What the heck is an anal fissure? Here’s everything you need to know

The anus is the muscular opening at the end of the digestive tract or intestines, an opening that stools, or faeces, use to exit the body.

An anal fissure is a small tear in the thin, moist tissue that lines the anus. It is commonly caused by constipation and straining or passing hard or large stools during a bowel movement.

They can typically cause pain and bleeding with bowel movements. You also may experience spasms in the ring of muscle at the end of your anus, called the anal sphincter.

Prevention and treatment of anal fissures

Anal fissures are common in young infants but can affect people of any age. Most anal fissures get better with simple treatments, such as increased fibre intake or soaking in a warm water bath. Some people with anal fissures may need medicine or, occasionally, surgery.

See your doctor if you have pain during bowel movements or notice blood on stools or toilet paper after a bowel movement.

You may be able to prevent an anal fissure by taking measures to prevent constipation or diarrhoea. Eat high-fibre foods, drink fluids and exercise regularly to keep from having to strain during bowel movements.

Symptoms

Symptoms include:

• Pain passing stools
• Pain after going to toilet that can last up to several hours
• Bright red blood on the stool or toilet paper after a bowel movement
• A visible crack in the skin around the anus
• A small lump or skin tag on the skin near the anal fissure

Causes

Common causes include:

• Passing large or hard stools
• Constipation and straining during bowel movements
• Long-lasting diarrhoea
• Anal intercourse
• Childbirth.

Less common causes include:

• Crohn’s disease or another inflammatory bowel disease
• Anal cancer
• HIV
• Tuberculosis
• Syphilis.

Risk factors

Factors that may increase your risk of developing an anal fissure include:

• Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
• Childbirth. Anal fissures are more common in women after they give birth
• Crohn’s disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract. This may make the lining of the anal canal more vulnerable to tearing.
• Anal intercourse
• Age. Anal fissures can occur at any age, but are more common in infants and middle-aged adults.

Complications

• Chronic anal fissure. When an anal fissure fails to heal within eight weeks it is considered chronic and may need further treatment.

• Recurrent anal fissure. Once you’ve experienced an anal fissure, you are prone to having another one.

• The tear can extend beyond the anus to surrounding muscles including the internal anal sphincter.

Diagnosis

To diagnose, your doctor will take full medical history and perform a physical examination, including a gentle inspection of the anus. Often the tear is visible. Usually this may be all that’s needed to diagnose an anal fissure.

The fissure’s location offers clues about its cause. A fissure that occurs on the side of the anal opening, rather than the back or front, is more likely to be a symptom of another disorder, such as Crohn’s disease. Your provider may recommend further testing to find out if you have an underlying condition.

Tests may include:

• Anoscopy. An anoscope is a tubular device inserted into the anus to help your doctor see the rectum and anus.
• Flexible sigmoidoscopy. Your doctor inserts a thin, flexible tube with a tiny video into the bottom portion of your colon. This test may be done if you’re younger than 45 and have no risk factors for intestinal diseases or colon cancer.
• Colonoscopy. This test involves inserting a flexible tube into your rectum to inspect the entire colon.

Colonoscopy may be done if you:

• Are older than age 45
• Have risk factors for colon cancer
• Have symptoms of other conditions
• Have other symptoms, such as stomach pain or diarrhoea

Treatment

Anal fissures often heal within a few weeks with appropriate home treatment. Take steps to keep your stool soft, such as increasing your intake of fibre and fluids.

Soak in warm water for 10 to 20 minutes several times a day, especially after bowel movements. This can help relax the sphincter and promote healing.

If symptoms persist, you’ll likely need further treatment.

Nonsurgical treatments:

Your healthcare provider may recommend:

• Externally applied nitroglycerin. This can help increase blood flow to the fissure and promote healing. It also can help relax the anal sphincter. Nitroglycerin is generally considered the treatment of choice when other conservative measures fail. Side effects may include a headache, which can be severe.

• Topical anaesthetic creams such as lidocaine may help relieve pain. Botox injection to paralyse the anal sphincter muscle and relax spasms.

• Blood pressure medicines such as nifedipine or diltiazem, to help relax the anal sphincter. These are generally applied to the skin but can be oral. However, when taken by mouth, their side effects can be greater. These medicines may be used when nitroglycerin is not effective or causes significant side effects.

Surgery

If you have a chronic anal fissure that is resistant to other treatments, or if your symptoms are severe, your health care provider may recommend surgery.

Doctors usually perform a procedure called lateral internal sphincterotomy. This involves cutting a small portion of the anal sphincter muscle.

This technique may help promote healing and reduce spasm and pain. Studies show that surgery is much more effective than any medical treatment for chronic fissure. However, surgery has a small risk of causing incontinence.

Lifestyle and home remedies:

Several lifestyle changes may help relieve discomfort and promote healing of an anal fissure, as well as prevent recurrences. Changes include:

• Adding fibre to your diet
• Drinking adequate fluids. Fluids help prevent constipation.
• Not straining during bowel movements. Straining creates pressure, which can open a healing tear or cause a new tear.
• Sitting in a warm bath. Also called a sitz bath, soaking in warm water for 10 to 20 minutes several times a day can soothe the skin and promote relaxation. If possible, take a sitz bath after bowel movements.
• If your infant has an anal fissure, change diapers frequently and wash the area gently. Also, be sure to discuss the problem with your child’s healthcare provider.

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