Anal Fissures

Anal fissures commonly occur from overstraining during bowel movements. Similarly, chronic constipation and diarrhoea which place excessive pressure on the anal canal,causing it to stretch and tear,may result in anal fissures. Other causes include:

• Childbirth
• Inserting foreign objects into the anus
• Anal intercourse
• Poor blood flow to the anus
• Tight or spastic anal sphincter muscles

In some cases, anal fissures are symptoms of a more complex illness such as anal cancer, leukemia, colitis, Crohn’s disease, HIV, syphilis and herpes.

Anal fissures may be easily detected by sight or touch, with symptoms being more noticeable during and after a bowel movement. These can include:

• Sharp pain when passing stools, followed by a burning sensation
• Bright red blood present on the stools or toilet paper
• Itching,which can be persistent or recurrent

Anal fissures may also be painless, but still take a long time to heal and may bleed occasionally.

There are patients who try to delay bowel movements in order to prevent the painful anal fissure from flaring up. However, this further increases the risk of constipation with larger and harder stools, which make them even more difficult to expel.

Certain factors mean that one may be more prone to developing anal fissures.These include:

• Age – It is observed that many infants develop anal fissures, though the reason remains unclear.In adults, the occurrence can be attributed to decreased blood supply to the anal region because of poor circulation.
• Childbirth – Women are more susceptible to anal fissures after giving birth.
• Constipation – Sitting on the toilet for too long, or excessive straining during bowel movements can cause the anal canal to stretch and tear.
• Diarrhoea – On-going diarrhoea causes the anal canal to become dry, making it prone to tearing.
• Anal Intercourse – Trauma sustained during anal sexual activities can result in anal fissures.

Although an anal fissure is not a life-threatening condition, it does come with complications that can affect overall quality of health and life.These are:

• Inability to heal – Most anal fissures heal by themselves in a week or two,but in some instances,they don’t. These are considered chronic fissures that require medical or surgical intervention.
• Recurrence – Anal fissures can return after healing.
• Anal stricture – The presence of scar tissue or a spastic anal sphincter may cause the anal canal to become narrow, which impedes the regular passage of stools.
• Sentinel pile and fibroepithelial polyps – There may excessive growth of skin around the anus externally, often due to the repeated attempts at healing. This is usually a sign that the anal fissure is chronic.

Most cases of anal fissures can be treated at home with stool softeners and sitz baths, and simple diet and lifestyle modifications. These include sticking to a high-fibre diet to avoid constipation, keeping hydrated during the day and not straining or sitting on the toilet for a prolonged period. Some anal fissures heal on their own within one to two weeks even without treatment.

If the anal fissures still do not improve after two weeks, you should seek medical attention. Initially,topical and anesthetic creams may be given to reduce pain and inflammation. Nitroglycerin ointments are also commonly prescribed to relax the sphincter, improve blood supply to the anal area and encourage healing. To treat a spastic anal sphincter, botulinum toxin injections can help lessen spasms by immobilising the sphincter muscle.

For severe anal fissures that are not responsive to diet and lifestyle changes and medications, surgery is the recommended treatment option. Lateral Anal Sphincterotomy(LAS)is typically performed,where a small portion of the sphincter muscle is removed to prevent pain and spasms.

The steps taken to prevent anal fissures are similar to the steps taken to avoid constipation. They include:

• Eating high-fiber food
• Drinking plenty of fluids
• Exercising regularly
• Cleaning the anal area and keeping it dry
• Changing diapers frequently (for infants)

While anal fissures cannot always be avoided, simple diet and lifestyle modifications can greatly reduce one’s risk of developing it more often.