Anal Fissure

What is anal fissure and what are symptoms of anal fissure?
An anal fissure is a cut or tear occurring in the anus (the opening through which stool passes out of the body) that extends upwards into the anal canal.
The anal canal is the last part of the large intestine, and is located between the rectum (a reservoir where stools are stored) and the anal orifice (the opening through which stools are passed out of the body).
The most common symptoms of anal fissures are:

  • a sharp pain on passing stools (faeces), often followed by a deep burning/aching pain that may last several hours
  • bleeding on passing stools – most people notice a small amount of bright red blood either in their stools or on the toilet paper
  • The pain also can affect urination by causing discomfort when urinating (dysuria), frequent urination, or the inability to urinate.
  • itching (pruritus ani), and a malodorous discharge may occur due to the discharge of pus from the fissure.

Anal fissures occur in the specialized tissue that lines the anus and anal canal, called anoderm. Unlike skin, anoderm has no hairs, sweat glands, or sebaceous (oil) glands and contains a larger number of sensory nerves that sense light touch and pain. (The abundance of nerves explains why anal fissures are so painful).

What causes anal fissure?

Anal fissures are most commonly caused by damage to the lining of the anus or anal canal. Most cases occur in people who have constipation, when a particularly hard or large stool tears the lining of the anal canal.
Other possible causes of anal fissures include:

  • persistent diarrhoea
  • inflammatory bowel disease (IBD), such as Crohn’s disease and ulcerative colitis
  • pregnancy and childbirth 
  • having unusually tight anal sphincter muscles (the muscles that surround the anal canal), which can increase the tension in your anal canal and make it more susceptible to tearing
  • Other causes of fissures are anal cancer, leukemia as well as many infectious diseases including tuberculosis, viral infections (cytomegalovirus or herpes), syphilis, gonorrhea, Chlamydia , chancroid (Hemophilus ducreyi), and human immunodeficiency virus (HIV).

How are anal fissures managed?
A careful history and examination by an expert can confirm the presence of an acute or chronic fissure. If rectal bleeding is present, an endoscopic evaluation using a rigid or flexible viewing tube is recommended to exclude a more serious disease of the anus and rectum. A sigmoidoscopy or colonoscopy is used depending on age and other risk factors. Atypical fissures that suggest the presence of other diseases may require other diagnostic studies.
In acute fissures, medical (non-operative) treatment is successful in the majority of patients. Of acute fissures, 80% to 90% will heal with conservative measures as compared with chronic (recurrent) fissures, which show only a 40% rate of healing.
Initial measures include:

  • making sure there is plenty of fibre in diet
  • staying well hydrated
  • not ignoring the urge to pass stools
  • using Sitz bath or cleaning perineum with shower head

Medication that may help include laxatives to help pass stools more easily and painkilling ointment to be applied directly to anus. Other ointments (GTN and Diltiazem) are used to improve healing of anal fissures.
In persistent cases where conservative treatment has not helped, surgery may be recommended. Surgery could include fissurectomy, Botulinum Toxin Injection, advancement flap or Lateral Sphincterotomy. Indications and success rates of surgery vary and side effects are present but Surgery is often very effective in treating anal fissures.

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