What Is An Anal Fissure?

Overview

Are you experiencing a painful crack or tear in your anus? Then, you could be having an anal fissure. Anal fissures are tears, ulcers, or cracks in the lining of your anus. They are pretty common and are sometimes mistaken for haemorrhoids (which are balls of swollen veins that often bleed).¹ They are seen in all age groups but are more common in young adults; those assigned male at birth (AMAB) and those assigned female at birth (AFAB) are equally affected. The major symptoms of an anal fissure are pain, which is very severe and more during defecation, and moderate bleeding when compared to that from other anal pathologies like haemorrhoids. You may also experience some spasms in your anus. Anal fissures could be acute or chronic (long-standing and greater than 8 weeks). 

Treatment ranges from simple interventions like increasing fibre diet and use of warm baths to using medications and occasionally, surgery. Anal fissures do not cause or increase your risk of colon cancer. However, other ailments that present the same way could predispose an individual to colon cancer, hence the need for proper evaluation of any individual with symptoms anal symptoms.⁶

Causes of anal fissure

Fissures occur commonly from trauma to the lining of the anal canal. Some causes are:^1,2 

• Passage of large, hard, or dry stools
• Straining and constipation during bowel movement
• Persistent diarrhoea
• Weight loss surgeries, because they also cause profuse diarrhoea
• Anal intercourse
• Low intake of dietary fibres
• Pregnancy and childbirth
• Anal spasms (can lead to further tearing of anal fissure and development of a chronic fissure)
• People with tight anal sphincters
• Trauma (for example, from high-level mountain biking)

Less common causes of anal fissures include:

• Inflammatory bowel diseases like Crohn's disease
• Anal tumours
• HIV/AIDS
• Tuberculosis (TB)
• Syphilis

Signs and symptoms of anal fissure

Anal fissures are very painful. This symptom of pain is actually the most prominent symptom and is very discomforting.⁵ The pain can last several minutes to hours and can prevent patients from moving their bowels due to fear of experiencing pain. Other symptoms include:

• Visible tear or ulcer on anal examination
• Bright red bleeding during or after bowel movements
• Anal spasm (this refers to contractions of anal muscles just beneath the fissure following the pain. Spasms lead to delayed healing of your anal fissure and cause you more pain; this is referred to as fissure cycle)
• Constipation (hesitation to defecate due to pain)
• Skin tag or lump close to the anal fissure (more common in chronic anal fissures)

Complications of anal fissures include

Some of the complications a person with an anal fissure might face are: 

• Failure to heal: When anal fissures do not heal within eight weeks, they become chronic and would need further evaluation and management
• Recurrence: Having an anal fissure once increases your risk of developing another one
• Tear of anal muscles: Anal tears could extend into the anal muscles causing a more painful condition
• Reduced quality of life: Anal fissures can affect the overall quality of life of an individual
• Difficulty with moving your bowels: This occurs due to the pain one experiences during bowel movements as a result of constipation which could even further complicate the ailment

Diagnosis of anal fissure

To make a diagnosis of anal fissure, your doctor will ask you questions regarding 

• The symptoms you've noticed like anal pain and bleeding during bowel movement 
• Your toilet habits
• Other personal histories will be taken to determine what could have possibly caused you to have an anal fissure
• A rectal examination will be done finally by gently parting your buttocks to visualise the extent of your anal fissure. 
• A colonoscopy may also be done for better visualisation of your colon and rectum

Management and treatment for anal fissure

Anal fissures will usually heal on their own in a few weeks but can easily reoccur if they are not properly handled. In some people, an anal fissure can last over 8 weeks, at this point it is referred to as chronic anal fissure.

There are two major methods for managing anal fissures. Your doctor could adopt any of them after taking into consideration your personal history and the result of your rectal examination. They are:

• Non-surgical method
• Surgical method

The benefits and possible side effects of these treatment options will be explained to you by your physician.

Non-surgical method

This method involves the following:^3,4

• A high-fibre diet is highly recommended as this will aid easy bowel movements. Consuming 30g of fibre per day is the target
• Over-the-counter fibre supplements to make your stools soft, formed, and bulky
• Over-the-counter stool softeners 
• Drinking enough water (at least 8 glasses) prevents hard stools and also aids fissure healing
• Warm tub baths (sitz baths) help to heal. It is done for 10 to 20 minutes, a few times per day. It helps to reduce anal spasms
• Medications for pain relief such as lidocaine, can be applied to the skin around the anus. Narcotic pain relievers are not really advocated because they can cause constipation
• Medications such as diltiazem, nifedipine, or nitroglycerin ointment help your anal sphincters to relax. This relaxation aids the healing process
• Regular exercise

Surgical method

Most anal fissures do not necessarily require surgical intervention.⁷ Chronic fissures can be difficult to treat and may require surgery.^1,4 The goal of surgery is to relieve the pain and spasms caused by anal fissures and also release the pressure in the anus, hence promoting healing. Surgical methods include:

• Injection of botulinum toxin (Botox) into the anal sphincter
• Lateral internal sphincterotomy (which involves surgical division of a part of the sphincter)

Both techniques are day cases, meaning you can return home after the procedure. The decision on which type should be made depends largely on your surgeon.⁸

FAQs

How is anal fissure diagnosed?

The diagnosis of anal fissure is done after your physician gets information regarding your personal history and symptoms you are currently experiencing like if there is any bleeding from your anus or a painful crack in your anal lining. A rectal examination is also done to visualise the anal fissure to differentiate it from other anal pathologies with similar symptoms.

How can I prevent anal fissure?

Anal fissures can be prevented by ensuring a proper diet rich in fibre as this enables ease of bowel movement. Constipation and frequent diarrhoea are also risk factors, so you should avoid them. Likewise, prevent anything that will make you strain. Infections like HIV/AIDS and tuberculosis should be promptly diagnosed and treated so that they don't cause anal fissures. Exercise regularly and drink enough water, about 8 glasses per day.

Who is at risk of anal fissure?

Anal fissures affect all age groups but it is more common in infants and young and middle-aged adults. The risk factors are constipation, frequent diarrhoea, straining, or passing bulky, hard, and dry stool. If someone has infections or anal tumours, they are at risk of developing an anal fissure. Some pregnant individuals also experience anal fissures during pregnancy or childbirth. Trauma to the anal lining could also come from high mountain biking and other rigorous forms of exercise. Autoimmune conditions like inflammatory bowel disease (Crohn's disease) can lead to anal fissures.

How common is anal fissure?

Anal fissures are quite common. All ages and sexes are affected equally, however, children (especially infants) and young and middle-aged adults are more affected. The peak age is between the ages of 15-40 years. About 1 in 10 people develop fissures in their lifetime.

When should I see a doctor?

You should see your doctor when you think you have an anal fissure. You shouldn't feel embarrassed as this is a very common condition that your general practitioner sees frequently. Likewise, you should discuss your symptoms with your GP and cooperate with physical examinations and any other investigation that should necessarily be conducted. Because some other conditions like haemorrhoids can mimic anal fissures, it is necessary that your GP should properly examine you to rule these out.

Most anal fissures will heal within a couple of weeks with basic treatment. In case you've had an anal fissure for longer than 8 weeks, surgery may be recommended because it is now a chronic fissure. Your GP will also discuss methods of prevention with you so that the fissure does not reoccur.

Summary

An anal fissure is a tear or break in the anal lining. It is painful and very common. Children and young and middle-aged adults (15-40 years) experience this ailment more commonly than older adults. The major causes are linked to dietary and bowel habits. Constipation and diarrhoea increase the risk of an individual having an anal fissure. Infections and tumours are less common causes. A diagnosis is best made by a doctor after a proper analysis of your history, addressing symptoms like bleeding, anal spasms, and pain along with proper investigations to rule out any other possible causes. A rectal examination is very important in order to rule out other similar anal problems. Treatment options are non-surgical and surgical. Surgery isn't commonly done unless in cases like chronic anal fissure which happens in some individuals. To prevent anal fissures, be sure to increase your intake of water, exercise regularly and prevent anything that may cause constipation or diarrhoea.