What is an Anal Fissure?
An anal fissure (fissure-in-ano) is a tear or split in the lining of the anal canal. They typically cause severe pain and bleeding with bowel movements. They are more common then you would think and I see a lot of them in the office.
What are the symptoms of an Anal Fissure?
The most common symptom of an anal fissure is pain or a burning feeling in the anal canal during or after a bowel movement. It can last minutes to hours. Frequently, people will also notice bright red blood on the stool or the toilet paper. Between bowel movements the fissure can be asymptomatic. Occasionally people notice an itching sensation as well. Sometimes the pain is so bad people are fearful of having a bowel movement and hold them in, making the stool even harder and making the fissure worse.
What causes an Anal Fissure?
An anal fissure is caused by focal lack of blood supply to the anal canal due to high pressure in the sphincter (muscle). Patients with tight anal sphincters are more prone to developing a fissure. When a hard, dry, constipated bowel movement goes through the anal canal this can cause trauma and lead to a fissure. Some people develop them without ever having constipation. Following a bowel movement, the pain causes the anal canal sphincter to spasm, resulting in decreased blood flow to the area of injury and inhibiting its ability to heal. The cycle continues and worsens with each bowel movement. Anal fissures can also be chronic and present for months or longer. Chronic fissures are typically associated with an external lump of skin we call a sentinel tag.
Does an Anal Fissure increase your risk of cancer?
What is the treatment for an Anal Fissure?
There are 2 main options for treating an anal fissure- medical and surgical. I always try medical treatment first. Most fissures don’t require surgery. The first step is always working on making the stool softer to stop the cycle of trauma to the anal canal. Bulking up on fiber (25-30g a day) and fluids (6-8 tall glasses of water) and even the addition of a stool softener if needed is how to begin. Topical pain medication and a soak in a warm bath (sitz bath) or hot tub, especially after bowel movements, helps relax and soothe the sphincter muscle which helps with healing. A good glass of wine won’t hurt either.
I typically also use topical medication that relaxes the anal sphincter even more and speeds up the healing process. I use either topical nitroglycerin (Rectiv) or topical diltiazem. The key with both of these medications is to start slow. If you use too much they can cause headache, light headedness or low blood pressure. The medication soaks in through your skin so it’s best to apply with a gloved finger as it will soak through your finger as well. Start with a small amount (about the size of a small green pea) and using your finger put the ointment up into your anal canal about 1-2 inches, rub it on, and you’re done. Try to do this at least twice a day, three times if you can. A recent fissure can heal rapidly and the pain will go away but the strength and spasm to the sphincter takes longer to normalize so don’t stop the medication too soon. I typically have my patients continue it 2-4 weeks after the pain is gone. Chronic fissures can take months. Also, it is important to avoid Viagra like or Cialis like medications while on this topical therapy.
If medical therapy fails then you can undergo surgical repair of the fissure. The technique for this has improved a lot over time and is done different ways by different surgeons but is very effective. We can discuss this in detail if your fissure gets to this point.
Will an Anal Fissure return?
Yes it can. The same issues that caused your first fissure can cause more in the future. That’s why, as we go through this treatment, we also discuss things like a good bowel regimen, appropriate fiber and fluids, physical activity that helps promote regular bowel movements and avoiding sitting for prolonged periods, especially on the hard commode. Usually, through these types of changes we can prevent a recurrence.
What do I do if I think I have an Anal Fissure?
Call me. Don’t continue with the pain. The longer you wait the more difficult they become to treat. I will help you make this go away.