Anal Fissures Frequently Asked Questions

They're painful and embarassing but if you have one you'll need treatment.

A fissure is a tear or ulcer in the lining of the anal canal. The anal canal is the last part of the rectum before the anus. Fissures can occur in anyone, but are more common in middle age or young adults. A fissure can be difficult to heal as it causes a spasm in the anal sphincter and aggravates itself.

Symptoms of a fissure include:

• Bright red blood in toilet bowel or on paper
• Painful bowel movements

A fissure is typically diagnosed with a visual or a rectal exam. A special tool called an anoscope or a sigmoidoscope may also be used. Either of these two tests can determine if the bleeding is truly from a fissure or caused by another problem.

Fissures can be caused by constipation or by forcing a hard bowel movement through the anus, during childbirth, or ulceration of hemorrhoids.

There are several risk factors for fissures. These include:

• Anal sex
• Constipation
• Crohn's disease
• Chronic use of laxatives
• Immunodeficiency disorders
• Leukemia
• Multiple pregnancies

Fissures are treated in a variety of ways. A physician will help you understand the treatments and their differences.

For acute fissures, treatment aims to lessen pressure on the anal canal by making sure stools are soft and ease discomfort or bleeding. These methods include:

• Warm baths (or Sitz baths)
• Eating more fiber to create softer stools
• Stool softeners (as prescribed by a physician)
• Topical hydrocortisone (suppositories or foams)
• Zinc oxide
• Petroleum jelly
• Topical anesthetics for pain
• Topical nitroglycerin cream

Patients may also be advised to avoid straining during a bowel movement, and to drink at least 8 glasses of water per day to prevent constipation. Cleaning the area after bowel movements may also be recommended. About 90% of fissures will heal without surgery.

If a fissure persists even after treatment, it may become chronic. A chronic fissure may need to be treated with surgery. Two types of surgery are done today -- anal dilation and lateral internal sphincterotomy (LIS).

Anal dilatation may be a choice for some patients, but it is being used less often due to the potential of incontinence as a complication. In anal dilatation, the anal canal is stretched.

More often the LIS surgery is used. LIS is usually done with a general anesthetic on an outpatient basis. In the procedure, a portion of the anal canal muscle is cut. The fissure itself is not removed, but any muscle spasms in the anus sphincter will be relieved, which helps the fissure to heal. This will allow the fissure to heal, and at a cure rate of more than 90%.

After surgery, it is important to keep the area clean and dry. Moist wipes instead of toilet paper and a stool bulking agent may be recommended.

One new non-surgical method being researched for use in healing fissures is Botox (botulism toxin) injections. The injections work by weakening the anal muscles and thereby allow them to heal. This method is considered more invasive than other non-surgical options, but it has a higher success rate than treatment with nitroglycerin.

Fissures are more common in people with Crohn's disease. Elderly or diabetic patients also have more difficulty in healing fissures. Fissures are not related to colon cancer.

The prognosis is good for acute fissures; they generally heal with non-invasive treatments. The cure rate using LIS surgery for chronic fissures is also encouraging. LIS can be repeated if the fissure does not heal with the first surgery. Fissures do not cause cancer and complications are uncommon.

_Sources:

American Society of Colon and Rectal Surgeons. Anal Fissure. American Society of Colon and Rectal Surgeons Mar 2006. Sept 19 2007.

Jackson Siegelbaum Gastroenterology. Anal Fissure, Abscess and Fistula. Chek Med Systems, Inc 2006. Sept 19 2007.

J.A. Lee. Anal fissure. ADAM 14 Jun 2006. Sept 19 2007.

Brisinda G, Cadeddu F, Brandara F, Marniga G, Maria G. Randomized clinical trial comparing botulinum toxin injections with 0.2 per cent nitroglycerin ointment for chronic anal fissure. Br J Surg Feb 2007. Sept 19 2007.