Anal Fissures – Causes, Symptoms, Treatment, Prevention

What are anal fissures?

The lining of the anus is very delicate. Passage of hard stools, often seen during constipation, can produce tears in the delicate mucosal lining of the anus. Such tears are technically referred to as anal fissures. The anal fissures may either be limited to the outermost epithelial layer or extend deeper into the anal mucosa. Initial tears in the anal mucosa are usually superficial in nature.

Deepening of anal fissures occurs over time. Anal fissures usually heal within a few weeks when managed properly. Anal fissures are equally likely to occur in both males and females. Although this condition can occur at any age, infants and adults in middle age are most commonly affected. In women, anal fissures are more likely to occur after childbirth.

The choice of treatment for anal fissures depends on the extent and duration of the tears. In many cases, superficial anal fissures heal on their own within six weeks.

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Signs and symptoms

The following are the main signs and symptoms of anal fissures:

  • Bleeding from the rectum: Bleeding from the rectum is one of the main signs of anal fissures. Rectal bleeding usually accompanies a bowel movement. Fresh blood can be seen on the tissue paper when cleaning up after a bowel movement.
  • Pain during bowel movement: Pain during bowel movements is also a common symptom of anal fissures. The nature of the pain may be described as a burning, stinging, or sharp pain. The pain in the anal area can be felt hours after a bowel movement. However, some anal fissures may be painless.
  • Itching in the anal area: Irritation or itching in the anal area is also a common symptom of anal fissures. At times, anal irritation may occur even in the absence of itching or pain in the anal region.
  • Presence of cracks, skin tags, and lumps in anus: The anal area may also have cracks, lumps or skin tags. These usually get detected by a doctor during a physical examination of the anus.

The above mentioned signs and symptoms of anal fissures are similar to the signs and symptoms of some other conditions such as hemorrhoids. Due to the relatively higher awareness about hemorrhoids or piles in the general population, people may mistakenly attribute the symptoms of anal fissures to hemorrhoids.

Moreover, anal fissures may also be accompanied by other conditions such as diarrhea, constipation, and hard stools. These conditions may cause anal fissures, but are not symptoms of anal fissures. Due to these confounding factors, it is important to seek medical attention for a proper diagnosis of the underlying condition.

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Causes of anal fissures

The main cause of anal fissures is trauma to the lining of the anal mucosa. The anal mucosa is a very delicate tissue that gets injured easily. When passing soft stools, the anal sphincters function normally, and do not have any problems in enlarging and contracting. However, narrowing of the anal canal can lead to an enlarged anal sphincter that fails to relax during defecation. Also, hard stools can injure the anal mucosa and cause anal fissures.

Other causes of injury to the anal mucosa include insertion of foreign bodies into the anus, anal intercourse, and rectal examination. In many cases, anal tears may go unnoticed. A majority of anal tears heal on their own without any medical intervention. However, in some cases, anal fissures can persist chronically. This is most likely to occur when blood flow to the anal area is impaired, resulting in reduced healing ability in the region.

Anal fissures may also be associated with conditions such as inflammatory bowel disease, infections, and anal cancer. People with altered bowel movements frequently have minor tears in the anal mucosa. The exact reason for anal fissures is not clear in all cases. For example, not all people having constipation (and other predisposing conditions) suffer from anal fissures.

Treatment for anal fissures

In most cases, anal fissures heal on their own within a few weeks. No medical treatment is necessary in such cases. Resolving or treating the underlying cause of the anal fissures prevents their recurrence after healing. For example, simple changes in diet and lifestyle may be enough to allow healing of the anal fissures and prevent their recurrence.

Conservative treatment of anal fissures can be done by applying petroleum jelly or giving sitz bath to the anal area. These measures can provide relief from the symptoms and aid in the healing of anal fissures. When anal fissures do not heal with conservative measures, medical or surgical treatment must the be considered.

Medical treatments for anal fissures can be classified into non-surgical and surgical methods.

  • Non-surgical treatments: If anal fissures are related to the presence of constipation, stool softeners can be used to treat the constipation. Local application of hydrocortisone cream can provide relief from the painful symptoms of anal fissures. Also, application of 0.4% nitroglycerin within the anus can assist in the healing process. Anal sphincters can be relaxed by using calcium channel blockers. Botulinum toxin may also be used to relieve the spasm of anal sphincter muscles.
  • Surgical treatments: In case of chronic anal fissures, or fissures that do not respond to conservative and non-surgical treatment, surgical treatment may be considered. A cut is made in the internal anal sphincter muscle to allow it to relax. Due to the risk of fecal incontinence, this surgical procedure (known as sphincterotomy) is only used as a last resort.

Prevention (Diet and Lifestyle)

The following changes in diet and lifestyle can help in the prevention and management of anal fissures:

Dietary changes

Constipation can be managed by regular consumption of a high fiber diet and increased water intake. Fiber supplements can also be used to prevent the occurrence of hard stools. Stool softeners may be used if these measures fail to prevent constipation.

Regular exercise

Regular exercise can help in the prevention of constipation and occurrence of hard stools which may cause anal fissures.

Regular bowel habit

Following a regular daily schedule of passing stools establishes a healthy bowel habit. Along with the dietary changes mentioned above, a regular bowel habit can aid in the smooth passage of the stools, without the need for straining. In case of constipation, one should not try to hold back stools due to the fear of pain. Holding back stool will further aggravate the condition by hardening the stools.

Sitz baths

Sitz baths refer to shallow warm water baths of the perineum region. The anal area can be soaked in lukewarm water (without any additives) for 10-20 minutes to provide relief from the symptoms of anal fissures. Sitz baths are especially recommended after a difficult stool movement.

Personal hygiene

After a bowel movement, one should not wipe the anal area aggressively with rough toilet paper. This can irritate the soft anal mucosa. Toilet paper should be soft. In case of discomfort, wet toilet paper or baby wipes may be used.

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