a woman straining during defecation

Anal fissure

Causes of anal fissure

The anal fissure (also called fissure-in-ano) is a linear or an oval ulcer (tear) in the anal canal. It usually extends from the linea dentata to the verge of the anal orifice. This small crack in the epithelial surface may cause severe pain after bowel movements. Small amounts of bright red blood can be presented and that’s why fissures are often mistakenly self-diagnosed as hemorrhoids. Fissures are usually caused by the passage of hard feces or extreme diarrhea. Chron’s disease is recognized as a predisposing factor. Other factors include previous anal surgery (such as hemorrhoidectomy) or the presence of another anorectal disease (hemorrhoids, anal stenosis, perianal fistula and others).

The most common anorectal diseases - internal and external hemorrhoids, anal fissure, and anal fistula
The most common anorectal diseases – internal and external hemorrhoids, anal fissure, and anal fistula.

Studies have shown that high resting tone and disturbance of the internal anal sphincter are also factors at work. The normal relaxation reflex of the intern sphincter is impaired and instead, the patient might feel spasms (contractions of the sphincter muscle).  The anal fissure tends to occur more often in younger men and women (range, 20-40 years). However, it can occur in any age and the sex distribution is equal. Anal fissures are most commonly located in the posterior midline, less so in the anterior midline (usually in women after childbirth).

Anal fissure symptoms

Patients with acute fissures complain of severe (pulsating) anal pain during and after the process of defecation. The pulsation is due to spasms of the internal anal sphincter. The pain usually lasts from several minutes to several hours. Some patients even claim the pain is persisting all day. This feeling is usually compared to “passing razor blades” from the rectum. The severe anal pain often leads to fear from having a bowel movement. This should be avoided at all cost. If you are delaying the bowel movement, it will harden and fecal impaction might form, which will further worsen the condition.

Conservative treatment for anal fissure

The treatment of anal fissure depends on its progression. Acute anal fissures are painful, but they might heal with conservative management. Sometimes fissures heal on their own and the patient doesn’t even realize that he had one. Clinical trials have shown that about 50% of the fissures can be healed with nonoperative measures. To treat acute fissure one should avoid constipation and hard stools. Hard feces and constipation can delay and setback the treatment or even lead to recurrence of the anal fissure. To achieve good results you should follow some simple steps that will make the stool bulky and soft:

  • Switch to a high-fiber diet and drink at least 64-70 oz of water (or more depending on the weight).
  • Dip into hot water or sitz baths for 10-15 minutes, two-three times per day.
  • Additional topical anesthetics or ointments could be beneficial if inserted into the anal canal. Application in the perianal region (outside the anus) has no effect on the fissure.
  • Taking natural stool softeners of bulk forming agents, such as psyllium or unprocessed bran will aid the effort.

Acute anal fissure should resolve in 4-6 weeks. If the fissure doesn’t heal conservatively it will proceed to chronic state (after 6-8 weeks). Chronic fissures are less painful, but severe symptoms tend to reoccur from time to time. Chronic fissures can develop the so-called sentinel piles (or tags). These small tags can persist as permanent fibrous skin tags, even after the fissure has healed. In addition, a hypertrophied anal papillae can appear in the anal canal. In a chronic fissure, the floor of the ulcer is actually uncovering the muscle fibers of the internal sphincter. Once the internal sphincter is bared with scarring and fibrosis, the fissure won’t be able to heal without an operation.

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