Impact Of Anal Fissures On Quality Of Life And Daily Activities

Overview

An anal fissure is a tear, or crack, in the anus. This is a common condition characterized by severe pain and difficult defecation, which alters one’s quality of life. Fissures can sometimes be confused with haemorrhoids. These are inflamed blood vessels in, or just outside, the anus. Both fissures and haemorrhoids often result from passing hard stool. Most fissures heal with self-care.¹

What is an anal fissure?

The anal canal is a short, hollow tube that surrounds muscles at the end of the rectum. The rectum is the lower part of the colon (i.e., the large intestine). An anal fissure is a painful linear tear or defect in the skin that lines the opening of the anus. ²

Prevalence

• Anal fissures can affect both men and women of all ages
• 85–90% of fissures occur in the posterior midline (back) of the anus, with about 10–15% occurring in the anterior midline (front)³
• Some patients experience fissures located both in the front and back of the anus
• Fissures that are present elsewhere (e.g., off to the side) should raise suspicion for diseases that may need further investigation³

Causes and risk factors

Anal fissures are caused by multiple factors, including:^4,5

• Trauma to the inner surface of the anus
• A hard, dry bowel movement or chronic constipation is typically responsible
• Diarrhea and loose stools
• Infant dyschezia
• Penetration

Certain factors precipitate anal fissures, including the following:^4,5

• Constipation with straining to pass hard stool.
• Severe diarrhoea
• Vaginal childbirth.
• Any inflammatory condition of the anal area.
• A low-fiber diet.
• Recent weight loss surgery leads to frequent diarrhoea

Impact on quality of life

Despite their small size, these fissures can significantly impact one’s quality of life, leading to chronic pain, bleeding, and fear of defecation due to anticipated pain in some cases.

Quality of life, a multifaceted construct, encompasses physical, psychological, and social aspects.

Physical symptoms

Symptoms can differ from person to person. Fissures are the most common cause of severe anal and rectal pain. The symptoms can include:

1. Pain during and after bowel movements lasting from several minutes to a few hours
2. Bleeding: fresh red blood from the anus on the toilet paper or on the stool
3. A visible tear or cut in the area
4. Spasms in the anal sphincter and a subsequent increase in anal sphincter muscle pressure, resulting in decreased blood flow to the site of the injury

Psychological impact

There is a high comorbidity of psychopathology in patients with chronic anal fissures:⁶

• Anxiety related to pain and bowel movements: stress and anxiety can contribute to digestive issues like constipation or diarrhoea, which can worsen or trigger anal fissures
• Fear of using the bathroom: many patients fear having a bowel movement and avoid defecation after the pain
• Impact on mental health and well-being: depression and anxiety negatively affect the quality of life and mental health
• Severe pain and bleeding have a negative impact on daily functioning

Impact on sleep and daily activities

Pain and discomfort from anal fissures can disrupt sleep, by making it difficult to find a comfortable position, ultimately leading to sleep deprivation. ⁷Anal fissures can make sitting for extended periods painful, which can affect productivity and concentration. People might need to take frequent breaks, use cushions, or work in standing positions to alleviate discomfort.

Management

The management of anal fissures depends on your symptoms and overall health, as well as the severity of the fissures.

• An acute anal fissure lasts for a short time. It often heals within 6 weeks when constipation is managed
• A chronic anal fissure lasts for 6 weeks or more and may need specific treatment, such as surgery

Conservative treatment

Most anal fissures do not require surgery. Here are some of the most common conservative treatments for an acute anal fissure:⁸

• A high-fibre diet and over-the-counter fiber supplements (25-35 grams of fibre/day) make one’s stool more consistent
• Stool softeners and high water intake are necessary to promote soft bowel movements and help the healing process
• Antidiarrheals (medicines to stop diarrhoea) may be required for loose and frequent stools
• Topical anesthetics, such as lidocaine, can be administered for anal pain
• A sitz bath involves sitting in warm water for 10-20 minutes several times a day (especially after bowel movements). This can help reduce pain, promote blood flow to the area, and accelerate healing

Medical interventions

Non-operative interventions will help with the resolution of pain and bleeding, as more than half of acute fissures can be treated in this manner with no side effects. Other medications may be prescribed when a patient has a chronic-type fissure, to promote relaxation of the anal sphincter muscles.⁸

Chronic fissures are generally more resistant to treatment, and your surgeon may recommend surgical intervention either as an initial treatment or following medical management. Narcotic pain drugs are not recommended for anal fissures, as they increase constipation.⁸

Surgery

Anal fissures that are resistant to conservative treatment may require surgical intervention. Other treatment options for anal fissures may include anal Botox or surgery.⁹

• Botulinum toxin (Botox) injections significantly promote the quality of life in those with chronic anal fissures. It is performed as an outpatient procedure and can temporarily relax the anal muscle, allowing the fissure to heal. It can be repeated if necessary
• Anal sphincterotomy is an effective treatment for anal fissures, and recurrence rates after the procedure are low. It aims to cut a portion of the anal sphincter muscle to relax and open the area

Surgical treatments have their risks and advantages. It is important to discuss them in detail with your provider.^9,10

Potential for chronicity

Anal fissure pain can cause your anal muscles to tighten and spasm. This delays the healing of the fissure. This spasm can also result in more tearing during bowel movements. This cycle leads to a chronic anal fissure. Instead of healing, they reinforce themselves in this vicious cycle, leading to a persistent wound.

Seek medical advice

If your symptoms persist after one or two months, you may need medical treatment. Contact your healthcare provider if you notice blood in your stool, or if your bowel movements are so painful that you are avoiding going to the bathroom.

FAQ’s

What are the signs that my condition is improving?

Most anal fissures resolve in a few days or weeks. The main sign of improvement is when bowel movements stop being painful. You might also stop seeing blood when you have a bowel movement.

Can anal fissures cause complications if left untreated?

Yes, untreated anal fissures can lead to complications such as chronic pain, persistent bleeding, the development of a sentinel pile (a skin tag), or infection leading to abscesses. Chronic fissures might also result in scar tissue and narrowing of the anal canal.

How does diet influence the healing of anal fissures?

A fibre-rich diet can soften stools, making bowel movements less painful and reducing the strain that can worsen or cause fissures. Fibre-rich foods such as fruits, vegetables, whole grains, and legumes are beneficial. Avoiding spicy foods and caffeine can also help minimize irritation.

Is surgery always necessary for chronic anal fissures?

Surgery is not always necessary and it’s typically considered after other treatments have failed. Non-surgical treatments, like Botox injections or topical medications, are usually considered first. Surgeries, like lateral internal sphincterotomies, are reserved for severe and persistent cases.

How can parents help children with anal fissures?

For children, ensure they drink plenty of fluids, eat a high-fibre diet, and avoid foods that can cause constipation. Encourage regular toilet habits and gentle wiping techniques. If symptoms persist, consult a paediatrician for appropriate treatment.

Can travelling exacerbate anal fissures?

Travelling can exacerbate anal fissures due to prolonged sitting, dehydration, and changes in diet and routine. To minimize discomfort, stay hydrated, take regular breaks to move around, and maintain a high-fibre diet even while on the go.

Summary

Anal fissures are normally not dangerous, but they can cause a lot of pain. Most anal fissures may heal within a few days or weeks. However, in more severe cases, fissures might not heal on their own, and require treatment.. Chronic anal fissures are known to have a negative impact on quality of life. This article addressed a wide range of conservative, medical, and surgical treatment options. Seek medical attention as soon as possible if you experience any symptoms relating to a chronic fissure. A healthcare provider will work with you to provide relief.