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Anal Fissures

Just like a papercut

If you have ever had a painful papercut on your finger, you understand all about anal fissures. The anus is the ring-like sphincter or valve at the end of your rectum. It opens and closes on your command to allow a bowel movement when convenient. An anal fissure is a small tear in the rim of the anus - just like a tiny papercut.

One problem with a papercut is that every time you use your hands, you tend to break open the small wound which delays healing causes more pain. The same holds true with an anal fissure. Every time you have a bowel movement, the anus is stretched and the fissure can possibly be reopened causing more symptoms. This makes some anal fissures chronic and difficult to heal. This problem is quite common and may cause considerable misery.

What causes an anal fissure?

The anal opening is only so big. To have a bowel movement the anal sphincter relaxes and open up as much as it can, but the stool must be still be soft enough to squeeze through the opening. If the stool is dry and hard, the anal sphincter is forced to open even wider than normal. This difficult passage can cause a tear in the rim of the anal opening, resulting in a fissure. Other causes of a fissure include severe diarrhea, inflammatory bowel disease, and sexually related trauma.

Classification of fissures

Fissures are graded as superficial or deep. A superficial fissure does not extend full thickness through the skin; a deep fissure results in exposing underlying muscle fiber. Fissures are also graded as acute or chronic. An acute fissure is less than thirty days duration; a chronic fissure is present for greater than thirty days.

Symptoms of an anal fissure

Once the skin is torn, each subsequent bowel movement can be painful. Just like a papercut, it doesn't take a very big tear to cause considerable misery. The pain is often quite severe. Patients often complain of a stinging pain during bowel movements. The pain often lasts for hours and gradually subsides. This occurs with each bowel movement. Many times there is also some bleeding on the toilet paper, which is usually of small quantity and generally bright red in color. The symptoms of an anal fissure are commonly mistaken for hemorrhoids, but hemorrhoids generally do not cause pain with bowel movements. In chronic cases, there may be the development of a localized swelling called a sentinel pile. This is commonly mistaken for a hemorrhoid.

Making a diagnosis

An accurate diagnosis is the first step in treatment. Your doctor can perform special tests to be certain about the cause of your symptoms. This will include an examination of the anus and anal canal in the office. The tear of the skin is usually easy to visualize. Occasionally a small viewing instrument, called an anoscope, is used in the evaluation. To rule out other more serious possibilities, a flexible sigmoidoscopy or full colonoscopy examination may be recommended.

Can anal fissures ever lead to colon cancer?

No! A fissure or a hemorrhoid can never turn into colon cancer. But, it is important to be sure that any rectal symptoms are thoroughly evaluated since conditions other than fissure can cause similar symptoms such as bleeding.

Anal fissures vs anal fistulas

These two conditions are often confused. A fissure is a tear or crack in the anal lining. A fistula is a totally different problem but often occurs in the same anal area. A fistula is more like a tunnel between the rectum and other body parts - such as between the rectum and the vagina ( a recto-vaginal fistula).

Non-surgical treatment

If you could just not use your anus for a few weeks, the fissure would probably heal faster, but, of course, you have to eat....and eliminate. Fortunately, over half of fissures heal either by themselves or with non-surgical treatment in a few weeks or months. Superficial fissures rarely require surgery; most are able to be treated with topical medications. Non-surgical treatments may include:

  • Apply 1/2 percent hydrocortisone cream to the anal area to help relieve irritation.
  • Apply a numbing ointment to the anal area to help relieve pain
  • Take oral pain-killers such as acetaminophen (Tylenol) for additional relief. Avoid constipating narcotic painkillers like codeine, Darvon.
  • A stool softener (Colace, Surfak) may help prevent constipation until the fissure heals
  • Soak the anal area in plain warm water for 20 minutes, several times a day to reduce pain (Sitz bath)
  • Eating high-fiber foods (fruits, vegetables, bran, whole-wheat grains)
  • Take a high-fiber supplement daily such as Metamucil, Citrucel, Fibercon
  • Drink 6 to 8 glasses (soda-can sized) of water to keep the stool from drying out
  • Do not strain too hard during bowel movements
  • Avoid anal sex
Call your doctor if you have any severe bleeding, high temperature, or if the fissure becomes more painful or shows no improvement after 3 days of treatment.

Alternative Treatments

Two new forms of treatment have recently been reported. One is the use of Nitroglycerine cream to the anal area to heal anal fissures. The other is the use of Botox (botulism toxin) injections to weaken the anal sphincter and allow the fissure to heal. Both of these treatments seem promising, but are too new to be recognized as effective. More research is needed.

Surgery

If a fissure continues to cause pain and bleeding and does not respond to conservative medical therapy, it is considered chronic and surgery may be required. Chronic fissures heal only 10% of the time without surgery. This may involve an operation to wedge out the area of the fissure and any underlying scar tissue. During the operation, one of the anal muscles is also usually cut (internal lateral sphincterotomy) or the anus forcible dilated. While these procedures sound terrible, they reduce spasm which can interfere with healing. Surgery can usually be performed without an overnight hospital stay. Although the pain often disappears a few days after surgery, full healing requires one to two months however most patients are back to normal activity within a week or two.

Risks of surgery

There is a risk of fecal incontinence (loss of the ability to control bowel movements) with these procedures, but the incidence of this is quite low. Infection and complications incident to anesthesia are also a concern, but again the risks are low. If you have any questions about this, you should discuss them with your doctor.

Return of the fissure

More than 90% of patients who require surgery for this problem have no further trouble from fissures as long as take measures to prevent constipation and straining with bowel movements.


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