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Anal Fissure

In a day and age where the average American eats fast food several times per week, and our conception of weight loss and healthy eating includes supplements and a lap band procedure, it’s no surprise that over 13 million hospitalizations and 100 million ambulatory care visits occur each year in our country due to digestive diseases. Amongst the more common of these diseases are chronic constipation, hernias, gallstones, irritable bowel syndrome, hemorrhoids, and gastroesophageal reflux disease. Slightly less common, and overlooked are anal fissures.

An anal fissure is a tear in the epithelium (the lining) of the anus or anal canal, which can cause bleeding, pain, and severe discomfort. Signs and symptoms often include :

  • pain and discomfort during and after a bowel movement (usually a sharp, stinging, and burning pain)
  • blood on the outside surface of the stool and toilet paper (tarry stool, or dark red blood mixed within the stool is a sign it might be something more serious)
  • visible breaks or tears in the anus or anal canal
  • constipation

Anal fissures are often a result of trauma to the anus and the anal canal, amongst other things. In adults, causes of fissures often include :

  • passing of large, hard stools
  • prolonged diarrhea
  • anal sex, anal stretching
  • chronic constipation
  • trauma caused by childbirth in women
  • decreased blood flow to the area
  • other conditions such as Crohn’s disease, ulcerative colitis, anal cancer, or STD’s
  • very tight or spastic muscles of the anal sphincter, which controls the closing of the anus

Anal fissures are also very common in young infants, and some studies suggest up to 80% of infants will have an anal fissure by the end of the first year of life. Changing diapers frequently helps prevent fissures in infants. Their occurrence decreases rapidly with age, becoming much less common in school aged children, but then increase again in adulthood.

anal fissure imageAnal fissure are usually diagnosed upon visual inspection of the anus, and sometime by examination with the tip of the finger. Although most fissures usually heal on their own after a few days (acute anal fissures,) those that do not heal on their own within approximately one month are considered chronic anal fissures and require medical attention, often medicine, and sometimes even surgery. Treatment options include conservative methods which heal most fissures ( approximately 85% ) within several months, but sometimes more aggressive options are required. Methods of treatment include :

  • medicated creams such as Anusol-HC, zinc oxide, or hydrocortisone to relieve itching
  • soaking in a sitz bath (warm bath) for approximately 20 minutes several times per day to relax the anal muscles
  • preventing constipation through use of stool softeners, increased fiber intake, increased intake of fluids, and avoiding substances that cause dehydration (such as caffeine)
  • cleansing area with more caution, and using moist and unscented wipes

When fissures do not go away with these more conservative measures, treatment can involve :

  • botox injections into muscles to relax the anal sphincter
  • nitroglycerin ointment to widen blood vessels and increase blood flow to the fissure while reducing pressure in the anal sphincter, which promotes healing of the fissure and reduces pain
  • blood pressure medications such as calcium channel blockers can also help
  • if the fissure does not heal with other treatments, the doctor can also opt for outpatient surgery, which involves a small incision in the anal sphincter muscle, called a lateral internal sphincterotomy, to reduce spasm and pain while promoting healing.

Although they often heal on their own, make sure to contact a healthcare professional if symptoms last for longer than one month. Also, remember that if the stool is dark, or if blood can be found within the stool instead of only on the outside, it is usually an indication of more serious underlying issues, and you should immediately contact a physician.

Justin Bokhoor – Medical Student

University of Miami Miller School of Medicine

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