When it comes to anal fissure, it is best to consult a specialist (a colorectal surgeon, proctologist, or gastroenterologist) in person. As specialists in anal fissure treatment, we often hear stories of people who could really use some help, but given the nature of the problem and the intimacy issues that may arise; they refuse to seek a specialist. This is why we decided to list some of the most common questions that patients usually ask and search for – along with the explanations and solutions available.

What is an anal fissure?

An anal fissure is a linear (or oval) tear in the mucosa of the anal canal, extending from the inside of the anal canal to the anal verge (the anus opening). Patients affected by an anal fissure commonly complain of severe anal pain during and after defecation. Other notable symptoms of an anal fissure are bleeding per rectum (the patient will usually find bright red blood on the toilet paper or on the stool), itching and burning sensation in the anal area.

Who can get an anal fissure?

It is assumed that anal fissures are very common, although it is difficult to estimate the disease prevalence. Anal fissures are not uncommon even in babies, but the larger proportion of patients are grown-ups. A specific group that might be susceptible to this condition are pregnant women and women who gave vaginal birth. Another risk group are people who have persistent constipation issues. It should be noted that many patients never seek medical care and thus the condition might be much more prevalent than what is seen in medical practice.

Chronic anal fissure

Depending on its progression, the anal fissure can be classified as acute or chronic. The majority of the anal fissures are acute. They are usually located in the midline posteriorly (at 6 o’clock) and in some cases are easy to spot even at home with a mirror and a light source. An acute anal fissure that does not resolve with conservative management within 6–8 weeks will turn into chronic state and will pose a challenge to treat. The chronic anal fissure will develop fibrosis and on the base of the fissure, the internal anal sphincter might be exposed (which is why it looks whitish). The chronic anal fissure is often associated with a sentinel perianal skin tag distally and a hypertrophied anal papillae on the inside.

How to heal an anal fissure?

The treatment of anal fissure depends on its progression and the symptoms present. Some anal fissures might be just small tears that will heal on their own in a week or two. If this is the case, however, many people might not notice or will not turn to a medical specialist. Still, it is estimated that more than 70% of all patients diagnosed with an anal fissure will heal with non-operative measures, such as sitz baths and fiber supplementation, topical anesthetics or sphincter relaxants (diltiazem, nifedipine, or nitroglycerin ointments).

The efficacy of calcium channel blockers (diltiazem and nifedipine) in treating anal fissures has been proven. Treatment with diltiazem cream is effective in about 70% of the cases. On top of that, the topical treatment comes off much cheaper and is equally effective as the treatment with Botox injections.

Anal fissures that fail to heal after medical treatment can be considered for surgery. The goal of some of the surgical procedures, such as manual dilatation (Lord’s procedure) or lateral internal sphincterotomy (LIS), is to relax the sphincter muscle and decrease the anal resting tone. Other procedures, such as fissurectomy take another approach – the fissure is excised and a fresh open wound is left on the place. The idea is that by removing the fibrosis tissue, you would give the tear a new chance to heal. However, given the ischemic nature of the fissure, this is probably not the best approach, which is why LIS is nowadays the preferred method. Unfortunately, all of the operative procedures come with increased risks. Persistent fecal incontinence has emerged as a major concern following lateral internal sphincterotomy, which is why medical treatment with topical agents are preferred as a first-line of treatment for most chronic anal fissures.

Anal fissure not healing

Patients who suffer from an anal fissure would often seek information about healing times. The truth is that anal fissures can last for long due to their etiology and it all depends on the case.  Some fissures might heal in a week or two, but an anal fissure that doesn’t heal in about 6 weeks will proceed to a chronic state that can linger on for years. The anal fissure is of an ischemic nature, this means that due to inadequate blood flow and in combination with persistent sphincter spasm and irritation, the tear is unlikely to heal on its own. With time if not properly treated the anal fissure will form fibrosis that will prevent it from healing without operative measures. It is thought that persisting anal fissures develop in patients who manifest increased resting anal pressure, which is why medical and operative treatment is directed at reduction of the anal pressure and improvement of the posterior midline blood flow.

Anal fissure with skin tag

Chronic anal fissures have inflammatory manifestations and may lead to the development of a complex with hypertrophic anal papilla (on the inside of the anal canal) and a sentinel pile (skin tag, visible on the outside). The skin tag itself can grow considerably in size and cause irritations, which is why it is usually removed during surgery for chronic anal fissure. Having any of these outgrows is a good reason to seek help from a specialist.

Skin tag anus photo (click)
skin-tag-near-anus-picture
Chronic anal fissures may develop skin tags (sentinel piles) that will persist even after the fissure has been healed.

Anal fissure and pregnancy

It is well known that a lot of women will complain from different anal symptoms during pregnancy – such as constipation, straining when defecating, dull or an acute pain in the anal region, rectal bleeding, itching and so on. These symptoms tend to become more pronounced during the third trimester of the pregnancy, than in the beginning. After childbirth, it is common for women to complain of hemorrhoids with constipation and straining being obvious associated risk factors.

Studies have shown that less than 10% of the pregnant women will develop anal fissures pre- or after birth. Anal surgeries are not done during pregnancy (exception is possible in specific cases), therefore the prevention of constipation is highly recommended. Moreover, women have shorter internal anal sphincter muscles, which puts them at higher risk of complications (fecal incontinence) after anal fissure operation. Interestingly, there is also a small group of patients, consisting mainly of pregnant women, who manifest atypical fissures with altered symptoms – they might not feel pain or might even suffer from incontinence, not constipation. Anal manometric studies have shown that this group of patients suffers from low-pressure fissures (as opposed to high resting pressure that is common in other people with anal fissure). The optimal therapy in this case is unclear. Ultimately, operative procedures that affect the sphincter mechanisms should be avoided. In general, women who have had children or are planning to have children should avoid surgical options due to the potential risk of fecal incontinence.

Anal fissure or hemorrhoids

For most people any pain or symptom in the anal region is due to hemorrhoids (piles). Anal fissures are very often self-diagnosed as hemorrhoids. Rectal bleeding and irritation are indeed part of the symptomatic complex of several anorectal conditions. Patients are not alone in this. Even an experienced specialist might come up with a wrong diagnosis, which can trouble the patient even further. Most people are not aware that piles are classified according to their anatomic origin. Thus, we have internal and external hemorrhoids.

Internal hemorrhoids originate from the inside of the anal canal, proximal to the linea dentata. External hemorrhoids are located outside of the anal canal, they develop from ectoderm and are covered with epithelium. The general classification might cause some confusion in patients who have no previous experience with the hemorrhoidal disease. Sometimes patients feel that their piles are located outside of the anal verge, but in fact, they prolapse from the inside. In this case, we are talking about a prolapse of the internal hemorrhoidal tissue. It is also important to note, that the patient can develop both internal and external hemorrhoids at the same time.

Hemorrhoids treatment

To address the degree of prolapse of the internal hemorrhoids, we use a fourth degree system (with grade I – being the least advanced and grade IV the most advanced state). Piles generally don’t cause much pain, unless they get thrombosed. It is important to note that most of the risk factors like constipation, straining, the passage of hard feces and even childbirth are overlapping for both conditions. Much like in anal fissures, hemorrhoids could lead to rectal bleeding (bright red blood) which only adds up to the confusion. Despite marketing efforts, topical products can’t really cure both problems at once. Moreover, some of the proposed measures for conservative treatment of anal fissures (the sitz baths with hot water) will actually aggravate the state of the hemorrhoidal disease (for hemorrhoids cold water is recommended). Surgical management of piles (especially hemorrhoidectomy) can lead to the occurrence of an anal fissure. On the other hand, lateral internal sphincterotomy and the weakening of the sphincter muscles may further the hemorrhoidal prolapse, which is why a combined operation to fix both problems could be offered to the patient.

Anal fissure: recovery after operation

Healing time for patients who had an anal fissure surgery could differ. Lateral internal sphincterotomy is quite effective (in more than 95% of cases) and improvement (in terms of relaxation and lower resting pressure) should be notable right after the operation. However, the healing of the fissure itself, along with the normalization of the defecation habits, the psychological state and some local irritations that may occur (itching, minor bleeding) could linger on for up to 4-6 weeks after the LIS. It is normal to feel a bit more tender and bruised down there for over a week. If the lateral sphincterotomy wasn’t combined with another operation, the patient shouldn’t really experience pain from the operation itself. There could still be some pain from the anal fissure but it will pass. Most people notice that the pain from an anal fissure goes away within a few days after the surgery. If no complications have arisen, you should be able to get back to work in several days (week at top). However, it will probably take about 8 weeks for your anal fissure to completely heal.

With other procedures, such as fissurectomy it is more complex – the patient is left with a fresh wound and usually then prescribed a medical treatment that should aid the healing process. Completely healing might take 3 months. After an operation for anal fissure, it is recommended to keep up with the diet measures and avoid constipation. A key to recovery is to make sure you have enough of liquid and fiber intake to prevent hard stools. You might be given laxatives or a topical preparation to aid the healing process. Sitting in warm water (sitz bath) after bowel movements will also help.

Incontinence after lateral sphincterotomy (LIS)

Lateral internal sphincterotomy involves partial, lateral division of the anal sphincter to lower the resting pressure and improve the blood flow in the area. It was popularized by Eisenhammer in 1951. Initially it was proposed that the internal anal sphincter should divided completely. However, this led to various complications, most importantly – persistent fecal incontinence. This is why different approaches have emerged. An open and closed technique have been described. The open sphincterotomy involves either a vertical or a radial incision. The internal sphincter is identified and divided under the direct vision of the operator. The closed sphincterotomy involves advancing a small blade through the anoderm, so the division is done without direct visual control.

Reported post-operative incontinence may vary (from 0-30%). This variation could be due to methodological differences, lack of a common definition for incontinence and even due to the experience of the operator. In general, the deeper the incision is, the higher the risk. It should be noted that in some cases short-term problems with flatulence control are normal and to be expected, especially in the first 3 weeks. The group of patients more prone to fecal incontinence includes: women over 45, women who have had a vaginal birth, people who have had a previous anal surgery.

The treatment of fecal incontinence is a complex topic. There are a variety of medical therapies available for the management of fecal incontinence, such as: bulking agents (fiber), constipating medicine (amitriptyline), biofeedback sittings. Operative measures include: anterior overlapping sphincteroplasty, sacral nerve stimulation, artificial bowel sphincter and even colostomy.

Don’t forget to check our in-detail page about anal fissures.

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Article author
Dr. Trayan Seliminsky, Gastroenterology, Medical University-Varna

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