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Anal Fissure

Understanding an anal fissure

An anal fissure is a small tear of the skin around the back passage (anus). Although the tear of an anal fissure is usually small (usually less than a centimetre), it can be very painful. This is because the anus is very sensitive. The pain tends to be worse when one passes stools (faeces) and for an hour or so after passing faeces. Often an anal fissure will bleed a little. One may notice blood after one passes faeces. The blood is usually bright red, and a small amount may be seen on the toilet paper or coating on faeces.

Anal fissures are common, both in adults and in children. They are not usually serious, but they are sore and can be distressing, particularly for children.

In most people the fissure heals within 1-2 weeks or so. Some fissures take longer to heal. A fissure that lasts more than six weeks becomes persistent and is called a chronic anal fissure. This is uncommon, but treatment can still be effective.

Grounds of an anal fissure

Stretching and tearing of the rim of the back passage (anus) can occur when a person passes particularly hard stools (faeces). In most people, this skin damage will heal quickly with no problems. But some people seem to have a higher than normal tone (pressure) of the muscle around the anus (the anal sphincter). The muscle is ‘tighter’ than usual. It is thought that this increased tone may reduce the blood supply to the anus and so slow down the skin healing process. This can cause an anal tear (fissure) to develop. Once a fissure has developed, pain when passing faeces can increase the anal tone further. This makes pain and symptoms worse and a vicious cycle can be set up.

Constipation can make an anal fissure more likely to develop. In about 1 in 10 cases, the fissure occurs during childbirth. Sometimes an anal fissure occurs if you have bad diarrhoea.

In a minority of cases, a fissure occurs as part of another condition. For example, as a complication of Crohn’s disease or an anal herpes infection. In these situations one will have other symptoms and problems as well.

Identification of an anal fissure

One’s doctor will usually diagnose an anal tear (fissure) by one’s typical symptoms and by examining the skin around one’s back passage (anus).

What is the initial treatment for an anal fissure?

In most people the tear (fissure) heals within a week or so, just like any other small cut or tear to the skin. Treatment aims to ease the pain and to keep the stools (faeces) soft whilst the fissure heals.

Easing pain and discomfort

Warm baths are soothing, and may help the back passage (anus) to relax which may ease the pain.

A cream or ointment that contains an anaesthetic such as lidocaine may help to ease the pain. You should only use this for short periods (up to 5-7 days). If one uses it for longer, the anaesthetic may irritate or sensitise the skin around the anus. The cream/ointment should be applied before going to the toilet.

A cream or ointment that contains steroid medication may be prescribed by a doctor if there is a lot of swelling (inflammation) around the fissure. Steroids reduce inflammation, and may help to reduce any swelling around a fissure. This may help to ease any itch and pain. You should not use it for longer than one week at a time.

Wash the anus carefully with water after one goes to the toilet. Area should be dried gently. Soap should not be used whilst it is sore as it may cause irritation.

Painkillers such as Paracetamol or Ibuprophen may help to ease the pain (but avoid codeine )

Avoiding constipation & keeping faeces soft

Eating plenty of fibre which is found in fruit, vegetables, cereals, wholemeal bread, etc

Drinking lots of fluids-. Adults should aim to drink at least two litres (10-12 cups) of fluid per day. One will pass much of the fluid as urine. However, some is passed out in the gut and softens the faeces. Most sorts of drink will do, but alcoholic drinks can be dehydrating and may not be so good.

Avoiding painkillers that contain codeine or Tramadol, as they are a common cause of constipation. Paracetamol is preferable to ease the discomfort of a fissure.

Fibre supplements and laxatives. If a high-fibre diet is not helping, one can take fibre supplements(bulking agents) such as ispaghula, methylcellulose, bran or sterculia. Methylcellulose also helps to soften faeces directly which makes them easier to pass. A laxative such as lactulose or a macrogol laxative may some times be suggested.

Toileting. The feeling of needing to pass faeces should not be neglected. Some people suppress this feeling and put off going to the toilet until later. This may result in bigger and harder faeces forming that are more difficult to pass later.

Anal fissures in children

The above measures apply to children who have a fissure as much as to adults. In children, the pain often makes them hold on to their faeces. This may lead to a vicious circle, as then even larger and harder faeces form. These then cause more pain when they are finally passed. Therefore, in addition to the above measures, a short course of laxatives may be prescribed for children with an anal fissure. The aim is to make sure their faeces are soft and loose whilst the fissure heals.

What if the anal fissure does not heal with the above measures?

An anal tear (fissure) will usually heal within 1-2 weeks in most people. However, it can take longer to heal in others. Even if it has lasted six weeks, technically becoming known as chronic anal fissure, there is still a reasonable chance that it will heal on its own without treatment. However, treatment can help to heal the fissure as quickly as possible.

Treatment aims to:

Relax the tone of the muscle around the back passage (anus). This allows a good blood flow and enables the fissure to heal as quickly as possible. Keep the stools (faeces) soft and easy to pass.

Glyceryl trinitrate/Diltiazem ointment

If one applies glyceryl trinitrate (GTN)/Diltiazem ointment to the anus, it relaxes the muscle around the anus (the anal sphincter). It also increases the blood supply to the damaged skin by dilating the blood vessels in that area. This may allow the fissure to heal better. It may also ease the pain. A doctor may advise to use glyceryl trinitrate (GTN)/Diltiazem ointment if you have had an anal fissure for longer than a week or so, and particularly if one has a persistent (chronic) anal fissure.

glyceryl trinitrate (GTN)/Diltiazem ointment may help in some, but not all, cases. Research studies have shown that, for people with a chronic anal fissure, about 6 in 10 fissures healed with glyceryl trinitrate (GTN)/Diltiazem treatment. So, the effect of glyceryl trinitrate (GTN)/Diltiazem ointment is modest, but may well be worth a try.

Some points to note if one uses glyceryl trinitrate (GTN)/Diltiazem ointment include the following:

You squeeze a dose of ointment on to a finger (which you can cover beforehand with cling film or similar). You then place the ointment just inside the anus.

The ointment is used every 12 hours until pain goes, or for up to 8 weeks maximum. Advise is to continue with the ointment for a full 6-8 weeks even if the pain goes much sooner. This is because it often takes 6-8 weeks of treatment for the fissure to heal fully, even if the pain has gone.

About 5 in 10 people have a headache after applying glyceryl trinitrate (GTN)/Diltiazem ointment. (The glyceryl trinitrate (GTN)/Diltiazem gets into the bloodstream and may cause a headache.) The headache usually goes within 30 minutes or so. Painkillers such as paracetamol will help if a headache occurs. If headaches are troublesome, using a smaller amount of ointment for a few days should be tried, and then gradually the amount back to normal over several days, increased.

Another tip if one gets bad headaches is to rub a smaller amount of ointment (a pea-sized amount) around the rim of one’s anus rather than inserting the full amount into the anus. glyceryl trinitrate (GTN)/Diltiazem is absorbed more into the bloodstream from the thin skin inside the anus. Using a smaller dose of ointment just on the rim of the anus may avoid side-effects. (However, it may not be as effective as using the full dose inserted into the anus.)

Occasionally, GTN ointment can cause dizziness and light-headedness because it can cause a drop in blood pressure. To try to avoid this, one should get up slowly after one has been lying or sitting down and avoid drinking too much alcohol.

Alternate medication

An injection of botulinum toxin into the anal sphincter muscle has also been shown to relax the anal sphincter muscle and so help anal fissures to heal. This treatment may be suggested in certain cases – for example, if other treatments have not been successful.

Operation

An operation is an option if the fissure fails to heal despite the above treatments. It is also an option if one has fissures which happen again (recur). The usual operation is to make a small cut in the muscle around the anus (internal sphincterotomy). This reduces the tone (pressure) around the anus and allows the fissure to heal. This is a minor operation which is usually done as day case surgery

The success rate with surgery is very high – at least 9 in 10 cases are cured.

As with any operation, there is a risk of complications. After this operation, some people have poor control of wind (gas). A very small number have soiling of underclothes, or mild bowel incontinence. But, studies have demonstrated that the risk of these complications is small. The vast majority of people who have this operation are pleased with the result to be free from the symptoms of an anal fissure. And for some, to be free of the problem of recurring anal fissure.

Chances of recurrence

Some people seem prone to anal tears (fissures) happening again (recurring). Up to half of people who have a persistent (chronic) anal fissure successfully treated with GTN ointment will have one or more recurrences at some future time. It is thought that these people have an ongoing higher-than-average pressure (tone) of the muscle around the back passage (anus). They are more likely to tear the rim of the anus if it is stretched. However, a further course of GTN ointment can be used to help to heal any future fissure. Surgery may be an option if there are frequent recurrences.

Obviating a further anal fissure

If one had had one anal tear (fissure), after it has healed one has a higher-than-average chance of having another one at some future time. The best way to avoid a further fissure is not to become constipated by using the measures described above. That is, a high-fibre diet, fluid, etc

Conclusion

An anal tear (fissure) causes pain around the back passage (anus). The pain is worse when one passes stools (faeces). A fissure heals within 1-2 weeks in most people, but lasts longer in some. Treatment aims to ease the pain until the fissure heals, and to keep the faeces soft and easy to pass. An anal fissure that lasts more than six weeks is called a chronic anal fissure. Treatment options for a chronic anal fissure include an ointment to relax the anal muscle, and surgery.