An anal fissure is a tear or ulcer (open sore) which develops in the lining of the anal canal. The most common symptoms of anal fissures include:
The anal canal
The anal canal is the last part of the large intestine (colon), and it is located between the rectum (a small pouch where stools are stored) and the anus (the opening through which stools are passed out of the body).
The anal canal is
approximately 2.5 - 4cm (1 - 1.5in) long in adults, and it is lined by a thin layer of
cells known as squamous epithelium cells. If this lining becomes damaged, an
anal fissure can develop.
Causes of anal fissures
Most anal fissures occur when passing particularly hard stools (during constipation) which may damage the anal canal. Other known causes of anal fissures include:
- childbirth
- persistent diarrhoea
- inflammatory bowel disease (IBD), which is a general term for conditions which cause inflammation of the intestines, such as ulcerative colitis and Crohn’s disease.
Anal fissures can
also be classified according to how long symptoms last. For example:
- acute anal fissures – where symptoms do not last longer than six weeks
- chronic anal fissures – where symptoms last longer than six weeks
Treating anal fissures
Anal fissures usually heal within a few weeks without the need for medical treatment. Switching to a high-fibre diet must also help to relieve symptoms and speed up the recovery time, because the fibre makes it easier to pass stools.
Treatment for chronic
anal fissures can vary from person to person. Some cases can be relieved by
switching to a high-fibre diet, whereas others may need medication or even
surgery.
It is not always
possible to prevent anal fissures, but patients can take steps to prevent
constipation, which is a common cause. This includes eating a healthy diet with
plenty of fibre and drinking regular fluids.
Who is affected
Who is affected
Acute anal fissures are relatively common. They affect both sexes equally, and occur in people of all ages, including children. However, younger adults between the ages of 20 to 40 years old, are most likely to develop one.
Chronic anal fissures
are less common than acute anal fissures, but they are certainly not rare. It
is estimated that about 10% of people who visit a proctologist (a doctor who
specialises in conditions which affect the rectum and anus) do so because they
have a chronic anal fissure.
Symptoms of anal fissure
The symptoms of an anal fissure usually include pain and bleeding.
An anal fissure causes a severe and sharp pain when patients pass stools (poo). Some people have described the pain as feeling like trying to pass broken glass. Once this sharp pain has passed, it is usually replaced by a deep burning pain, that may be felt for several hours after patients have been to the toilet.
Anal fissures may also cause bleeding when patients pass stools. Most people may notice a small amount of bright red blood, either in their stools or on the toilet paper.
Patients must speak to their physician (doctor) if they suspect that they have an anal fissure. Most anal fissures get better without treatment, but the doctor will want to rule out other conditions, such as haemorrhoids (swollen blood vessels in the anus and rectum). They may also recommend treating the possible cause, such as by dietary advice for constipation.
Diagnosing anal fissure
To diagnose an anal fissure, the doctor will first ask about the patient's symptoms and the type of pain they have been experiencing. The doctor may also ask about the patient's toilet habits.
The doctor will usually need to carry out a physical examination to confirm that a patient has an anal fissure. In most cases, the doctor will be able to see the fissure by gently parting the patient's buttocks.
If the doctor
cannot see a fissure, then he may press gently on the edge of the patient's anus. If the patient has an anal fissure, then the patient will usually experience some pain when gentle
pressure is applied.
Very rarely, the doctor may need to perform a digital rectal examination (where he inserts a lubricated, gloved finger into the patient's anus to feel for abnormalities) in order to diagnose an anal fissure.
Very rarely, the doctor may need to perform a digital rectal examination (where he inserts a lubricated, gloved finger into the patient's anus to feel for abnormalities) in order to diagnose an anal fissure.
The doctor (physician) may refer the patient to a specialist, if they suspect something serious may be causing the anal fissure. The type of specialist will depend on the suspected cause of the patient's fissure.
A specialist in
hospital (e.g. colorectal surgeon or gastroenterologist) may have to examine the area more thoroughly, and this will usually be
done after using a topical anaesthetic, such as a cream, in order to numb the
area and help with the anal pain.
Preventing anal fissure
It is not always possible to prevent an anal fissure. However, one of the best ways to prevent one from developing is to avoid becoming constipated. The best ways to prevent constipation are:
High Fibre Diet
Patients must ensure that they ave
enough fibre in their diet. Most adults do not eat enough fibre. People must have
approximately 18g of fibre a day. They can increase their fibre intake by eating
more of these foods:
- fruit
- nuts
- seeds
- vegetables
- wholegrain rice
- oats
- wholewheat pasta
- wholemeal bread
Eating more fibre will keep the bowel movements regular, because it helps food pass through the digestive system more easily. Foods high in fibre also make people feel fuller for longer.
If a person is increasing his/ her fibre intake, it is important to increase it gradually. A sudden increase
may make them feel bloated. They may also produce more flatulence (wind) and have stomach cramps.
Fluids
People need to ensure that they drink plenty of fluids, in order to avoid dehydration and they need to steadily increase their intake when they are exercising or when it is hot. They need to try to cut back on the amount of caffeine, alcohol and fizzy drinks they consume.
Toilet habits
Patients should never ignore the urge to go to the toilet. Ignoring the urge may significantly increase their chances of having constipation. The best time for someone to pass stools is first thing in the morning, or about 30 minutes after a meal.
When people use the
toilet, they must make sure that they have enough time and privacy to pass stools comfortably.
Exercise
Keeping mobile and active will greatly reduce someone's risk of getting constipation. Ideally, people need to do at least 150 minutes of physical activity every week. Not only will regular exercise reduce their risk of becoming constipated, but it will also leave them feeling healthier and improve their mood, energy levels and general fitness.
Treating anal fissure
Like other small cuts or tears to the skin, an anal fissure will often heal by itself within a few weeks. However, patients may require treatment to help ease the pain and discomfort which an anal fissure may cause.
Patients must see their doctor if they have the symptoms and signs of an anal fissure, because it may be
caused by an underlying condition. If this is the case and the condition is not
treated, the fissure may not be able to heal and the problem will reoccur.
There are a number of
treatments which encourage anal fissures to heal, as well as easing associated pain. These include:
Soft stools are easier to pass with less pain and discomfort, so the doctor may recommend ways to soften the stools (e.g. stool softners).
Laxatives are a type of medicine which may help soften patients' stools. Adults with an anal fissure will usually be prescribed a bulk-forming laxative. Bulk-forming laxatives work by helping stools to retain fluid, making them softer and denser.
Children with an anal
fissure are usually prescribed an osmotic laxative. This works by increasing
the amount of fluid in the bowels, which in turn stimulates the body to pass
stools. Once someone starts taking a laxative, his physician may have to
adjust the dose until he finds that his stools are soft and easy to pass.
As well as using
laxatives, people must also increase the amount of fibre in their diet.
Foods which are high in fibre include:
- wholegrain bread
- seeds
- oats
- vegetables
- brown rice
- beans
- grains
- fruit and dried fruit
Adults must aim to
eat at least 18g of fibre every day. They can see how much fibre a food item
contains by looking at the nutritional information on the back of the food packet.
If someone is increasing his fibre intake, he should do so gradually. A sudden increase may cause
stomach cramps and make him produce more wind, leaving him feeling bloated. It
is also important to make sure that he drinks plenty of water. He should aim
to drink approximately 1.2 litres (six to eight glasses) of water a day, or
more when he is exercising or when it is hot.
It is important for patients with anal fissures to avoid causing pain or irritation when wiping after passing a stool. If they use baby wipes, they should not use products which contain fragrance or alcohol, as this could lead to discomfort or itching. If a patient uses toilet paper, he must use a soft brand if possible, and avoid rubbing the area too hard.
A topical medicine is one that people apply directly to the affected area. Topical anaesthetics work by desensitising (numbing) the skin, which in the case of an anal fissure, will help ease the sharp and severe pain patients may experience when passing stools.
Lidocaine is the most
commonly prescribed topical anaesthetic. It either comes in the form of a gel
or an ointment. Lidocaine is usually only used for one to two weeks, because the
fissure should start to heal within this time. It is usually applied shortly
before passing a stool, but patients must always follow the instructions which come
with the medicine.
If a patient experiences prolonged, burning pain after passing stools, they may be prescribed an analgesic (painkiller) such as paracetamol or ibuprofen. Again, the patient must always follow the dosage instructions on the patient information leaflet or the medication packet.
If a patient's symptoms do not start to improve after a week, they may be prescribed a medicine called glyceryl trinitrate (GTN). GTN works by expanding nearby blood vessels, which helps to increase the blood supply to the site of the fissure. The increase in blood supply must enable the fissure to heal faster.
GTN also reduces anal
pressure. This should help reduce the peri-anal pain. It comes in the form of an
ointment and it is applied directly to the anal area, usually every 12
hours. GTN is not suitable
for use by pregnant or breastfeeding women.
It is also unsuitable for children. Headaches are a very common side effect of this type of medicine. Approximately 50% of people using GTN will experience a headache. Some people may also feel dizzy or light-headed after using GTN. Patients will usually have to use GTN ointment for six to eight weeks, or until their fissure has completely healed.
It is also unsuitable for children. Headaches are a very common side effect of this type of medicine. Approximately 50% of people using GTN will experience a headache. Some people may also feel dizzy or light-headed after using GTN. Patients will usually have to use GTN ointment for six to eight weeks, or until their fissure has completely healed.
Calcium channel
blockers are a type of medication which is usually used to treat high blood
pressure (hypertension). However, they have also proved useful in treating
cases of anal fissures in some patients.
Topical calcium
channel blockers work by relaxing the sphincter muscle and increasing the blood
supply to the site of the fissure. Side effects of
topical calcium channel blockers may include:
- headaches
- dizziness, especially when standing up from a sitting or lying position
- itchiness or burning at the site when patients apply the medication
However, the side
effects caused by calcium channel blockers should pass within a few days once the body gets used to the medication. There is no evidence
that calcium channel blockers are more effective than GTN, so they tend only to
be used in people unable or unwilling to take GTN.
Botulinum toxin is a relatively new treatment for anal fissures. It is usually used if other treatments have failed. Botulinum toxin is a powerful poison which is safe to use in small doses. In cases of anal fissure, an injection of the toxin can be used to paralyse the sphincter muscle. This should prevent the muscle from spasming (contracting), helping to reduce pain and allowing the fissure to heal.
Botulinum toxin is an
effective treatment in the short to medium term, with three out of four people
remaining symptom-free for six months after treatment. Further treatment may be
required in the long-term, as around half of people experience a return of
their symptoms within three years.
The doctor will usually arrange for the patient to have a follow-up appointment, about 8 weeks after the start of their treatment. This will enable them to check that the patient's fissure has healed, or is showing adequate signs of improvement. If the patient's condition has not been completely treated, the physician may recommend a further follow-up appointment six to eight weeks later.
If a patient's anal fissure
is particularly severe, or does not respond to treatment after 8 weeks, a patient may have to be referred to a proctologist (a doctor who specialises in
conditions which affect the rectum and anus), or a gastroenterologist or a colorectal surgeon, for specialist treatment. This will
usually involve having some type of surgery.
There are a number of different surgical techniques that can be used to treat an anal fissure.
An internal sphincterotomy involves removing a section of the sphincter muscle. This helps to reduce the tension in the muscle, preventing further spasms of the sphincter and allowing the anal fissure to heal. An internal sphincterotomy is a relatively straightforward operation which can be performed using a local anaesthetic on a day patient basis, which means patients will not have to spend the night in hospital.
An internal
sphincterotomy is an effective treatment with a good track record of success.
About 95% of people who have this type of surgery will experience healing of
their anal fissure. Around 1 in 10 people (10%) will experience bowel incontinence after having surgery due to damage to the
anal muscles. This means they will lose some control of their bowel
movements.
However, it is usually a mild type of incontinence where the patient is unable to prevent themselves from passing wind, and they may also experience some mild soiling. The symptoms of incontinence usually improve in the first few months after surgery, and they resolve within two months. However, in around 1 in 200 cases (0.5%) the incontinence is permanent.
However, it is usually a mild type of incontinence where the patient is unable to prevent themselves from passing wind, and they may also experience some mild soiling. The symptoms of incontinence usually improve in the first few months after surgery, and they resolve within two months. However, in around 1 in 200 cases (0.5%) the incontinence is permanent.
A fissurectomy is the surgical removal of an anal fissure, along with the surrounding tissue. Fissurectomies are not as widely used as internal sphincterotomies because they do not treat the underlying causes. Therefore, a fissurectomy may not prevent anal fissures from reoccurring in the future.
However, a
fissurectomy may be a recommended treatment option for children, because
removing a section of the sphincter muscle at an early age could cause
permanent incontinence.
Advancement anal
flaps involve taking healthy tissue from another part of the patient's body and using it
to repair the fissure, and thus improve the blood supply to the site of the anal fissure. This is often
recommended to treat cases of chronic anal fissure, that have occurred as a
result of pregnancy or other injury to the anus.
Source: NHS Choices.
http://healthitis.blogspot.com
Source: NHS Choices.
http://healthitis.blogspot.com