Anal fissures are tears that occur in the most superficial lining cell layer of the anus which is thin and moist. Anus is the muscular opening situated at the end of the digestive tract which releases the stools from the GI tract. The lining cell layer of this anus is thin and moist, which is why it is predisposed to get fissures.
The posterior midline of the anal canal is the region where anal fissures occur most recently. It is more common among infants and middle-aged adults while it can be found among any age.
Etiology
- Trauma caused due to strained evacuation of hard stools
- Repeated diarrhea can also damage the anus
- Vaginal delivery in women
- Anal intercourse
- Large stools
- Sexually transmitted diseases such as HIV and Syphilis
- Diseases such as Crohn’s disease
- Rectal carcinoma
Clinical Features
- Severe anal pain associated with defecation which can even remain for several hours after defecation.
- This pain can get resolved spontaneously after a spontaneous time from defecation and can recur with the next defecation.
- Passage of red blood through the anus, which appears in tissue after wiping the anus.
- Itching and irritation.
- Mucous discharge.
- A visible crack in the skin near the anus.
- Small lumps or skin tags can also occur.
Diagnosis of Anal Fissures
Initially, the doctor will ask a few questions about symptoms in the history taking to assess you, which will be followed by a physical examination which includes an examination of the anus. Most often the fissure can be seen during per rectal examination and physical examination is adequate to diagnose fissures.
But anoscopy, colonoscopy, and flexible sigmoidoscopy can be also used to visualize and confirm the diagnosis of the fissure.
Complications
- Some fissures may remain without healing for long periods.
- Repetitive fissures can occur.
- The fissure can extend up to anal sphincters causing incontinence and making it harder to heal.
- Anal fistulas can also develop which can worsen the circumstances.
Management of Anal Fissures
Pharmacological Management
- Stool softeners such as Paraffin wax can be subscribed to reduce the formation of hard and large stools while making defecation easier.
- Topical application of painkillers as local anesthetics can also bring symptomatic relief.
- Relaxation of the anal sphincter which is a muscular ring that controls defecation can which can be achieved by giving nitric oxide as topical GTN.
- Botox injection can also be given as an alternative treatment.
Non-Pharmacological Management
- Addition of fiber to the diet to bulk up the stool.
- Adequate water intake must be established.
- Warm baths can be advised in order to achieve symptomatic relief.
- Surgical procedures such as forceful manual sphincter dilatation is used to reduce sphincter tone. Lateral anal sphincterotomy is another surgical procedure done for fissures.
Lifestyle Management
- Lifestyle modification steps can be implemented to relieve symptoms, avoid compliance and prevent a recurrence.
- The inclusion of 25 to 35 grams of fiber in your diet can help keep stools soft and improve fissure healing. Fiber-rich foods include Fruits, Vegetables, and Whole grains.
- Drinking at least 4 liters of water per day will help you prevent constipation.
- Improving bowel habits by avoiding straining during defecation can prevent the occurrence of anal fissures.
- Sitting in a warm bath consisting of soaking warm water for 10-20 minutes several times a day can bring symptomatic relief.
References
- Bailey and Love’s Short Practice of Surgery- 27th Edition
- Kumar and Clerk’s Clinical Medicine -8th Edition- Parveen Kumar, Michael Clark
- Oxford Handbook of Clinical Medicine – 10th Edition
- Browse’s Introduction to the Symptoms and Signs of Surgical Disease – 4th Edition – Norman L. Browse, John Black, Kevin G. Burnand and William E.G. Thomas
