Anal fissure, what to do when it appears

An anal fissure is a small wound or tear of a few millimeters, located at the margin of the anus, which causes significant pain during or after defecation, and sometimes minimal bleeding. The evacuation of hard and straining stools can cause this tear, but it can also be caused by diarrhea crises, as well as by various inflammatory diseases of the area. This is followed by a spasm of the anal sphincter, which may prevent healing, thus making it chronic.

Symptoms of anal fissure

The main symptom is pain, which can be variable but is generally very intense, sometimes unbearable, and may start at the moment of defecation. It is more common for the pain to appear after the bowel movement, feeling a tearing sensation that can last minutes, hours, and sometimes a large part of the day, reappearing with the next bowel movement.

Occasionally there may be a small amount of bleeding, which can be observed when wiping, or itching.

How is anal fissure diagnosed and how to distinguish it from other problems?

As it is a typical symptomatology, experts in coloproctology assure that it is easy to suspect that it is an anal fissure. The exploration will allow to observe the small wound when separating the margin of the anus. If the fissure is chronic, it is often associated with a small elevation of the skin of the anus, like a false hemorrhoid.

It looks like a small triangular wound and is also located in specific areas of the anus, in the posterior and anterior commissures. Lateral wounds should be distinguished from ulcers due to inflammatory bowel disease, tumors or venereal diseases, among others. Occasionally, endoscopies, ultrasound scans, exudates or manometric studies can be performed to rule out other processes, assess the sphincters or check anal pressures, mainly in patients with unusual symptoms or risk factors for incontinence.

How to initially treat anal fissure

At least 50% of fissures heal spontaneously or with non-operative treatment. This consists mainly of stool softeners, such as fiber, or other laxatives. Another treatment is the use of sitz baths with warm water for about 10 minutes several times a day, or the application of a cream that relaxes the anus.

What to do if the anal fissure does not heal

The cause of the fissure not healing is a spasm of the internal sphincter of the anus, which means that when defecating, this muscle does not relax normally and, therefore, the effort has to be increased. This closes a vicious circle of effort-fissure-spasm-persistence of the fissure, so it is necessary to act.

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There are specific creams or ointments to relax this muscle, such as glycerol nitrate, diltiazem or nifedipine, which increase the percentage of healing and should always be used before deciding on surgical treatment. Another option is the use of local injections of botulinum toxin, with the same objective.

What does anal fissure surgery involve and what complications can it entail?

If surgery is necessary, it can usually be performed on an outpatient basis. The surgery is quick and very effective. It consists in sectioning a small portion of the internal sphincter of the anus through a minimal incision in its lateral margin. Its objective is that, by relaxing the sphincter, the vicious circle disappears and the fissure heals. The improvement after the operation is rapid and is noticeable at the first defecation, although the fissure takes some weeks to heal. The postoperative period is simple, practically no painkillers are required and the operative wound is so small that it hardly needs any healing, except for local hygiene.

Complications are rare, but it is necessary to be aware of them. The section of a minimal portion of the muscle does not usually produce problems of gas or stool leakage after surgery. However, in subjects with weaker sphincters due to age, numerous births or other risk factors, alterations may occur, generally mild, and it may be necessary to use techniques to preserve the sphincter in these cases, performing a skin flap (as a graft covering the fissure).

Can anal fissure recur?

With the intervention, more than 90% of patients will heal. In the rest, the fissure may not heal, or it may reappear months or years later. In these cases, if the symptomatology is important, a new detailed evaluation will be required, with the possibility of a new surgical intervention.

Is anal fissure related to colon, rectal or anal cancer?

There is no relation between both problems; however, since tumors may present similar symptoms, it is essential to consult a specialist coloproctologist in case of symptoms such as anal pain or bleeding.