Anal Fissure

Introduction to Anal Fissure

An anal fissure is a small, longitudinal tear or defect in the moist layer that lines the anus and the entire back passage. Tear in the anal area can be caused because of an injury caused by passage of hard stools or excessive straining during bowel movement. They are mostly localized to the distal portion of the dentate line. Fissures of anal canal can be classified on the basis of its causes. In acute cases, an anal fissure normally gets healed within 4 to 8 weeks by conventional therapy. Chronic, non-healing fissures lasting more than 10 weeks, may need surgical intervention.

Primary Fissures: These fissures are traditionally non-threatening and short-lived in nature and are caused due to injury to the local tissues. The injury may be related to passage of hard stools, chronic diarrhea, normal child birth (vaginal delivery), recurring trauma or anal intercourse.
Secondary Fissures: Such fissures often occur in patients with prior surgeries in the anus, patients of inflammatory bowel disease, infections and even cancer.

Incidences of fissures are common in India and many people suffer from them at some point in their lives. A fissure is a crack in the anal area that can be caused because of the damage caused by passage of hard stools or excessive straining during bowel movement. Fissures are extremely painful with minimal bleeding. Most fissures heal with good dietary advice and change in lifestyle. The recurrent fissures can lead to scarring, making the anal orifice incapable of full relaxation. This stage requires surgical intervention. The procedure of choice today is Lateral Sphincterotomy. It gives immediate pain relief and is a day procedure. Fistulas usually present as a discharge through a small opening in the anal region. The discharge is usually cyclical coming on and off and associated with some pain. Fistulas may have presented as abscesses initially which would have failed to heal. Fistulas require surgical intervention and will not usually heal with medical treatment. Conventional fistulectomies involve removal of the entire fistula tract through open surgery which leads to a wound that needs to heal.

Symptoms of Anal Fissure

The most frequently reported symptom of an anal fissure is pain, reported by patients as severe and tearing in nature, usually during passing of stools. This pain may also last for minutes to hours after stool passage.
Bleeding, described as noticing bright red spots of blood on the toilet paper, toilet bowl or as streaks on stools. On rare occasions, blood may flow in the form of drip during defecation.
Self-detection of a pile by the patient in his/her anal canal.
In case of secondary fissures, characteristic features of the underlying disease such as IBD, TB, HIV/AIDS need to be assessed for further investigations

Diagnostic Assessment of Anal Fissure

Medical history and physical examination of a suspected patients permits spot diagnosis of anal fissure on the basis of symptom evaluation in majority of patients without needing detailed investigations. An ideal way of physically examining a fissure is through gentle separation of the patient’s buttocks, while he/she is lying in a lateral position. The area of focus during this examination should be the posterior midline. Upon examination, an acute anal fissure can be seen as a new cut. However, cuts with raised edges and exposing the internal sphincter of the anal muscle fibres indicate a chronic anal fissure.
A digital rectal evaluation is normally not required for diagnosing an anal fissure and is often contraindicated due to its painful nature.
However, in rare cases, anoscopy or other radiological diagnostic modalities are recommended, in case the fissure is not visible or diagnosis is not clear.
Radiological evaluation is also suggested if there is major bright red blood flow in the patient and he/she carries an elevated risk of malignancy or symptoms indicate an secondary anal fissure

Treatment of Anal Fissures

A) Conventional/Conservative Treatment

Most fissures heal with good dietary advice and change in lifestyle.

Anal fissures mostly get healed by taking measures to soften your stools. Such measures can include consuming a high-fiber intake (e.g. psyllium or ispaghulla) or taking OTC medicines to soften your stools.
Warm water (Sitz) baths are also considered beneficial in terms of improved hygiene, pain relief and decreased muscle spasm.
Application of local anesthetic or topical creams can also aid healing of fissures and can be considered as first-line conservative treatment for fissures in terms of pain relief. These treatment measures may contain drugs including glyceryl trinitrate, calcium channel blockers or lignocaine and hydrocortisone.
Some experts may recommend the use of botulinum toxin injections as a second line treatment, mainly in high-risk patients, prior to recommending a surgery. However, there is no agreement among experts regarding a definite dose or route of injection.

B) Surgery

Surgery to treat fissures are recommended to patients who are non-responsive to conventional treatment. Also, recurrent fissures can cause scar tissue formation, making the anal orifice incapable of complete relaxation, requiring surgical treatment. Evidence recommends to observe response of conservative therapy in patients for 4 to 12 weeks, before recommending them for surgery.

Patients with resistant or recurring chronic fissures with severe symptoms may necessitate surgical treatment, involving cutting of a small part of the muscle that relaxes or tightens to open or close the anus to pass stools, to decrease its spasm and pain (Lateral Internal Sphincterotomy). This surgery is associated with an excellent healing rate of around 95% in prescribed patients. However, being a surgical procedure, it is associated with a risk of adverse events such as recurrence or loss of control over flatus or passage of stools.

C) Advancement Anal Flaps

This method involves taking healthy dissected tissues from other body parts and utilizing them for repairing the fissure and raising supply of blood at the affected site. This method may be preferred for treating long-term anal fissures as a result of pregnancy or trauma to anal canal.

In recent times, newer techniques are also used such as VAAFT – Video Assisted Anal Fistula Treatment. VAAFT uses a fine small camera which navigates the tract and destroys the same with electric current. This process seals the tract and helps it heal later. Statutory warning: This information is provided with the objective of creating general awareness of the disease and treatment options considering the best interest of people. Please consult a doctor for the right diagnosis and suitable treatment options as per the situation.