Question 1 of 10

    Anal Fissure (Fissure in Ano)

    Anal fissure 2[1]

    Anal fissure is a linear crack or tear in the mucosa (anoderm) of the distal anal canal. It is often painful and involves the epithelium in the short term. In the long term, it involves the full thickness of the mucosa. They result from forceful dilatation of the anal canal most commonly during defecation.

    This disorder emerges due to the following process: anatomic/foreign.

    Presentation

    Most patients with anal fissure will complain of pain on defecation. This pain is described as burning or tearing, worse during defecation and lasts for hours after bowel movement. This pain worsens with each bowel movement and makes the patients unwilling to have a bowel movement leading to worsening constipation and even more pain. Patients also complain of fresh blood on stool or on the toilet paper but it is not mixed with stool. There is no significant blood loss in anal fissure even though a few drops of blood may be seen dripping into the toilet water [4].

    Most anal fissures occur in the posterior or anterior midline. Any fissure occurring outside the midline should raise suspicions of underlying medical conditions like infection, Crohn disease or cancer.

    Entire body system
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  • gastrointestinal
    Anal or Rectal Pain
    • Using an anoscope may also help your doctor find other causes of anal or rectal pain such as hemorrhoids .[healthline.com]
    Blood in Stool
    • Other possible symptoms may include: The presence of bright red blood on stool and toilet paper following a bowel movement Pain, both during and after a bowel movement Redness, irritation and itching around the anus Noticeable cracks around the skin of[celebrationsurgeons.com]
    • Some children may find the sight of bright red blood in stools and toilet paper distressing.[medicalnewstoday.com]
    • Symptoms of Anal Fissures Anal pain Anal itching Localized pain during bowel movements Bright red blood in stool Causes of Anal Fissures Anal fissures are typically the result of some form of trauma to the anus.[ibdcrohns.about.com]
    • […] on stools or toilet paper after a bowel movement.[mayoclinic.org]
    • An anal fissure may cause one or more of the following symptoms: a visible tear in the skin around your anus a skin tag , or small lump of skin, next to the tear sharp pain in the anal area during bowel movements streaks of blood on stools or on tissue[healthline.com]
    Dyschezia
    • Constipation and dyschezia (retaining stool in the rectum) during pregnancy are the main risk factors for their development.[uhhospitals.org]
    Fecal Incontinence
    • However, permanent fecal incontinence may appear after surgery and available data about this complication are controversial.[link.springer.com]
    • If you are interested in this procedure, you should be referred to a colorectal surgeon, and be aware that fecal incontinence can be a complication of the procedure; however, if this side effect does occur, it's usually minor.[trihealth.com]
    • Anal dilation, or stretching of the anal canal (Lord's operation), has fallen out of favour in recent years, primarily due to the unacceptably high incidence of fecal incontinence.[en.wikipedia.org]
    • Complications from surgery include the risk for infection, bleeding, and persistent gas and fecal incontinence, or uncontrolled bowel movements.[swedish.org]
    Rectal Bleeding
    • Anal fissures often cause rectal bleeding.[nwcch.com]
    • RECTAL BLEEDING: It is usually small amounts of bright, red blood that can be seen on the toilet paper or in the toilet water.[colonrectal.org]
    • Patients suffer from anal pain lasting up to several hours after defecation and rectal bleeding.3 Most acute anal fissures heal spontaneously, but a proportion progress into chronic fissures with symptoms beyond 8-12 weeks.[clinicaltrials.gov]
    • It is the most common cause of rectal bleeding in babies and children.[medicalnewstoday.com]
    • Symptoms of pain and rectal bleeding will alert your doctor to make a simple examination of the outer end of the anal canal.[sproutman.com]
    Rectal Pain
    • In some cases of rectal pain, you may need an endoscopy for better evaluation of your symptoms.[healthline.com]
    • RECTAL PAIN: People often describe it as burning or tearing pain with a bowel movement.[colonrectal.org]
    • Anal fissures are an extremely common problem and in fact represent the most common cause of rectal pain and bleeding in the adult population.[colonandrectalsurgeonskc.com]
    • Rectal Pain Symptoms Rectal pain is pain or discomfort in the lower portion of the gastrointestinal tract.[medicinenet.com]
    • Once a fissure develops, these symptoms can occur after every bowel movement; the rectal pain can be severe and can last several minutes to hours.[uptodate.com]
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  • musculoskeletal
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  • urogenital
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  • psychiatrical
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  • Workup

    Usually, a diagnosis of anal fissure can be made with the combination of a gentle perineal examination and the history. Digital rectal exams are painful and are better deferred. If the fissure cannot be seen on examination, anoscopy should be done. Anoscopy is a painful procedure and application of topical lidocaine helps to alleviate the pain and improve tolerance. Patients with chronic fissures tend to tolerate pain better and proctosigmoidoscopy should be done [5].

    Test Results

    Proctoscopy
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  • Treatment

    Treatment of anal fissure incorporates both medical and surgical components. Medical treatment involves the use of stool softeners and agents to make the stool more malleable and decrease the trauma associated with defecation. Sitz bath, in which the patient is advised to soak in a hot bath, will help to soothe the muscle spasm and decrease the pain associated with it and also help improve blood supply to the area and promote healing.

    Infiltration of the internal sphincter with botulinum toxin creates a reversible paralysis which leads to better perfusion and a faster healing rate. Nitroglycerin ointment is also effective treatment although its side effect, headache, limits its use. Nifedipine ointment has a similar mechanism of action as nitroglycerin without the undesired side effect [6]. When conservative measures have failed, surgery is performed and the procedure of choice is lateral internal anal sphincterotomy.

    Prognosis

    It is not a life threatening condition so the mortality from anal fissure is essentially non-remarkable. It however has crippling morbidity. Less than 10% of patients will have a recurrence of anal fissure after sphincterotomy. This recurrence is may be attributed to an underlying disease or from an improperly/incompletely performed sphincterotomy. This necessitates frequent visits to the surgeon and possibly more surgical procedures.

    Complications

    Anal Fissure
    • The incidence of anal fissures is around 1 in 350 adults.[en.wikipedia.org]
    • Diagnosis of Anal Fissure To diagnose anal fissures, the doctor spreads apart your buttocks to view the anus.[healthcommunities.com]
    • fissures Anal fissure symptoms A common symptom of anal fissures is blood in stool.[medicalnewstoday.com]
    Constipation
    • This includes treating and preventing constipation by eating food rich in dietary fiber, drinking enough water, occasional use of a stool softener, and avoiding constipating agents.[en.wikipedia.org]
    • Constipation can cause the skin of the anus to tear.[jama.jamanetwork.com]
    • In other words, constipation is an effect and an aggravating factor, not a cause of anal fissure.[sproutman.com]
    • This will put fewer burdens on your digestive system and prevent constipation.[findhomeremedy.com]
    • As a result, constipation gets increasingly prolonged and the patient’s sufferings intensify.[pravdareport.com]
    Crohn's Disease
    • If Crohn’s disease is not present, it still may be worthwhile to try a course of antibiotics.[gicare.com]
    • Related: Living with Crohn's Disease Passing hard stools is the primary cause of anal fissures; however, other factors can make you more prone: Experiencing a difficult vaginal delivery Having certain diseases like Crohn’s disease , sarcoidosis, anal[trihealth.com]
    • Acute anal fissures can be caused by trauma from dry, hard stools that are difficult to pass, childbirth, Crohn's disease, anal intercourse, or anal instrumentation.[clinicaladvisor.com]
    • Among patients with Crohn's disease, 4% will have an anal fissure as the first manifestation of their Crohn's disease, and half of all patients with Crohn's disease eventually will develop an anal ulceration that may look like a fissure.[medicinenet.com]
    Hemorrhoids
    • Unlike external hemorrhoids, internal hemorrhoids cause pain indirectly.[gutsense.org]
    • Aside from being annoying, hemorrhoids (swollen veins in the rectum) can be painful and itchy.[youngwomenshealth.org]
    • Anal fissures are frequently confused with hemorrhoids, but hemorrhoids usually do not cause pain while passing stool.[healthcommunities.com]
    • Many people assume that pain in that part of the body signifies hemorrhoids, so they self-treat with hemorrhoid remedies first, says Daniel L.[columbiasurgery.org]
    Perianal Abscess
    • abscess, perianal fistula, pregnancy, primary anal fissure, rectal ulcer, secondary anal fissure, skin wounds, thrombosed external hemorrhoids, wound care, wound healing.[uhhospitals.org]
    Syphilis
    • Examples of sexually transmitted infections that may affect the anorectal area are syphilis, herpes, chlamydia and human papilloma virus.[en.wikipedia.org]
    • Furthermore, an anal fissure may be a sign of a more serious condition, such as: syphilis herpes gonorrhea chlamydia HIV infection AIDS Crohn's disease ulcerative colitis tuberculosis tumor Symptoms of Anal Fissure The hallmark of anal fissures is pain[healthcommunities.com]
    • […] there are other possible causes like persistent diarrhea, inflammatory bowel disease (IBD), Crohn’s disease, ulcerative colitis, straining during childbirth, tight anal sphincter muscles, and, in rare cases, a sexually transmitted infection, such as syphilis[top10homeremedies.com]
    • Pathologies that may lead to fissures include syphilis, chronic IBD, tuberculosis, and HIV/AIDS. 3 Posterior fissures are in a poorly perfused area of the anus, the posterior anal canal.[clinicaladvisor.com]
    • […] anorectal area Presence of an underlying medical problem: such as Crohn's disease and ulcerative colitis [types of inflammatory bowel disease ]; anal cancer ; leukemia ; infectious diseases (such as tuberculosis ); and sexually transmitted diseases (such as syphilis[my.clevelandclinic.org]
    Ulcerative Colitis
    • The fissure can be acute (coming on suddenly and lasting a short time) or chronic (longer lasting), and may be a disorder on its own or a symptom of another disorder, such as Crohn's disease or ulcerative colitis.[southbaysurgeons.com]
    • Other common causes of anal fissures include: childbirth trauma in women Anal sex Crohn's disease ulcerative colitis poor toileting in young children.[en.wikipedia.org]
    • Furthermore, an anal fissure may be a sign of a more serious condition, such as: syphilis herpes gonorrhea chlamydia HIV infection AIDS Crohn's disease ulcerative colitis tuberculosis tumor Symptoms of Anal Fissure The hallmark of anal fissures is pain[healthcommunities.com]
    • However, there are other possible causes like persistent diarrhea, inflammatory bowel disease (IBD), Crohn’s disease, ulcerative colitis, straining during childbirth, tight anal sphincter muscles, and, in rare cases, a sexually transmitted infection,[top10homeremedies.com]
    • colitis [types of inflammatory bowel disease ]; anal cancer ; leukemia ; infectious diseases (such as tuberculosis ); and sexually transmitted diseases (such as syphilis , gonorrhea , Chlamydia , chancroid, HIV ) Decreased blood flow to the anorectal[my.clevelandclinic.org]
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  • Etiology

    The precise etiology of this condition is unknown although it is believed to be caused by trauma. The commonest source of trauma is from passage of particularly hard stools. The etiology is also associated with constipation, straining, inflammation, childbirth, anal cancer, and infections like syphilis, HIV, herpes and tuberculosis. Other factors that contribute to the formation of fissures are previous anorectal surgeries like hemorrhoidectomy or fistulotomy [2].

    Epidemiology

    Anal fissure occurs more in younger children and middle aged adults with an incidence of as much as 1 in 350. It is occurs with identical frequency in both sexes. There is no documented racial predilection.

    Sex distribution
    Age distribution

    Pathophysiology

    Most cases of minor anal tears heal on their own within 4 to 6 weeks, but if there is an underlying abnormality in the internal sphincter, these injuries progress and result in acute and chronic fissures. In studies done on anal physiology, at least one abnormality has been found in the anal sphincter of patients with anal fissure. The most common abnormalities are the ones that lead to increased anal canal and sphincter resting pressure like hypertonicity and hypertrophy of the internal anal sphincter.

    Another mechanism is due to poor perfusion of the posterior anal commissure. This rather mild blood supply is further compromised in patients with hypertrophied internal anal sphincters which makes the posterior midline of the anal canal ischemic. The pain experienced during each bowel movement due to stretching of the mucosa and grazing of this area with stool causes spasm which causes more pain and further compromises the blood supply to the area and leads to poor healing [3].

    Prevention

    It is not entirely possible to prevent anal fissure but the risk can be reduced by taking steps to avoid constipation. Such measures include eating a high fiber diet, maintaining proper hydration preferably with water and regular exercise. Also, don’t ignore the urge to have a bowel movement, the longer the wait, the harder and dryer the stool gets [7].

    Summary

    Anal fissure is a fairly common condition and most of the cases resolve without any medical intervention. It is common in young infants and it often causes pain and blood in stool. If it doesn’t resolve, professional help should be sought [1].

    Patient Information

    Definition

    Anal fissure is a tear in the delicate lining of the anal canal. It results from forceful stretching of the mucus lining of the anal canal and happens mostly during defecation.

    Cause

    It is mostly caused by passage of hard stool which results from constipation. Other causes could be from chronic illnesses, inflammation of the anal region and previous surgical procedures on the anal region.

    Symptoms

    The commonest symptom is pain on passing stools. Pain is often burning and tearing in nature and last for hours after passing stools. There could also be blood seen on the stool or on the toilet paper used for cleaning. There could also be drops of blood could be seen in the toilet water, this blood loss is not enough to cause any significant drop in blood levels [8].

    Diagnosis

    Diagnosis is usually by careful examination of the anal canal, and this is usually enough to reach a definite conclusion. If the fissure is not seen, some imaging studies could be performed. These procedures are painful and are usually performed under anesthesia [9].

    Treatment

    Treatment involves the use of medications to soften the stools. Also sitz baths help to relax the spasm and reduce pain. Some topical solutions are also used to reduce pain, improve blood supply and improve healing. Surgery may be done if conservative measures fail to produce desired effects [10].

    Self-assessment

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    References

    1. Grucela A, Salinas H, Khaitov S, et al. Prospective analysis of clinician accuracy in the diagnosis of benign anal pathology: comparison across specialties and years of experience. Dis Colon Rectum. Jan 2010;53(1):47-52.
    2. Schiano di Visconte M, Munegato G. Glyceryl trinitrate ointment (0.25%) and anal cryothermal dilators in the treatment of chronic anal fissures. J Gastrointest Surg. Jul 2009;13(7):1283-91.
    3. Samim M, Twigt B, Stoker L, Pronk A. Topical diltiazem cream versus botulinum toxin a for the treatment of chronic anal fissure: a double-blind randomized clinical trial. Ann Surg. Jan 2012;255(1):18-22.
    4. Abd Elhady HM, Othman IH, Hablus MA, et al. Long-term prospective randomised clinical and manometric comparison between surgical and chemical sphincterotomy for treatment of chronic anal fissure. S Afr J Surg. Nov 2009;47(4):112-4.
    5. Rather SA, Dar TI, Malik AA, et al. Subcutaneous internal lateral sphincterotomy (SILS) versus nitroglycerine ointment in anal fissure: A prospective study. Int J Surg. Feb 13 2010
    6. American Society of Colon and Rectal Surgeons, Standards Task Force. Practice Parameters for Ambulatory Anorectal Surgery. In: Diseases of the Colon & Rectum. Vol 34. Philadelphia, Pa: Lippincott Williams and Wilkins; 1991:. 285.
    7. Gibbons CP, Read NW. Anal hypertonia in fissures: cause or effect?. Br J Surg. Jun 1986;73(6):443-5.
    8. Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. Jan 1989;32(1):43-52. 
    9. Richard CS, Gregoire R, Plewes EA, et al. Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group. Dis Colon Rectum. Aug 2000;43(8):1048-57; discussion 1057-8. 
    10. Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. Jan 1996;83(1):63-5.

    • A prospective survey of 474 patients with anorectal abscess - DR Read, H Abcarian - Diseases of the Colon & Rectum, 1979 - Springer
    • Abnormal transient internal sphincter relaxation in idiopathic pruritus ani: physiological evidence from ambulatory monitoring - R Farouk, GS Duthie, A Pryde - British journal of , 1994 - Wiley Online Library
    • A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure - G Brisinda, G Maria, AR Bentivoglio - England Journal of , 1999 - Mass Medical Soc
    • Anal fissure and thrombosed external hemorrhoids before and after delivery - L Abramowitz, I Sobhani, JL Benifla, A Vuagnat - Diseases of the colon & , 2002 - Springer
    • A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure - G Brisinda, G Maria, AR Bentivoglio - England Journal of , 1999 - Mass Medical Soc
    • Randomized trial between subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional Parks' operation in the treatment of anal - V Filingeri, G Gravante - European review for medical and , 2005 - europeanreview.org
    • 'Reversible chemical sphincterotomy'by local application of glyceryl trinitrate - PB Loder, MA Kamm, RJ Nicholls - British journal of , 2005 - Wiley Online Library
    • A review of chronic anal fissure management - EE Collins, JN Lund - Techniques in coloproctology, 2007 - Springer
    • A prospective randomized study with mineral oil and oral lavage solution for treatment of faecal impaction in children - V Tolia, CH LIN, Y SUR - Alimentary pharmacology & , 1993 - Wiley Online Library
    • A comparison of botulinum toxin and saline for the treatment of chronic anal fissure - G Maria, E Cassetta, D Gui, G Brisinda - England Journal of , 1998 - Mass Medical Soc
    • AGA technical review on perianal Crohn's disease - WJ Sandborn, VW Fazio, BG Feagan, SB Hanauer - Gastroenterology, 2003 - Elsevier
    • Anal fissure - C Oh, CM Divino, RM Steinhagen - Diseases of the colon & rectum, 1995 - Springer
    • Anal canal pressures are low in women with postpartum anal fissure - H Corby, VS Donnelly, C O'herlihy - British journal of , 1997 - Wiley Online Library
    • A comparison of botulinum toxin and saline for the treatment of chronic anal fissure - G Maria, E Cassetta, D Gui, G Brisinda - England Journal of , 1998 - Mass Medical Soc
    • Aetiology and treatment of anal fissure - JN Lund, JH Scholefield - British journal of surgery, 2005 - Wiley Online Library
    • A prospective randomized study with mineral oil and oral lavage solution for treatment of faecal impaction in children - V Tolia, CH LIN, Y SUR - Alimentary pharmacology & , 1993 - Wiley Online Library

    Media References

    1. Anal fissure 2, Public Domain

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