// Workers AI · dad joke modeDoes an anal fissure go to parties? It's a tear-ful experience.
| 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 fissure heals 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 as they are more likely to heal than chronic ones. 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 simular 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]Surgical procedures are generally reserved for people with anal fissures who have tried medical therapy for at least one to three months and have not healed. It is not the first option in treatment.
The main concern with surgery is the development of anal incontinence. Anal incontinence can include the inability to control gas, mild fecal soiling, or loss of solid stool. Some degree of incontinence can occur in up to 45 percent of patients in the immediate surgical recovery period. However, incontinence is rarely permanent and is usually mild. The risk should be discussed with one's surgeon.
Surgical treatment, under general anaesthesia, is either anal stretch (Lord's operation) or lateral sphincterotomy where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter spasming and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general or regional anaesthesia. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.
Lateral internal sphincterotomy
[edit]Lateral internal sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%).[10] In this procedure the internal anal sphincter is partially divided in order to reduce spasming and thus improve the blood supply to the perianal area.
This improvement in the blood supply helps to heal the fissure, and the weakening of the sphincter is also believed to reduce the potential for recurrence.[11] The procedure is generally performed as a day surgery after the patient is given general anesthesia. The pain from the sphincterotomy is usually mild and is often less than the pain of the fissure itself. Patients often return to normal activity within one week.
LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%).[12]
Though lateral internal sphincterotomy (LIS) is considered safe on a short-term basis, there are concerns about its long-term safety. Pankaj Garg et al. published a systematic review and meta-analysis in which they analyzed the long-term continence disturbance two years after the LIS procedure. They found the incidence of long-term continence disturbance to be 14%, so caution and careful patient selection are needed before undergoing LIS.[13]
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 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.
- ↑ "Anal Fissure". The Lecturio Medical Concept Library. 16 October 2020. Retrieved 28 June 2021.
- ↑ 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.
- ↑ Wolff, B. G.; Fleshman, J.W.; Beck, D. E.; Church, J. M. (2007). The ASCRS Textbook of Colon and Rectal Surgery. Springer. p. 180. ISBN 978-0-387-24846-2. Retrieved 15 July 2009.
- ↑ Garg P, Garg M, Menon GR (March 2013). "Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis". Colorectal Disease. 15 (3): e104–17. doi:10.1111/codi.12108. PMID 23320551. S2CID 23739830.
External links
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