An anal fissure is a small tear in the thin, moist tissue (mucosa) that lines the anus. An anal fissure may occur when you pass hard or large stools during a bowel movement. Anal fissures typically cause pain and bleeding with bowel movements. You also may experience spasms in the ring of muscle at the end of your anus (anal sphincter).
An anal fissure usually isn’t a serious condition. It can affect people of all ages, and it’s often seen in infants and young children since constipation is a common problem in these age groups. In fact, it’s thought that around one in 10 people get one at some point in their life. Anyone can get an anal fissure, including children, but it’s most common in people aged 15 to 40.
Most anal fissures heal with home treatment after a few days or weeks. These are called short-term (acute) anal fissures. If you have an anal fissure that hasn't healed after 8 to 12 weeks, it is considered a long-term (chronic) fissure. A chronic fissure may need medical treatment.
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Causes of anal fissure
For most people who develop an anal fissure, there isn’t any obvious reason why. It’s usually thought to happen if your anal canal has been damaged though, often as a result of a hard or painful bowel movement. As a result, the muscles around your anus (the internal sphincter muscles) spasm and tense up. This reduces the blood supply to the area, which stops the tear from healing properly. Having further hard bowel movements can then make the fissure come back, or get worse.
Sometimes, there is a clear underlying reason why you may develop an anal fissure. These may include the following:
. Straining when you go to the toilet due to constipation.
. Being pregnant or giving birth – this can put pressure on your perineum (the area between your anus and vulva).
. Having an inflammatory bowel disease, such as Crohn’s disease.
. Having a sexually transmitted infection or a skin infection.
. Having a condition that affects your skin, such as psoriasis.
. Taking certain medicines, such as painkillers containing opioids, or having chemotherapy.
. Having had trauma to your anus, for example, through having anal sex or through surgery.
. Having bowel cancer.
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Symptoms of anal fissure
If you have an anal fissure, you may have the following symptoms.
. A sharp, searing or burning pain in, or around, your bottom when you pass faeces. You can continue to feel some pain for hours afterwards. Some people describe the pain of an anal fissure as like passing broken glass.
. Bleeding when you pass faeces. Not everyone has bleeding with an anal fissure. But if you do, you might see blood in the toilet bowl after you’ve had a bowel movement.
. Spasms (sudden tightening) in the muscles around your anus when you pass faeces.
. A tearing sensation in your anus when you pass faeces.
These symptoms may not always be due to an anal fissure. For instance, piles (haemorrhoids) can cause pain in your anus too. If you have any of these symptoms though, contact your GP. It’s always important to seek medical advice if you notice bleeding after passing faeces.
Certain factors raise the risk for anal fissures, including:
. Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
. Eating a low-fiber diet
. Intense diarrhea
. Recent weight loss surgery, because it leads to frequent diarrhea
. Childbirth. Anal fissures are more common in women after they give birth.
. Minor trauma, especially trauma caused by high-level mountain biking
. Crohn's disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing.
. Anal fissures may also result from inflammatory bowel disease, surgery, or other medical treatments that affect bowel movements or the anus.
. Anal intercourse.
. Anal fissures can occur at any age, but are more common in infants and middle-aged adults.
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Complications of anal fissure can include:
. Failure to heal. An anal fissure that fails to heal within eight weeks is considered chronic and may need further treatment.
. Recurrence. Once you've experienced an anal fissure, you are prone to having another one.
. Pain and discomfort
. Uncontrolled bowel movements and gas
. A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds your anus closed (internal anal sphincter), making it more difficult for your anal fissure to heal. An unhealed fissure can trigger a cycle of discomfort that may require medications or surgery to reduce the pain and to repair or remove the fissure.
How is an anal fissure diagnosed?
A doctor can usually diagnose an anal fissure simply by examining the area around the anus. However, they may want to perform a rectal exam to confirm the diagnosis.
During this exam, the doctor may insert an anoscope into your rectum to make it easier to see the tear. This medical instrument is a thin tube that allows doctors to inspect the anal canal.
Using an anoscope may also help your doctor find other causes of anal or rectal pain such as hemorrhoids. In some cases of rectal pain, you may need an endoscopy for better evaluation of your symptoms.
You can reduce your risk of developing an anal fissure by preventing constipation. This is really important if you’ve already had an anal fissure, as it can help to stop it coming back. You can help to prevent constipation by making sure you have a healthy balanced diet that contains plenty of fibre, drinking enough fluids and exercising regularly.
If you have another health condition that increases your risk of getting an anal fissure, speak to your doctor. They will talk you through how to best manage your condition and reduce your risk of getting an anal fissure.
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Treatment of anal fissure
Most anal fissures heal by themselves within six to eight weeks. There are a number of things you can do to help it heal, and relieve your pain and discomfort. These include the following:
. Gradually increase the fibre in your diet, by including plenty of wholegrain foods, fruit and vegetables. This will help keep faeces soft and easier to pass.
. Make sure you’re drinking enough fluids, especially if you’re increasing your fibre intake.
. Keep the area clean and dry, to prevent infection.
. Go to the toilet as soon as you have the sensation of needing a bowel movement, and try not to strain when you go. ‘Holding on’ when you need to pass faeces and straining can make a fissure worse.
. Try sitting in a warm bath to relieve any pain, particularly after you’ve had a bowel movement.
If your pain is particularly severe, or your symptoms aren’t improving, there are a number of treatments you can try.
The following medicines can help to relieve pain associated with an anal fissure, or help it to heal.
. Laxatives or stool softeners, such as ispaghula husk or lactulose. These work by softening your faeces, making them easier to pass. You can buy them over the counter from a pharmacist without a prescription. It’s best to get advice from your pharmacist or GP first though.
. Over-the-counter painkillers, such as paracetamol or ibuprofen. These can help with the pain of an anal fissure. You can buy these from a pharmacy or supermarket without a prescription. Make sure you read the patient information leaflet in the packet.
. Anaesthetic ointment (e.g. lidocaine). Your GP may prescribe this for a few days if you’ve been having extreme pain when you pass faeces. You apply this ointment to your anus to help numb the area before you have a bowel movement.
. Glyceryl trinitrate (GTN). This is an ointment that helps your internal sphincter muscle to relax. It improves blood flow to your anal area, helping the fissure to heal. Your GP may prescribe this if you’ve had a fissure for over a week, and other measures don’t seem to be helping. You’ll need to use it for six to eight weeks.
. Calcium-channel blockers (e.g. diltiazem cream). Like GTN ointment, this medicine relaxes the muscles in your anus and improves blood flow to the area. It’s associated with fewer side-effects than GTN ointment. In some areas, your GP may need to refer you to a colorectal surgeon to get a prescription for this medicine.
Procedures to treat anal fissure
If other treatment options haven’t helped your anal fissure to heal, or it keeps coming back, your GP may refer you to a colorectal surgeon. Your surgeon will talk to you about what other options they may recommend for treating your anal fissure. These may include the following.
. Botulinum toxin (Botox) injections. In this procedure, your surgeon will apply the injection directly into your internal sphincter muscle. The aim is to temporarily relax this muscle so that your fissure can heal.
. Fissurectomy. This involves cutting away the damaged skin from around your anal fissure, along with any ‘sentinel’ skin tags (lumps of skin associated with the fissure). Your surgeon may suggest you have this alongside Botox injections.
. Lateral internal sphincterotomy. This is a type of surgery that involves cutting the sphincter muscles around your anus, to release the tension and let your fissure heal. Your doctor will usually only suggest this after you’ve tried other treatments first, including Botox.
. Anal advancement flaps. This involves taking healthy skin from your anal lining and using it to replace the broken skin in your fissure. You may have it at the same time as a sphincterotomy, or afterwards if your fissure still doesn’t heal.
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Recovering from Anal Fissure Surgery
It is important to note that complete healing with both medical and surgical treatments can take up to approximately 6-10 weeks. However, acute pain after surgery often disappears after a few days. Most patients will be able to return to work and resume daily activities in a few short days after the surgery.
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