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An anal fissure is a crack, tear or cut in the lining of the anus (back passage). A fissure may be acute or chronic, depending on how long it has been present. Sometimes, the skin at the bottom of the fissure may become swollen which may give the mistaken impression that the pain and bleeding are due to piles or haemorrhoids.
Fissures can occur at any age, but most commonly occur in young children and adults. Many fissures occur for no particular reason. However, direct trauma to the area may be a factor in many cases. Anything that can cut or irritate the inner lining of the anus can cause a fissure. Most commonly constipation leading to a hard, dry bowel movement may cause a fissure.
Other causes of a fissure include diarrhoea or inflammatory conditions of the anal area. Fissures may also develop after delivery of a baby (post partum). Anal fissures may be acute (recent onset) or chronic (present for a long time or recurring frequently). Chronic fissures often have a small external lump associated with the tear called a sentinel pile or skin tag. This is commonly mistaken for standard piles or haemorrhoids
The symptoms of a fissure are pain, especially when passing a bowel motion, and some bleeding. Occasionally, people experience discharge of an abscess in association with a fissure. Fissures are quite common, but are often confused with other causes of pain and bleeding, such as piles or haemorrhoids. Patients may try to avoid defecation because of the pain.
Often treating the constipation or diarrhoea can cure a fissure. An acute fissure is usually managed with dietary changes and local creams (non-
A number of specific creams have come on the market over the last few years. These have been designed to reduce the spasm within the anal sphincter and can heal up to 80% of fissures. Some fissures, if they do not respond to these methods, may require an operation. The most commonly used ointments are
Fissures can recur easily, and it is quite common for a healed fissure to recur after a hard bowel movement. Even after the pain and bleeding has disappeared one should continue to aim for good bowel habits and adhere to a high fibre diet or fibre supplement regimen. If the problem returns without an obvious cause, further assessment may be needed.
A fissure that fails to respond to treatment should be re-
An operation may be necessary in order to get a more detailed look at the fissure and possible take a biopsy. This is called an Examination under Anaesthesia (EUA). Your colorectal surgeon may also recommend additional measures including injection of the anal sphincter with Botox. This relaxes the anal sphincter muscle and may heal up to 85% of fissures. The effect is transient (8-
Persistent fissures may require a lateral internal anal sphincterotomy. This is a highly effective treatment for a fissure and recurrence rates after this type of surgery are low. Surgery usually consists of a small operation to cut a portion of the internal anal sphincter muscle (a lateral internal sphincterotomy). This is a fairly minor operation and most cases can be performed as a day case without the need to stay overnight. This sphincterotomy operation helps the fissure heal by decreasing pain and spasm which improves the blood supply to the skin.
A small percentage of patients who undergo a sphincterotomy may find impaired control of the bowel motions after operation (minor faecal incontinence). Surgery is not therefore usually performed without first trying non-
Other operations, less frequently performed, include anal stretch or anoplasty. If a sentinel pile is present, it too may be removed to promote healing of the fissure. This may be combined with either injection with Botox or sphincterotomy.
A small number of patients who undergo injection of the anus with Botox may experience transient weakness in the sphincter muscle and some incontinence of stool.
As discussed above, sphincterotomy also infrequently may interfere with one’s ability to control bowel movements. Patients who have had previous anorectal surgery or women who have sustained a preceding injury to the anal sphincter during childbirth may be at increased risk of these problems.
Surgery is generally very safe. However, all surgical treatments do have other risks, and your colorectal specialist will address these with you.
Complete healing occurs in a few weeks, although pain often disappears after a few days
No! Persistent symptoms, however, need careful evaluation since conditions other than fissure can cause similar symptoms. Your doctor may request additional testing even if your fissure has successfully healed. A colonoscopy may be required to exclude other causes of bleeding.
Yes. Glasgow Colorectal Centre surgeons’ Richard Molloy and Graham MacKay are happy to assess patients with an anal fissure and will advise on investigation and management, be it medical treatment or surgery including injection of the fissure with Botox.
If you have any questions about anal fissure or other colorectal issues, your own GP is often the best first port of call.
If appropriate, they will be able to arrange a referral to a colorectal specialist centre such as the Glasgow Colorectal Centre.