Anal fissure
| Anal fissure | |
|---|---|
| Other names | Fissure in ano, rectal fissure |
 | |
| An anal fissure | |
| Specialty | Gastroenterology  |
An anal fissure is a break or tear in the skin of the anal canal. Symptoms associated with acute fissures include pain with defecation, anal spasm, and bleeding with defecation.[1] Fissures persisting for longer than 4 weeks, or recurrent fissures, are defined as chronic.[2] Anal fissure is a common condition although published epidemiological data are limited.[3] Half of patients with fissures heal with nonoperative management. Surgical treatment, if required, has a high success rate.[1]
Causes
[edit]Although the exact cause of anal fissure is unknown, most anal fissures are thought to be due to trauma to the anal mucus membrane most commonly from the passage of large, hard stools, or repeated irritation from chronic diarrhea.[1]
Most anal fissures are in the midline. If they occur off the midline, they warrant evaluation for an underlying diagnosis such as Crohn's disease, HIV/AIDS, and associated secondary infections, ulcerative colitis, tuberculosis, syphilis, leukemia, or cancer.[4]
Non-healing or recurrent anal fissures are considered chronic. The most common cause of impaired healing is spasming of the internal anal sphincter muscle. The high anal pressure resulting from spasm can impair blood supply to the anal mucosa, resulting in a non-healing ulcer.[5]
Diagnosis
[edit]The diagnosis of anal fissure is made by history and physical examination. Anal fissure is a common condition and the main symptoms include anal pain and bleeding. The pain is often severe and typically occurs during and after defecation; chronic fissures can cause pain that lasts many hours after a bowel movement.[4]
Suspected diagnosis of an anal fissure is confirmed by physical examination with visual examination of a split or tear of the skin at or just inside the anus. Associated findings include a sentinel skin tag and hypertrophied anal papilla.[4]
Anal fissures cannot be visualized with end-viewing endoscopes. In addition, instrumentation of the anal canal is traumatic and only rarely gives diagnostic information. When severe anal pain cannot be diagnosed comfortably, examination under anesthesia is recommended.[4]
Prevention
[edit]Preventative measures for anal fissure include avoidance of straining during defection, high fiber diet, and adequate fluid intake. Treatment of constipation and diarrhea as well as any underlying associated medical conditions is recommended.[6]
Treatment
[edit]About half of all fissures heal with conservative care, which includes fiber supplementation, increased fluid intake, sitz baths, and topical analgesics.[7] Conservative care alone is appropriate for most acute fissures. For chronic or recurrent fissures, topical therapy, botulinum toxin injection, and surgery are available.[7]
Topical Therapy
[edit]Topical therapy for anal fissures is directed at relaxing the anal sphincter allowing for increased blood flow and fissure healing. After conservative care, topical therapy is recommended as a first-line treatment.[7] Topical therapy includes nitroglycerin ointment and diltiazem (calcium channel blocker) ointment. Nitroglycerin has the side effect of headache, making diltazem ointment the preferred topical agent.[7]
Botulinum Toxin Injection
[edit]Direct injection of botulinum toxin (Botox) into the anal sphincter to relax it is a nonsurgical procedure used to promote anal fissure healing.[8] Botulinum toxin injection has similar fissure healing results compared to topical therapies although comparisons are difficult given the wide variety of dosing protocols used in studies. Combination therapy of botulinum toxin injection and topical therapy has been suggested to improve healing and symptoms in patients with chronic anal fissure.[9] Overall, botulinum toxin injection has similar results compared with topical therapies as first-line therapy for chronic anal fissures and modest improvement in healing rates as second-line therapy following failed treatment with topical therapies.[7]
Surgery
[edit]Lateral internal sphincterotomy
[edit]Lateral internal sphincterotomy (LIS) is the surgical treatment of choice for chronic anal fissure in patients without preoperative fecal incontinence.[7] The procedure involves an incision into the anal spincter muscules. Cutting the muscle reduces spasm and lowers resting pressure which improves blood supply to the affected area and promotes healing.[10] LIS has superior healing rates in comparison to topical therapy or botulinum toxin, with sucess rates of 88-100% and is the most effective surgical procedure in patients without preoperative gas or stool incontinence.[11]
Fecal incontinence is a known complication of LIS with as many as 39% of patients experiencing temporary incontinence after LIS. These symptoms typically resolve within 6-8 weeks.[12]
Groups with increased risk for postoperative incontinence include women with prior vaginal delivery and those with prior ano-rectal surgery.[13][14]
Long term incontinence rates in a large retrospective study (which excluded higher risk patients) showed about 25% of patients had some degree of postoperative incontinence long term. The majority of these patients had incontinence for gas only. About 2% had liquid stool incontinence, and no patients had incontinence for solid stool. No patient required constipating medications in their lifestyle and only one patient (1%) required pads.[15]
Newer surgical techniques have lowered the incidence of postoperative incontinence. "Tailored" sphincterotomy which reduces the extent of the incision has been found to have the same efficacy as conventional LIS with reduced fecal incontinence.[16][17]
Fissurectomy
[edit]Fissurectomy involves excision of the skin on and around the anal fissure and excision of the sentinel pile if one is present. The surgical wound can be left open. New skin tissue grows and it heals.[citation needed]
Fissurectomy wound 1.5 weeks after the OP
Fissurectomy wound 3.5 weeks after the OP
Fissurectomy wound 12.5 weeks after the OP
See also
[edit]
References
[edit]- 1 2 3 Beaty, JS; Shashidharan, M (2016). "Anal Fissure". Clinical Colon Rectal Surgery. 29 (1): 30–37. doi:10.1055/s-0035-1570390. PMC 4755763. PMID 26929749.
- ↑ Nelson, Richard L. (12 November 2014). "Anal fissure (chronic)". BMJ Clinical Evidence. 2014: 0407. ISSN 1752-8526. PMC 4229958. PMID 25391392.
- ↑ Mapel, Douglas W.; Schum, Michael; Von Worley, Ann (16 July 2014). "The epidemiology and treatment of anal fissures in a population-based cohort". BMC Gastroenterology. 14 129. doi:10.1186/1471-230X-14-129. ISSN 1471-230X. PMC 4109752. PMID 25027411.
- 1 2 3 4 American Gastroenterological Association (1 January 2003). "American Gastroenterological Association medical position statement: Diagnosis and care of patients with anal fissure, This document presents the official recommendations of the American Gastroenterological Association (AGA) on Anal Fissures. It was approved by the Clinical Practice Committee on May 19, 2002 and by the AGA Governing Board on July 27, 2002". Gastroenterology. 124 (1): 233–234. doi:10.1053/gast.2003.50006. ISSN 0016-5085. PMID 12512045.
- ↑ van Meegdenburg, Maxime M.; Trzpis, Monika; Heineman, Erik; Broens, Paul M. A. (2016). "Increased anal basal pressure in chronic anal fissures may be caused by overreaction of the anal-external sphincter continence reflex". Medical Hypotheses. 94: 25–29. doi:10.1016/j.mehy.2016.06.005. ISSN 1532-2777. PMID 27515194.
- ↑ "Anal Fissures: Causes and Prevention". WebMD. Retrieved 2 August 2026.
- 1 2 3 4 5 6 Grieco, M.J.; Bhama, A.R.; Davids, J.S; Hawkins, A.T.; Paquette, I.M; Lightner, A.L.; Feinberg, A.E; Feingold, D.L. (2022). "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures". Diseases of the Colon & Rectum. 66 (2): 190–199. doi:10.1097/DCR.0000000000002664. PMID 36321851.
- ↑ Jost, W.; Schimrigk, K. (1993). "Use of Botulinum Toxin in Anal Fissure". Diseases of the Colon and Rectum. 36 (10): 974. doi:10.1007/BF02050639. PMID 8404394. S2CID 44959287.
- ↑ Lysy, Joseph; Israeli, Eran; Levy, Sharon; Rozentzweig, Gloria; Strauss-Liviatan, Nourit; Goldin, Eran (2001). "Long-term results of "chemical sphincterotomy" for chronic anal fissure: a prospective study". Diseases of the Colon and Rectum. 49 (6): 858–864. doi:10.1007/s10350-006-0510-9. ISSN 0012-3706. PMID 16741641.
- ↑ Villanueva Herrero, J. A.; Henning, W.; Sharma, N.; Deppen, J. G. (2022). "Internal Anal Sphincterotomy". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID 29630265. Retrieved 28 June 2021.
- ↑ Nelson, Richard L; Chattopadhyay, Arpita; Brooks, William; Platt, Isobel; Paavana, Thumri; Earl, Sophie (2011). "Operative procedures for fissure in ano". Cochran Database of Systematic Reviews – via Cochrane Library.
- ↑ Liang, Jennifer; Church, James M. (1 October 2015). "Lateral internal sphincterotomy for surgically recurrent chronic anal fissure". The American Journal of Surgery. 210 (4): 715–719. doi:10.1016/j.amjsurg.2015.05.005. ISSN 0002-9610.
- ↑ Themes, U. F. O. (28 June 2016). "Incontinence After Lateral Internal Sphincterotomy/Fistulotomy". Abdominal Key. Retrieved 3 August 2026.
- ↑ Kement, M.; Karabulut, M.; Gezen, F.C.; Demirbas, S.; Vural, S.; Oncel, M. (5 May 2011). "Mild and Severe Anal Incontinence after Lateral Internal Sphincterotomy: Risk Factors, Postoperative Anatomical Findings and Quality of Life". European Surgical Research. 47 (1): 26–31. doi:10.1159/000324902. ISSN 0014-312X.
- ↑ Realis Luc, A.; Di Vittori, A.; Salvatore, A.; Gravante, G.; De Simone, V.; Micarelli, A.; Clerico, G.; Trompetto, M.; Gallo, G. (22 July 2025). "Long-term incontinence rates after traditional lateral internal sphincterotomy: a 5-year retrospective analysis from a high-volume tertiary referral center for proctologic disorders". Techniques in Coloproctology. 29 (1): 149. doi:10.1007/s10151-025-03189-1. ISSN 1128-045X. PMC 12283820. PMID 40696236.
- ↑ Littlejohn, David R. G.; Newstead, Graham L. (1997). "Tailored lateral sphincterotomy for anal fissure". Diseases of the Colon & Rectum. 40 (12): 1439–1442. doi:10.1007/bf02070709. ISSN 0012-3706.
- ↑ Murad-Regadas, Sthela Maria; Fernandes, Graziela Olivia da Silva; Regadas, Francisco Sergio Pinheiro; Rodrigues, Lusmar Veras; Pereira, Jacyara de Jesus Rosa; Regadas Filho, Francisco Sergio Pinheiro; Dealcanfreitas, Iris Daiana; Holanda, Erico de Carvalho (2013). "How much of the internal sphincter may be divided during lateral sphincterotomy for chronic anal fissure in women? Morphologic and functional evaluation after sphincterotomy". Diseases of the Colon and Rectum. 56 (5): 645–651. doi:10.1097/DCR.0b013e31827a7416. ISSN 1530-0358. PMID 23575405.
External links
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