Most people become aware of an anal fissure when they have severe pain while using the bathroom, and see bright red blood on the passed stool, in the toilet bowl or on the toilet paper. These cracks or tears in the anal canal are common in both sexes, and can occur in all age groups. While these symptoms may indicate a variety of anal and rectal problems, anal fissures can usually be quickly diagnosed and treated through non-invasive means. A colorectal surgeon, also known as a proctologist, is trained in the gentle and rapid diagnosis of an anal fissure.
What is an Anal Fissure?
Anal fissures typically begin as a minor tear in the anal mucosa. Often, this trauma is caused by passing large or hard stool. Chronic constipation and diets that lack fruits, vegetables and other sources of dietary fiber can exacerbate hard stools, leading to an increased risk of anal fissure development.
Anal fissures probably happen more commonly than anyone realizes, but they normally heal quickly and with only minor pain or discomfort during bowel movements. When there is continued trauma due to large stools, or when the sufferer has other underlying issues with the sphincter, these cracks and tears may become symptomatic acute or chronic problems.
Will Testing for an Anal Fissure be Painful?
Your doctor should be very aware of how painful anal fissures can be, and most will do everything possible to avoid a painful examination. Because of their location, many can be diagnosed by observation only. Acute fissures usually appear as fresh tears, while chronic anal fissures often look like an older cut with a lump on each end.
If a diagnosis cannot be confirmed by observation alone, the doctor may need to insert a gloved, lubricated finger into your anal canal. This is known as a digital rectal exam. Topical anesthetics may be used for this exam to reduce pain. Another option is to check the area using an anoscope, which is a small, lighted tube that allows the doctor to view your anal canal.
Most anal fissures are located in the midline, either at the top or the bottom of the anus. When anal fissures appear in one of the ordinary locations and lack any other irregular features, no lab testing is needed. If they occur in other areas or accompany other signs of a more serious problem, additional tests may be necessary to rule out an underlying illness.
How Are Anal Fissures Treated?
Most anal fissures can be successfully healed with non-invasive treatments. Doctors often recommend non-prescription stool softeners or stool-bulking medications to relieve constipation and soften stools. Softer stools are less painful and easier to pass for those with anal fissures. This also gives the anus the opportunity to heal without further injury. Most patients are put on a high-fiber diet, and some are also prescribed laxatives to prevent constipation.
Doctors also recommend soaking in a shallow sitz bath several times a day to relieve symptoms, stop any spasms that may occur, and speed healing. Sitz baths can be especially helpful following bowel movements, when cleaning with toilet paper can cause pain.
If the fissure needs additional help healing, doctors may prescribe prescription drugs alongside conservative treatments. These may include:
- Anesthetic ointments for pain relief
- Topical steroids
- Calcium channel blockers, known as CCBs
- Nitroglycerin gel or cream
Commonly, a topical preparation of 0.4 percent nitroglycerin is applied directly to the affected area. This ointment, sometimes known as NTG or glycerol trinitrate, relaxes the internal sphincter, helps reduce spasms and allows the anal fissure time to heal. It may also increase blood flow to the area, meaning healing can occur faster. NTG treatment is often effective, but there are some adverse effects that limit its use. This may include severe headache and dizziness.
What Type of Surgery is Usually Used to Treat Anal Fissures?
When conservative and non-invasive treatments fail to heal an anal fissure, surgery may be necessary. In most cases, a lateral sphincterotomy is used to allow the anal canal to heal. This surgery requires snipping a small amount of the anal sphincter muscle in order to reduce pain, eliminate spasms and speed healing. This is by far the most effective treatment for anal fissures, but there are risks associated with general anesthesia, as well as a small risk of fecal incontinence after the surgery.
In some cases of chronic fissures, a fissurectomy may be used to remove the scarred, torn skin around the fissure in addition to a lateral sphincterotomy. This reduces the chances that another crack or tear will occur in the same area, as well as improve the chances that the skin will heal quickly and fully.
How Likely is This to Happen Again?
Because the area has been weakened, there is an increased risk that a torn or cut area will tear again. This means that it is not uncommon for an anal fissure treated through non-surgical means to recur. Sticking to a high-fiber diet can greatly reduce these chances. Less than ten percent of patients have a recurrence after surgery to treat an anal fissure, and the chances of recurrence are even lower for those who had a fissurectomy as well.