures. Patients suffering from persistent anal pain should be examined to rule out these other conditions. A colonoscopy or an exam in the operating room with anesthesia may be needed.
Surgery for treating anal fissure includes surgical division of a portion of the internal anal sphincter (lateral internal sphincterotomy). This is performed typically as same-day outpatient procedures or occasionally in the office setting. The goal of these surgical options is to promote relaxation of the anal sphincter, thereby decreasing anal pain and spasm and allowing the fissure to heal. Surgical sphincterotomy is reported to be successful in more than 90% of patients. All surgical procedures carry some risk; rarely, a sphincterotomy may affect the ability to control gas and stool passage. Dr. Schultzel will discuss these risks with you to determine the appropriate treatment for your particular situation.
It is important to note that complete healing with both medical and surgical treatments can take up to 6 to 10 weeks. Most patients will be able to return to work and resume daily activities just a few days after surgery.
Absolutely not. Persistent symptoms, however, need careful evaluation since conditions other than an anal fissure can cause similar symptoms. Your colon and rectal surgeon may request additional tests, even if your fissure has successfully healed. A colonoscopy may be required to rule out other causes of rectal bleeding.