Introduction
Anal fissures are small, oval-shaped tears in the anal canal. These occur commonly due to constipation, diarrhea, or trauma. The posterior midline is the most common place or location of anal fissure. The anterior midline is another common location, especially in women. These are diagnosed easily with the help of the patient's history of symptoms. Therefore, imaging tests and blood tests are rarely used.
The patient is typically presented with severe pain in the anal region that develops after passing the stool. Most of the time, the anal fissure is confused with external hemorrhoids because of the location and symptoms. Therefore, the patient's history must be carefully noted, as external hemorrhoids are not associated with severe pain. In contrast, the pain due to an anal fissure stays for several minutes to hours. In addition, 90% of anal fissures heal with medications. If medications fail to treat an anal fissure, a surgical procedure to cut and stretch the sphincter muscles, called anal sphincterotomy, is the most effective.
What Causes an Anal Fissure?
An anal fissure is commonly caused by:
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Long-standing diarrhea.
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Inflammatory bowel disease.
What Are the Anal Fissure Symptoms?
Most commonly, the patient complains of
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Pain in the anal region, especially during defecation, and sometimes, bleeding is present.
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Cramping around the anal area.
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Sharp pain while pooping.
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Presence of cracks in and around the anal area.
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Blood on the poop.
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Skin tags are present in the anal area.
What Is the Pathophysiology of Anal Fissure?
The anal canal has two structures: the internal anal sphincter and the external anal sphincter. The internal anal sphincter is four centimeters long and three millimeters thick. The primary function of the internal anal sphincter is contraction to prevent leakage of stool.
The location of the anal fissure is the dentate line (a line that divides the anal canal into upper and lower thirds). This area is sensitive to trauma because of increased pressure during hard stools or constipation. In addition, the spasms in the sphincter muscles cause pain.
How to Perform an Anal Fissure Diagnosis?
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Patient’s History - The patient suffers severe pain in the anal region for several hours, especially during defecation, and has a history of hard stools or constipation.
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Physical Examination - The anal sphincter may become tender, due to which the patient feels pain when the doctor examines them with gentle pressure or touch. Lacerations or tearing off will be present in the anal region.
What Is the Anal Fissure Treatment?
The first line of treatment for anal fissures is:
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Increase in fiber and water intake.
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Sometimes, fiber supplementation such as psyllium is prescribed.
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A stool softener such as docusate is prescribed.
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A topical anesthetic such as lidocaine jelly 2 percent is prescribed to relieve the pain.
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Steroid-based ointments are sometimes prescribed.
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The most commonly prescribed ointment is Nitroglycerin, but it has many side effects, such as headaches. Therefore, 2 percent Diltiazem is prescribed, which does not have side effects.
Surgical Management
When the first line of treatment fails, surgical intervention is suggested. The gold standard treatment is the lateral internal anal sphincterotomy. It is a surgical procedure to cut and stretch the sphincter muscles. The doctor can do it with an open technique or a closed technique.
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Open Technique:
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Local or general anesthesia is given to the patient.
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The anal canal of the patient is examined through an anoscope (a small tube helps to examine the lining of the anal canal and rectum).
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An incision or cut is made on the boundary or outer lining of the anal canal. This area is called an intersphincteric groove.
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The sphincter muscle fibers are exposed.
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The muscle is elevated and divided using electrocautery (a procedure in which an electric current is applied to destroy the diseased or abnormal tissues).
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The incision is left open for healing or sometimes closed with sutures.
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Closed Technique:
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Local or general anesthesia is given to the patient.
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The anal canal of the patient is examined through an anoscope (a small tube helps to examine the lining of the anal canal and rectum).
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The intersphincteric groove is palpated with hands, and a blade or scalpel is inserted to divide the sphincter.
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It is left open for healing.
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What Are the Signs of Healing Anal Fissure?
Healing of the anal fissure is of two types.
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Acute Anal Fissure: Acute anal fissure usually heals with home remedies in six weeks. Some cases may have recurrence.
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Chronic Anal Fissure: Acute anal fissure progresses to chronic anal fissure and cyclical too.
What Are the Indications of Anal Sphincterotomy?
It is indicated when:
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The medication and other treatment therapies failed to heal the anal fissure within six weeks.
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The patient has a good ability to control fecal or stool movements. It is called fecal continence.
What Are the Contraindications of Anal Sphincterotomy?
The anal sphincterotomy cannot be done in patients who do not have good fecal continence.
What Are the Complications of Anal Sphincterotomy?
The major complications are:
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Anal incontinence. It means that the patient fails to control the movement of the stool resulting in soiling (collection of light material on the skin surface).
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Infection in the anal region.
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Bleeding from the surgery site.
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Formation of a fistula between the anal canal and the skin.
What Is the Differential Diagnosis of Anal Fissure?
The symptoms and presentation of anal fissure may mimic the following conditions:
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Hemorrhoids (swelling of veins in the rectum or anal canal).
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A perianal abscess (pus formation in the rectum and anal region).
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Inflammatory bowel disease (inflammation of the bowel or large intestine).
Who Is Most Affected by Anal Fissure?
An anal fissure can occur in any age group. More commonly, children and adults of middle age are affected. Men and women are equally affected by anal fissures.
What Is the Prognosis of Anal Sphincterotomy?
The prognosis of anal sphincterotomy is good. However, in four to six percent of the patients, anal fissures reoccur.
Conclusion
Anal fissures can be acute or chronic. Patients with an acute fissure have a history of pain and other symptoms of less than three months, and if the symptoms persist for more than three months, it becomes a chronic fissure. Medications and lifestyle changes such as dietary and increased water intake are the first lines of treatment. Most anal fissures heal with conservative treatment. However, if conventional treatment fails to cure an anal fissure, then surgical management of the anal fissure is indicated.
