Anal Fissures (Cracks / Tears) Causes, Treatment, Prevention

What are anal fissures?

Anal fissures are tiny tears that occur in the delicate lining of the anus. This tearing is often associated with constipation and the passage of hard stool. At first these tears only involve the outermost layer (epithelium) of the anal mucosa but over time it can extend deeper. Pain and rectal bleeding are some of the symptoms of anal fissures but with proper management it can heal within a few weeks.

It can affect both males and females equally. Anal fissures are more common in children, especially infants, and im middle-aged adults but can affect a person of any age. Women are also more likely to experience anal fissures at the time after childbirth. Treatment varies depending on the duration and depth of the tear although in many instances anal fissures heal o its own within about 6 weeks, even without any treatment.

Causes of Anal Fissures

The exact cause of anal fissure is not always clear. It is often associated with trauma to the anus, as is the case with passing hard stools, but fissures do not affect every person with the same predisposing factors. Minor tears are not uncommon in people with altered bowel habit like constipation and chronic diarrhea. It can also occur with certain infections, inflammatory bowel disease (IBD) and may also arise with anal cancer.

The anal mucosa is very delicate. Soft stool that is easily passed out when the sphincter is functioning normally without being enlarged or contracting tightly should not be a problem. In the event that the anal canal becomes narrowed, the sphincter is enlarged, does not relax fully during defecation, or when the stool is hard it can lead to the stool injuring the anal mucosa. This may culminate in tears.

Insertion of foreign bodies into the anus, a rectal examination and even anal intercourse may also cause fissures. In most instances these tears go by largely unnoticed and heal quickly without medical treatment. In some cases however, the tears may persist and become a chronic problem. This is more likely to occur where the blood flow to the anus is impaired which reduces the tissue’s ability to heal.

Signs and Symptoms

The signs and symptoms of anal fissures may be mistaken for other conditions like hemorrhoids. Many people are more aware of hemorrhoids (piles) than fissures. Therefore it is important that the area is examined by a doctor for a conclusive diagnosis.

• Rectal bleeding is one of the main symptoms and is usually seen as fresh blood on the toilet paper when wiping after a bowel movement.
• Painful bowel movements which is often severe and described as sharp, stinging and burning. The pain can persist for even hours after defecating. There are instances where fissures can be painless.
• Anal itching is another common symptom. Sometimes a person may feel irritation in the anal area without obvious itching or pain.
• Cracks, lumps and skin tags on and around the anus may also be visible. Most people will not be able to see these lesions and it is usually detected during physical examination.

Constipation, diarrhea, hard stools and other symptoms may be present as part of the conditions that cause anal fissures and not due to the fissures itself.

Treatment of Anal Fissures

Treatment is usually not necessary for most cases of anal fissures. The tears heal on its own within a few weeks and may not necessarily recur if the causative condition has resolved or is properly treated. Simple dietary and lifestyle measures may be sufficient to prevent these fissures from occurring again and aid with rapid healing.

Sitz baths and petroleum jelly are some of the non-medicated means of soothing the symptoms and aiding with healing of the cracks. However, when anal fissures are severe, do not respond to conservative measures and persist or recur then medical treatment is necessary.

Non-Surgical Treatment

• Stool softeners where constipation and hard stools are present.
• Intra-anal application of 0.4% nitroglycerin to assist with healing.
• Botulinum toxin to ease muscle spasm of the anal sphincter.
• Hydrocortisone cream to relieve the symptoms.
• Calcium channel blockers to relax anal sphincter muscles.

Surgical Treatment

Surgery is only considered for chronic fissures and sometimes for acute fissures that are still symptomatic after 3 to 4 weeks without responding to non-surgical measures. This procedure known as a sphincterotomy involves cutting into the internal anal sphincter muscle to allow it to relax.  It is only reserved for severe cases as there is a small risk of it leading to fecal incontinence.

Prevention and Conservative Management

There are simple dietary and lifestyle measures that can be used to manage anal fissures without medical treatment as well as help in preventing fissures from arising in the first place.

• A high fiber diet and plenty of water can help prevent hard stools and constipation. Fiber supplements may should also be considered. Exercise is helpful for preventing constipation and hard stools. If these measures are ineffective, stool softeners may be used to prevent fissures.
• Establishing regular bowel habit involves scheduling bowel movements on a daily basis. Sitting and attempting to pass stool without training will often help to establish a proper habit in a few weeks, along with a high fiber diet, increased water intake and exercise.
• Sitz baths are simple and effective ways of easing the anal discomfort as well as preventing fissures in people with constipation and hard stools. It is a shallow bath of lukewarm water without any soap or other additives. Sitting in a sitz bath for 10 to 20 minutes especially after a difficult stool is advisable.
• Avoid excessive wiping or using poor quality rough toilet paper that can irritate the anus further. Soft toilet paper, or even wet toilet paper, is preferable when there is discomfort. If necessary baby wipes may be used for cleaning after a bowel movement.
• Do not hold back stool. Many people do this due to fear of the pain and bleeding that arises with a bowel movement in people suffering with anal fissures. Restraining stool further contributes to constipation and hard stools that can exacerbate the symptoms of fissures.