Anal Fissures

What is an anal fissure?

An anal fissure is a tear in the lining of the anus or anal canal (the opening through which stool passes out of the body). The fissure can be painful and may bleed.

Who is at risk for anal fissures?

Anal fissures can occur in anyone at any age. The chance of having an anal fissure decreases as people get older. People who have had fissures in the past are more likely to have them in the future.

What causes an anal fissure?

Anal fissures can be caused by trauma to the anus and anal canal. The trauma can be caused by one or more of the following:

• Chronic (long-term) constipation
• Straining to have a bowel movement, especially if the stool is large, hard and/or dry
• Prolonged diarrhea
• Anal sex, anal stretching
• Insertion of foreign objects into the anus

Causes other than trauma include:

• Longstanding poor bowel habits
• Overly tight or spastic anal sphincter muscles (muscles that control the closing of the anus)
• Scarring in the anorectal area
• An underlying medical problem, such as Crohn's disease and ulcerative colitis (types of inflammatory bowel disease); anal cancer; leukemia; infectious diseases (such as tuberculosis); and sexually transmitted diseases (such as syphilis, gonorrhea, Chlamydia, chancroid, HIV)
• Decreased blood flow to the anorectal area

Anal fissures are also common in young infants and in women after childbirth.

What are the signs and symptoms of an anal fissure?

Signs and symptoms of an anal fissure include:

• Pain during, and even hours after, a bowel movement
• Constipation
• Blood on the outside surface of the stool
• Blood on toilet tissue or wipes
• A visible crack or tear in the anus or anal canal
• Burning and itching that may be painful
• Discomfort when urinating, frequent urination, or inability to urinate
• Foul-smelling discharge

How is an anal fissure diagnosed?

Usually, your doctor can diagnose an anal fissure by visual inspection of the anus or by gentle exam with the tip of the finger.

How are anal fissures treated?

The goal of anal fissure treatment is to lower the pressure on the anal canal by making stools soft, and to ease discomfort and bleeding. Conservative treatments are tried first and include one or more of the following:

• Preventing constipation through the use of stool softeners, drinking more fluids while avoiding caffeine-containing products (which cause dehydration), and dietary adjustments (increase in intake of high fiber foods and fiber supplements);
• Soaking in a warm bath (also called a sitz bath), 10 to 20 minutes several times a day, to help relax the anal muscles;
• Cleansing the anorectal area more gently;
• Avoiding straining or prolonged sitting on the toilet;
• Using petroleum jelly to help lubricate the anorectal area.

These practices heal most fissures (80 to 90 percent) within several weeks to several months. However, when treatments fail and anal fissures persist or come back, other measures can be tried, including:

• Using hydrocortisone-containing suppositories, foams, or creams to reduce inflammation;
• Applying other creams and ointments. These may include a medicated cream (to help heal the fissure), a topical muscle relaxant (to relax the anal muscles), an anesthetic ointment (to reduce pain, if pain interferes with having a bowel movement), or nitroglycerin or calcium channel blocker ointments (to relax the anal muscles and increase blood flow to the region, promoting healing).
• Injecting botulinum toxin type A (Botox) into the anal sphincter. The injection temporarily paralyzes the anal sphincter muscle, relieving pain and promoting healing.
• Surgery

What does surgery for an anal fissure involve?

Before surgery is considered, your doctor will re-examine you and may conduct other tests to determine why other treatments have failed to heal the fissure.

A fissure may fail to heal because of scarring or muscle spasms of the internal anal sphincter muscle. Surgery usually consists of making a cut to a small portion of the internal anal sphincter muscle to reduce pain and spasms and allow the fissure to heal. Cutting the muscle rarely results in the loss of ability to control bowel movements.

The surgery can usually be performed on an outpatient basis (the patient goes home the same day). Pain is relieved after a few days and complete healing takes place in a few weeks.

Can anal fissures be prevented?

For fissures in infants:

• Change diapers frequently.
• Treat constipation, if that is found to be the cause.

For fissures in adults:

• Keep the anorectal area dry.
• Wipe the area with soft materials, a moistened cloth, or cotton pad. Avoid rough and scented toilet paper.
• Promptly treat all occurrences of constipation and diarrhea.
• Avoid irritating the rectum.