An anal fissure is an unnatural crack or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on the toilet paper, sometimes in the toilet. If acute they may cause severe periodic pain after defecation [1] but with chronic fissures pain intensity is often less. Anal fissures usually extend from the anal opening and are usually located posteriorly in the midline, probably because of the relatively unsupported nature of the anal wall in that location. Fissure depth may be superficial or sometimes down to the underlying sphincter muscle.
Causes
Most anal fissures are caused by stretching of the anal mucosa beyond its capability. For example, anal fissures are common in women after childbirth[2], after difficult bowel movements, anal sex, and in infants following constipation.[3]
Superficial or shallow anal fissures look much like a paper cut, and may be hard to detect upon visual inspection, they will generally self-heal within a couple of weeks. However, some anal fissures become chronic and deep and will not heal. The most common cause of non-healing is spasming of the internal anal sphincter muscle which results in impaired blood supply to the anal mucosa. The result is a non-healing ulcer, which may become infected by fecal bacteria.[4]
Be advised that anal fissures can be confused with a rare cancer such as anal cancer. It is wise to visit a proctologist if you experience anal bleeding. Few general practitioners or gynecologists recognize anal cancer because of its rarity.
[edit] Prevention
For adults, the following may help prevent anal fissure:
Avoiding straining when defecating. This includes treating and preventing constipation by eating food rich in dietary fiber, drinking enough water, occasional use of a stool softener, and avoiding constipating agents such as caffeine.[5] Similarly, prompt treatment of diarrhea may reduce anal strain.
Careful anal hygiene after defecation, including using soft toilet paper and/or cleaning with water.
In cases of pre-existing or suspected fissure, use of a lubricating ointment (e.g hemorrhoid ointments) can be helpful.
In infants, frequent nappy/diaper change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough water (i.e. sufficiently diluted juices) may thus help avoid fissures. In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.
Taking precautions during anal sex, such as using artificial lubricants.
[edit] Treatment
Non-surgical treatment is recommended as first-line treatment of acute and chronic anal fissures.[6] [7] Customary treatments included warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.
Surgical treatment, under general anaesthesia, was either anal stretch (Lord's operation) or lateral sphincterotomy where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter tone and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general anaesthetic and can be painful postoperatively. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.
A new medical/surgical development came in 1993 when researchers reported injecting botulinum toxin into the anal sphincter to relax the sphincter and promote fissure healing.[1]
From 1995, doctors began to prescribe various drugs to reduce the tone of the internal sphincter and operations for anal fissure have since then decreased by two-thirds. All treatment options have recently been reviewed by Collins and Lund.[8]
[edit] Chemical sphincterotomy
Chronic fissures rarely heal because of poor blood supply caused by excessive sphincter spasm. Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[9][10][11] [12] and then calcium channel blockers with in 1999 nifedipine ointment,[13][14] and the following year with topical diltiazem.[15] Branded preparations are now available of topical nitroglycerine ointment (Rectogesic as 0.2% in Australia and 0.4% in UK), topical nifedipine 0.3% with lidocaine 1.5% ointment (Antrolin in Italy since April 2004) and diltiazem 2% (Anoheal in UK, although still in Phase III development). A common side effect drawback of nitroglycerine ointment is headache, caused by systemic absorption of the drug, which limits patient acceptability.
A combined surgical and pharmacological treatment, administered by colorectal surgeons, is direct injection of Botulinum toxin into the anal sphincter to relax it. This treatment was first investigated in 1993.[16] Combination of medical therapies may offer up to 98% cure rates,[17]
[edit] Surgical sphincterotomy
Surgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. Despite their high success rate (~95%), they are used only after medical treatment has failed due to their potential complications. These include general risks from anesthesia, infection and anal leakage (fecal incontinence). Surgical procedures include:
Lateral internal sphincterotomy or excising a portion of the sphincter.
Anal dilation, or stretching of the anal canal, (Lord's operation) is no longer recommended because of the unacceptably high incidence of fecal incontinence.[18] In addition, anal stretching can increase the rate of flatus incontinence.[19]
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