Definition: An anal fissure is a cutaneous tear in the ectodermal portion of the anal canal and is usually found in the postero-lateral wall or in other words at 12 o’clock or 6 o’clock positions around the anal circumference.
Clinical Features
- It commonly occurs after a bout of constipation and is very painful.
- Patients find themselves in a vicious circle where they appreciate that the next bout of defecation will be painful, hence they avoid passing a stool and progressively become more constipated.
- When the bowel is eventually opened the tear is made more worse.
- Fresh bleeding is common and this can be a cause of bleeding per rectum in many patients.
A diagnostic feature of an anal fissure is anal pain after defecation and in chronic cases the skin at the lower part of the fissure becomes swollen and can be used as a marker of an anal fissure- the sentinel pile. This may be the only sign of a chronic anal fissure and it is often too painful to examine the patient proctoscopically.
Etiology
Anal fissures are very common in young infants, but may occur at any age. The rate of anal fissures drops with age. Fissures are much less common among school-aged children than infants.
In adults, fissures may be caused by passing large, hard stools, or by having diarrhea for a long time.
Other factors may include:
Management
Most fissures heal on their own and do not need treatment. To prevent or treat anal fissures in infants, be sure to change diapers often and clean the area gently.
Non-surgical treatments are recommended initially for acute and chronic anal fissures. These include topical nitroglycerin or calcium channel blockers, or injection of botulinum toxin into the anal sphincter.
Other measures include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.
Surgical Treatment
The Standard Task Force of the American Society of Colon and Rectal Surgeons has recommended a surgical procedure called partial lateral internal sphincterotomy as the technique of choice for the treatment of anal fissures.
Several surgeons have described procedures that stretch and tear the anal sphincters for the treatment of anal fissures. Though anal stretching often is successful in alleviating pain and healing the fissure, it is a traumatic, uncontrolled disruption of the sphincter.
- Decreased blood flow to the area in older adults
- Too much tension in the sphincter muscles that control the anus
Management
Most fissures heal on their own and do not need treatment. To prevent or treat anal fissures in infants, be sure to change diapers often and clean the area gently.
Non-surgical treatments are recommended initially for acute and chronic anal fissures. These include topical nitroglycerin or calcium channel blockers, or injection of botulinum toxin into the anal sphincter.
Other measures include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.
Surgical Treatment
The Standard Task Force of the American Society of Colon and Rectal Surgeons has recommended a surgical procedure called partial lateral internal sphincterotomy as the technique of choice for the treatment of anal fissures.
Several surgeons have described procedures that stretch and tear the anal sphincters for the treatment of anal fissures. Though anal stretching often is successful in alleviating pain and healing the fissure, it is a traumatic, uncontrolled disruption of the sphincter.
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