Anal fissure
Encyclopedia
An anal fissure is a break 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 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.
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 spasm
ing 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.
In adults, fissures may be caused by constipation, the passing of large, hard stools, or by prolonged diarrhea as well as anal sex. In older adults, anal fissures may be caused by decreased blood flow to the area.
Anal fissures are also common in women after childbirth and persons with Crohn's disease
.
In infant
s, frequent diaper
change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough fluids (i.e. breastmilk, proper ratios when mixing formulas). In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.
into the anal sphincter.
Other measures include warm sitz bath
s, topical anesthetics, high-fiber diet and stool softeners.
and then calcium channel blockers with in 1999 nifedipine
ointment,
and the following year with topical diltiazem
.
Branded preparations are now available of topical nitroglycerine ointment (Rectogesic (Rectiv) as 0.2% in Australia and 0.4% in UK and US), 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
(Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993. However it must be noted that, in many cases involving Botox injections the patients eventually had to choose another cure as the injections proved less and less potent, spending thousands of dollars in the meantime for a partial cure. Lateral sphincterotomy is the Gold Standard for curing this affliction.
Combination of medical therapies may offer up to 98% cure rates.
The main concern with surgery is the development of anal incontinence. Anal incontinence can include inability to control gas, mild fecal soiling, or loss of solid stool. Some degree of incontinence can occur in up to 45 percent of patients in the immediate surgical recovery period. However, incontinence is rarely permanent and is usually mild. The risk should be discussed with your surgeon.
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 spasming 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.
LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%).
. In addition, anal stretching can increase the rate of flatus incontinence.
In the early 1990s, however, a repeatable method of anal dilation proved to be very effective and showed a very low incidence of side effects. Since then, at least one other controlled, randomized study has shown there to be little difference in healing rates and complications between controlled anal dilation and LIS, while another has again shown high success rates with anal dilation coupled with low incidence of side effects.
Anal canal
The anal canal is the terminal part of the large intestine.It is situated between the rectum and anus, below the level of the pelvic diaphragm. It lies in the anal triangle of perineum in between the right and left ischioanal fossa....
. 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
Rectal pain
Rectal pain is the symptom of pain in the area of the rectum. A number of different causes have been documented.-Anal fissures:Anal fissure is the most common cause of rectal pain...
after defecation 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.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 spasm
Spasm
In medicine a spasm is a sudden, involuntary contraction of a muscle, a group of muscles, or a hollow organ, or a similarly sudden contraction of an orifice. It is sometimes accompanied by a sudden burst of pain, but is usually harmless and ceases after a few minutes...
ing 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.
In adults, fissures may be caused by constipation, the passing of large, hard stools, or by prolonged diarrhea as well as anal sex. In older adults, anal fissures may be caused by decreased blood flow to the area.
Anal fissures are also common in women after childbirth and persons with Crohn's disease
Crohn's disease
Crohn's disease, also known as regional enteritis, is a type of inflammatory bowel disease that may affect any part of the gastrointestinal tract from mouth to anus, causing a wide variety of symptoms...
.
Prevention
For adults, the following may help prevent anal fissures:- Avoiding straining when defecating. This includes treating and preventing constipationConstipationConstipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
by eating food rich in dietary fiberDietary fiberDietary fiber, dietary fibre, or sometimes roughage is the indigestible portion of plant foods having two main components:* soluble fiber that is readily fermented in the colon into gases and physiologically active byproducts, and* insoluble fiber that is metabolically inert, absorbing water as it...
, drinking enough water, occasional use of a stool softener, and avoiding constipating agents such as caffeine. 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. hemorrhoidHemorrhoidHemorrhoids or haemorrhoids , are vascular structures in the anal canal which help with stool control. They become pathological or piles when swollen or inflamed. In their physiological state they act as a cushion composed of arterio-venous channels and connective tissue that aid the passage of...
ointments) can be helpful.
In infant
Infant
A newborn or baby is the very young offspring of a human or other mammal. A newborn is an infant who is within hours, days, or up to a few weeks from birth. In medical contexts, newborn or neonate refers to an infant in the first 28 days after birth...
s, frequent diaper
Diaper
A nappy or a diaper is a kind of pant that allows one to defecate or urinate on oneself discreetly. When diapers become soiled, they require changing; this process is often performed by a second person such as a parent or caregiver...
change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough fluids (i.e. breastmilk, proper ratios when mixing formulas). In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.
Treatment
Non-surgical treatments are recommended initially for acute and chronic anal fissures. These include topical nitroglycerin or calcium channel blockers, or injection of botulinum toxinBotulinum toxin
Botulinum toxin is a protein produced by the bacterium Clostridium botulinum, and is considered the most powerful neurotoxin ever discovered. Botulinum toxin causes Botulism poisoning, a serious and life-threatening illness in humans and animals...
into the anal sphincter.
Other measures include warm sitz bath
Sitz bath
A sitz bath is a bath in which a person sits in water up to the hips. It is used to relieve discomfort and pain in the lower part of the body, for example, due to hemorrhoids , anal fissures, rectal surgery, an episiotomy, uterine cramps, inflammatory bowel disease, and infections of the bladder,...
s, topical anesthetics, high-fiber diet and stool softeners.
Medication
Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,and then calcium channel blockers with in 1999 nifedipine
Nifedipine
Nifedipine is a dihydropyridine calcium channel blocker...
ointment,
and the following year with topical diltiazem
Diltiazem
Diltiazem is a non-dihydropyridine member of the class of drugs known as calcium channel blockers, used in the treatment of hypertension, angina pectoris, and some types of arrhythmia....
.
Branded preparations are now available of topical nitroglycerine ointment (Rectogesic (Rectiv) as 0.2% in Australia and 0.4% in UK and US), 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
Botulinum toxin
Botulinum toxin is a protein produced by the bacterium Clostridium botulinum, and is considered the most powerful neurotoxin ever discovered. Botulinum toxin causes Botulism poisoning, a serious and life-threatening illness in humans and animals...
(Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993. However it must be noted that, in many cases involving Botox injections the patients eventually had to choose another cure as the injections proved less and less potent, spending thousands of dollars in the meantime for a partial cure. Lateral sphincterotomy is the Gold Standard for curing this affliction.
Combination of medical therapies may offer up to 98% cure rates.
Surgery
Surgical procedures are generally reserved for people with anal fissure who have tried medical therapy for at least one to three months and have not healed. It is not the first option in treatment.The main concern with surgery is the development of anal incontinence. Anal incontinence can include inability to control gas, mild fecal soiling, or loss of solid stool. Some degree of incontinence can occur in up to 45 percent of patients in the immediate surgical recovery period. However, incontinence is rarely permanent and is usually mild. The risk should be discussed with your surgeon.
Surgical treatment, under general anaesthesia, was either anal stretch (Lord's operation) or lateral sphincterotomy
Lateral internal sphincterotomy
Lateral internal sphincterotomy is an operation performed on the internal anal sphincter muscle for the treatment of chronic anal fissure. The internal anal sphincter is one of two muscles that comprise the anal sphincter which controls the passage of feces...
where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter spasming and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general anaesthetic
General anaesthetic
A general anaesthetic is a drug that brings about a reversible loss of consciousness. These drugs are generally administered by an anaesthesia provider to induce or maintain general anaesthesia to facilitate surgery...
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.
Lateral internal sphincterotomy
Lateral internal sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%). In this procedure the internal anal sphincter is partially divided in order to reduce spasming and thus improve the blood supply to the perianal area. This improvement in the blood supply helps to heal the fissure, and the weakening of the sphincter is also believed to reduce the potential for recurrence. The procedure is generally performed as a day surgery after the patient is given general anesthesia. The pain from the sphincterotomy is usually mild and is often less than the pain of the fissure itself. Patients often return to normal activity within one week.LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%).
Anal dilation
Anal dilation, or stretching of the anal canal (Lord's operation) has fallen out of favour in recent years, primarily due to the perceived unacceptably high incidence of fecal incontinenceFecal incontinence
Fecal incontinence is the loss of regular control of the bowels. Involuntary excretion and leaking are common occurrences for those affected. Subjects relating to defecation are often socially unacceptable, thus those affected may be beset by feelings of shame and humiliation...
. In addition, anal stretching can increase the rate of flatus incontinence.
In the early 1990s, however, a repeatable method of anal dilation proved to be very effective and showed a very low incidence of side effects. Since then, at least one other controlled, randomized study has shown there to be little difference in healing rates and complications between controlled anal dilation and LIS, while another has again shown high success rates with anal dilation coupled with low incidence of side effects.