Causes, Signs, Issues, Prevention, Therapy, Ayurveda Understanding

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S

What is Anal Fissure?

Fissure means a crack or tear.

A crack or tear occurring in the lining of the anal canal is called as an ‘anal fissure’. Due to this one would experience anal pain and rectal bleeding while passing stools (bowel movements). Fissures in the anal region are usually caused by trauma mainly due to straining while passing hard stools. They can occur either gradually or suddenly. Similarly fissures can either heal slowly or quickly. Most fissures get better with simple treatments including fiber intake, proper hydration or sitz bath. Some people would need medicines. Occasionally surgery is needed for treating anal fissures.

How common are anal fissures?

Anal fissures are very common. They are commonly seen in infants but can affect people of any age. They are also common in pregnant women. About half of these people who suffer from anal fissures will get them before they hit 40 years of age.

Causes of Anal Fissure

Main cause of anal fissure

Trauma – This is the most important cause for the tear in the anal lining to occur leading to diagnosis of fissure. Trauma can be in the form of straining while defecation or stretching.

Thin mucus lining – This tear occurs in the mucus membrane of the anus. Since the mucus lining is thinner and delicate in comparison to the outer skin of the anal opening it undergoes tear easily. Babies often get anal fissures because of too thin mucus lining of the anal canal. An injury or inflammation occurring in the mucus layer can also cause fissures since the tissues can get weakened as an effect of chronic inflammation.

Tight anal sphincters – Also, tight anal sphincters (muscles which control the bowel movement) can add tension to the anal lining and also reduce blood flow to the tissues around the anus. This makes easier for it to tear.

The other causes of anal fissures include –

Symptoms of Anal Fissure

Below mentioned are the symptoms of anal fissure –

• Sharp pain occurs in the anal region while passing stools / feces (pooping) which can last for several minutes to several hours after. The pain is described by patients as sharp, cutting, tearing or burning in nature. People also sense the pain radiating to their butts, upper thighs or lower back.
• Pain in the anal region after bowel movements that can last up to several hours.
• Visible crack in the skin surrounding the anus
• Burning sensation or itching along with passing stools / feces (pooping)
• Fresh, red blood visible in the stools / poop
• Spasms in the anal muscles / sphincters
• A lump on the skin tag on the skin near the fissure
• Bleeding may be seen in the form of bright red blood on the stool after bowel movement

Anal fissures v/s hemorrhoids

Anal fissures and hemorrhoids present with similar causes and symptoms and hence cause confusion in the diagnosis. Both these conditions are caused when one strains too much to pass the stools. Both these conditions can cause anal pain, anal itching and rectal bleeding. Among both these conditions hemorrhoids are more common in comparison to the fissures. On the other hand hemorrhoids do not always cause pain but anal fissures are the most common cause of anal pain. 90% of all fissures cause pain. While pain of hemorrhoid can be constant, the pain from a fissure usually occurs in episodes.

Complications of Fissure

Difficult healing and chronic anal fissures – When anal fissures do not heal all by themselves in a few weeks few complications would develop. They can stay long and get worse to be called as ‘chronic anal fissures’. They leave a persistent wound. Spasms and tightening of anal muscles / sphincters can also occur due to constant pain and muscle clenching. The tension in the anal muscles and spasms would pull apart the fissure and may also reduce blood flow to the tissues therein. This makes fissures hard to heal and more painful.

Recurrence – is common in anal fissure cases. Once you get it, you are prone to have one more.

Fissure affecting anal sphincter – will make it difficult to heal. When unhealed it may cause severe symptoms and discomfort demanding medicines or surgery to reduce pain and to repair the fissure.

Chronic fissures which have not healed may cause complications including anal fistula, anal stenosis and fecal impaction.

Risk Factors

Risk factors of anal fissure include –

• Constipation
• Childbirth
• Anal intercourse
• Crohn’s disease
• Being infants and middle aged adults

Diagnosis and Tests for Anal Fissures

Inspection of the fissure and interrogation will help your doctor to diagnose anal fissures. Digital rectal exam may be done if the patient tolerates and hence allows the exam to be done. This will not only allow the doctor to see the fissure and also rule out other possible causes for the symptoms.

Acute fissures of recent origin looks like a fresh tear (like a paper cut). Chronic fissure is likely to have a deeper tear. It may also show fleshy growths internally or externally.

A fissure located on the side of the anal opening instead of on the back or front is more likely a symptom of another disorder (such as Crohn’s disease). The below mentioned tests may be recommended to find out if there is an underlying condition –

• Anoscopy
• Flexible Sigmoidoscopy
• Colonoscopy

What is the right time to see the doctor?

You need to see your doctor if you have pain during defecation / bowel movements or if there is blood on stools after bowel movement.

Prevention of Anal Fissures

Treat the anal conditions promptly – In chronic anal conditions / diseases, trouble in defecation and unexplained pain one should see the doctor / healthcare provider as soon as possible. Complications like anal fissure can be prevented from developing or relapsing if they are treated sooner.

Regularize your bowel movements – If bowel movements are not regularized or monitored it would lead to severe constipation which can soon become a complicated medical problem. One needs to follow these tips to achieve this –

• Eat right foods
• Drink good quantities of water
• Indulge in enough exercise
• Take fiber diet or add fibers to your diet, but if taking fiber is worsening your constipation do not take it
• Probiotics might help
• Schedule your bowel movement and make time for it but make sure not to spend too much time (you may strain for bowel movements the more you stay there), don’t do diverging activities like replying messages, reading book or using laptop in the toilet
• Take proper measures to prevent constipation or diarrhea
• Don’t avoid defecation urge, address it as and when it comes
• Don’t make drastic changes in your eating habits or in what you are used to eat
• If constipation does not respond to treatments or diet changes or if it lasts for many weeks or months see the doctor immediately to rule out serious medical causes which might be responsible for your constipation
• Prescribed laxatives or pro-motility drugs might help
• Dietary vegetables or taking mineral oil may help as a home remedy when used for long time

Note – Chronic constipation can be a sign of a serious condition existing in the backdrop, like IBS, celiac disease, hyperthyroidism or hypercalcemia. So attention is needed when constipation is not resolved with simple measures or changes.

Dealing fissures at home

 As said, anal fissures will usually heal on their own. Self care will make the healing process easy. Below mentioned are some tips which can be followed at home –

• Stool softener may be used to ease defecation 
• Step stool may be used at toilet, it would support your feet and helps in positioning your hips in squatting position
• Wipe / clean your anus properly after defecation
• Do not strain during bowel movement
• Topical ointment or cream may be applied to the fissure
• Petroleum jelly is also useful in fissure healing
• Sitz Bath – would relieve symptoms of fissure and helps in relaxing the muscles. It shall be taken twice or thrice daily, for at least 10-15 minutes at a stretch.
• Plan your diet – drink plenty of water to hydrate self, eat more fresh fruits and vegetables and avoid spicy foods and nuts
• Change diapers frequently – if the infant has anal fissure. Anal region should be washed gently and thoroughly. Pediatrician’s opinion shall be brought into picture.

Fiber diet – Consuming about 25-35 grams of fiber in a day keeps the stools soft. This also helps improve healing of fissure. Fruits, vegetables, nuts and whole grains are fiber rich foods. Alternatively fiber supplements can be taken. Intake of fibers needs to be increased gradually since they may cause gas and bloating. If fibers worsen the condition or symptoms, fibers shall be discontinued.

Good and Bad foods for those suffering from anal fissures

Fiber rich foods which are useful in fissures include oats, whole grains, wheat bran, beans, peas, nuts and seeds, citrus fruits and prunes.

The foods which should be avoided by people suffering with fissure include spicy foods, hot peppers, cheese, red meat, frozen foods, fast foods, popcorn, processed foods, preserved foods, pre-prepared foods.

Management and Treatment of Anal Fissure

Acute anal fissures are temporary and they go away all by themselves and might not require treatment. Self care would be sufficient.

Steps to keep the stool soft should be taken which includes intake of fiber included foods and fluids. One should soak in warm water (sitz) for 10-20 minutes many times in a day and should especially be done after bowel movements. This would relax the anal sphincters and promote healing. Treatment would be needed if symptoms still persist after doing all these.

One may manage with a cream for application (prescribed) which might relieve the pain temporarily / topical anesthetic creams (Ex. Lidocaine). On the other hand, fissures which have not healed even after several weeks will need treatment.

While it is noted that most anal fissures heal within few days to few weeks, a chronic fissure might last for more than eight weeks. It might require an additional six to 12 weeks for the fissure to heal in cases of chronic anal fissures which are being treated.

Medicinal treatment

Goal – Medical treatment in a chronic anal fissure aims at relaxing the sphincter muscles surrounding the anal canal. This allows the fissures to begin closing and also helps restore blood flow to the tissues.

Medications used for anal fissures include nitroglycerin ointment, calcium channel blockers, bulk laxatives and botox injection (as a last resort).

Surgery

Your doctor / healthcare provider may recommend surgery if you have chronic anal fissure which is resistant to other treatments.

Minor procedure to set right the stubborn fissure may be needed in case they do not heal with medication or if there is a relapse after they are healed. Surgery, in comparison to medications has 90% success rate. The surgical procedure for anal fissure is called as internal sphincterotomy. In this procedure a small cut into the sphincter would release the tension permanently. Studies have shown that surgery is more effective than medical treatment for chronic fissure. Surgery also has a small risk of causing incontinence.

Research Works in Anal Fissures

The epidemiology and treatment of anal fissures in a population based cohort – The conclusions said that anal fissure is a common clinical problem and the incidence varies substantially by age and sex. Associated comorbidities include constipation, obesity and hypothyroidism. Most people are prescribed with topical treatments. Surgical interventions for anal fissure including botulinum toxin and lateral internal sphincterotomy are uncommon.

A new theory on the cause of anal fissure – impaction theory – The impaction theory refers to the impaction factors i.e. various kinds of primary lesions in ano-rectum that hinders defecation, cause excessive dilatation of anus while defecating, exceed the anal dilatation limit and open the whole layer of anal skin. The typical symptoms include periodic pain, repeated anal dilatation or tear and fusiform ulcer caused by wound infection, namely anal fissure.

Find more research studies here.

Anal Fissure – Ayurveda Understanding

Parikartika – A condition called as Parikartika mentioned in different contexts in Ayurveda treatises can be closely compared to ‘anal fissures’.

This term parikartika has been mentioned as a complication of ‘vamana – therapeutic emesis’ and ‘virechana – therapeutic purgation’. It is also a symptom of Vataja Atisara, Vataja Grahani and Purisha Udavarta.

The treatment principles of these conditions shall be considered in treating anal fissure.

Related Reading – Parikartika