Diagnosis and Treatment: Anal Fissure

What is an anal fissure?
How is it diagnosed?
What is the treatment?
What is the recovery time and cure rate after surgery?
Anal Fissure At A Glance
Related Disorders

What is an anal fissure?

An anal fissure is a fairly common, painful condition in which the lining of the anal canal is torn. The anal canal is the last part of the rectum which ends at the anus. Stool passes through the anal canal and anus during a bowel movement. An anal fissure is caused by constipation or a forceful bowel movement, though a tight anus also may be a contributing factor. Once the skin is torn, each subsequent bowel movement can be painful, and the pain often is severe. There often is bleeding associated with the painful bowel movement. The amount of bleeding is small and may be noticed in the toilet bowl or on the toilet paper as 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.

How is it diagnosed?

The diagnosis of an anal fissure is made by examination of the anus and anal canal. The tear usually is easy to see, although occasionally a small viewing instrument, called an anoscope, may be used in the evaluation.

What is the treatment?

Initial treatment of an anal fissure generally is conservative and consists of stool softeners, high fiber diet with fiber supplements, and sitz baths (i.e., sitting in a tub of warm water). Suppositories, foams and creams that contain hydrocortisone such as ProctoFoam HC, Anusol HC, and ProctoCream HC are prescription medications that can be applied to the anal area to reduce inflammation.
About 50-75% of anal fissures treated in this fashion will heal in several weeks to months. If the fissure does not heal, surgery can be done. Surgical options include anal dilatation (stretching of the anal canal), or internal lateral sphincterotomy, which involves cutting a portion of the anal sphincter muscle. Both of these procedures serve to decrease the tension and spasm in the sphincter that causes the fissure and keeps it from healing. Surgery is very effective at healing fissures, although it is associated with the usual risk of surgery--primarily the anesthesia and the possibility of infection--and occasionally incontinence (leakage of stool). Suturing (sewing) the tear does not work and can lead to a larger fissure or an infection.
Recently, several new forms of treatment have been described for the treatment of fissures. In one, ointment containing nitroglycerin is applied to the anus. In another, an ointment containing a calcium channel blocking drug, nifedipine, is applied. In a third treatment, botulinum toxin is injected into the anal muscle. All of these treatments promote the healing of fissures by relaxing the anal sphincter muscle. Experience with the newer treatments is limited, particularly with respect to their long-term effectiveness and the frequency of side effects, but they look promising. The studies done to date suggest that they are between 70 and 90% effective at healing fissures in 6-8 weeks.
Nitroglycerin has been used for decades in the treatment of angina. Patients suffering from angina develop chest pains because of lack of blood supply to the heart muscle due to narrowing of the coronary arteries (arteries in the heart). Nitroglycerin taken sublingually (under the tongue) or orally relieves angina by relaxing the muscle surrounding the coronary arteries, enlarging the artery and increasing the blood supply to the heart. By a similar mechanism, nitroglycerin ointment promotes healing of fissures by relaxing the muscles of the anal sphincter. It also may promote healing by improving the supply of blood to the anal region. Anal nitroglycerin, like oral nitroglycerin, may cause headaches.
Nifedipine relaxes the muscle of the anal sphincter. It may increase blood flow to promote healing and also may serve to reduce inflammation. In a small but well-done study, six weeks of twice a day nifedipine ointment caused 95% of chronic anal fissures to heal. Side effects were minimal.
Botulinum toxin paralyzes muscles. Injection of the toxin into the sphincter muscle close to the fissure relaxes the anal sphincter and promotes healing. Botulinum toxin should be reserved for patients whose chronic fissures do not respond to simpler treatments.

What is the recovery time and cure rate after surgery?

Recovery time after surgical treatment usually is minimal, and generally no hospitalization is required. The cure rate is in the 95-98% range. There is a risk of fecal incontinence (leakage of stool) with these procedures, but the incidence of this is quite low.

Anal Fissure At A Glance

Anal fissures are tears in the anal canal.
Anal fissures usually can be treated conservatively by such measures as stool softeners, sitz baths, and/or suppositories or foams.
Chronic anal fissures may require surgery.

Related disorders:
Constipation
Anal Itching
Rectal Bleeding
Laxatives For Constipation