Anal Fissures
Its causes, symptoms, diagnosis and treatment

What is an anal fissure (fissure-in-ano)?

An anal fissure (fissure-in-ano) is a small cut or tear in the skin or moist tissue (mucosa) lining the opening of the anus, mostly in the posterior (back) midline of the anus. Usually oval in shape, the tear causes severe pain and bleeding with bowel movements. Fissures are common in young infants but can affect people of any age. Often confused with other causes of pain and bleeding such as hemorrhoids.

What causes an anal fissure?

Some of the common causes of the anal fissure are:

• Passing hard and large stools
• Straining during bowel movements & constipation
• Inflammation in the anorectal area due to inflammatory bowel disease (Crohn’s disease)
• Childbirth
• Chronic diarrhea

Some of the less common causes of anal fissures include anal cancer, tuberculosis, syphilis, herpes, & HIV. Infancy, aging and anal intercourse increase the risk of developing anal fissure.

What are the signs and symptoms of an anal fissure?

• Anorectal pain, severe during bowel movements
• Lasting pain (for hours) after bowel movements
• Blood spotting on the stool or toilet paper after a bowel movement
• Itching & irritation around the anus
• Visible crack, lump or tag in the skin around the anus

What are the complications of anal fissures?

A fissure may cause complications such as:

• Poor healing and chronic fissure: Poor or slow healing of fissures lead to a chronic state which may need further treatment. A chronic anal fissure likely has the tear, as well as two separate lumps or tags of skin, one internal (sentinel pile) and one external (hypertrophied papilla).
• Recurrence: There are high chances anal fissure will recur.  
• Tear in surrounding muscle: The anal fissure may extend to the surrounding muscles (internal anal sphincter), which delays healing. When anal fissure remains unhealed for more than 6 weeks, the patient requires medication or surgery to reduce pain, repair or remove the fissure.

Can anal fissures be prevented?

Anal fissures may be prevented by taking the following steps:

• Eat high-fiber foods: whole grains, peas, beans, citrus fruits, & banana.
• Drink fluids and exercise regularly to keep from having to strain during bowel movements.
• Do not ignore the urge to go: Over the time, stools get harder to pass.
• Do not strain or sit for long: This increases pressure in the anal canal.
• Avoid skin irritants such as soap, bubble bath.

How are anal fissures diagnosed?

The physician will carefully evaluate the medical history & anorectal symptoms and perform a digital rectal examination under anesthesia. Any fissure on the side of the anal opening is called as Crohn’s disease. In such cases the doctor may perform:

• Flexible sigmoidoscopy: A thin, flexible tube with a tiny camera is inserted into the colon to inspect the area inside. Anyone younger than 50 years without risk factors for intestinal diseases is eligible.
• Colonoscopy: A flexible tube is used to inspect the entire colon. This test is for those who are above 50 years of age and have risk factors for colon cancer or who show signs such as abdominal pain or diarrhea.

How are anal fissures (fissure-in-ano) treated?

Anal fissures heal in a few weeks, proper self-care with steps to keep the stool soft and support healing is important. Increasing the intake of fiber and fluids helps. The doctor may suggest medicine to ease the pain, promote healing, and relax the anal sphincter muscle.

For chronic anal fissure that is resistant to medical and conservative approaches, the doctor may decide to perform a surgery called as lateral internal sphincterotomy (LIS). During the surgery, a small portion of the sphincter muscle is removed. This helps to reduce pain and pressure and allow healing of fissure.

What is the recovery like from surgery for anal fissure?

In most cases, complete healing occurs within 8 weeks after surgery. It is important to discuss the post-surgery care and recovery. Some pain and discomfort in the area after surgery is common. However, the pain due to surgery is lesser than the pain due to fissure itself. After surgery, it is common to be temporarily unable to control gas and experience mild fecal leakage or infection. Most fissures respond well to surgeries and for easy recovery doctor may recommend:

• Soaking the affected area in a warm bath
• Painkillers
• Laxatives and stool softeners for a week
• Fiber-rich diet

What factors govern the cost of surgery for anal fissure? Is there an insurance coverage available?

The cost of surgery is governed by several factors, such as

• Availability of skilled and specialized surgeon and facilities
• Medical condition of the patient
• Time-to-recovery
• Usage of medications and additional investigations

Check if the hospital is enrolled with the majority of Third-party Administrator (TPA) and insurers. If you have an insurance policy, seek help from the TPA desk at the hospital to determine whether your policy covers the surgery or not.

References:

• https://inflammatoryboweldisease.net/symptoms/complications/fissure/
• https://www.webmd.com/digestive-disorders/anal-fissure-overview#1
• https://my.clevelandclinic.org/health/diseases/14466-anal-fissure/diagnosis-and-tests
• https://www.verywellhealth.com/what-is-a-fissure-1941776

Disclaimer:

“The content of this publication has been developed by a third party content provider who is clinicians and/or medical writers and/or experts. The information contained herein is for educational purpose only and we request you to please consult a Registered Medical Practitioner or Doctor before deciding the appropriate diagnosis and treatment plan.”