An anal fissure is a cut or tear occurring in the anus (the opening through which stool
passes out of the body) that extends upwards into the anal canal. Fissures are a common
condition of the anus and anal canal and are responsible for 6-15% of the visits to a
colonic and rectal (colorectal) surgeon. They affect men and women equally and both the
young and the old. Fissures usually cause pain during bowel movements that often is
severe. Anal fissure is the most common cause of rectal bleeding in infancy.
Anal fissures occur in the specialized tissue that lines the anus and anal canal, called
anoderm. At a line just inside the anus--referred to as the anal verge or intersphincteric
groove--the skin (dermis) of the inner buttocks changes to anoderm. Unlike skin,
anoderm has no hairs, sweat glands, or sebaceous (oil) glands and contains a larger
number of somatic sensory nerves that sense light touch and pain. (The abundance of
nerves explains why anal fissures are so painful.) The hairless, gland-less, extremely
sensitive anoderm continues for the entire length of the anal canal until it meets the
demarcating line for the rectum, called the dentate line. (The rectum is the distal 15 cm of
the colon that lies just above the anus and rectum and just below the sigmoid colon.)

Most anal fissures are caused by stretching of the anal mucosa beyond its capability. For
example, anal fissures are common in women after childbirth, after difficult bowel
movements, and in infants following constipation.
Superficial or shallow anal fissures look much like a paper cut, and may be hard to detect
upon visual inspection, they will generally self-heal within a couple of weeks. However,
some anal fissures become chronic and deep and will not heal. The most common cause
of non-healing is spasming of the internal anal sphincter muscle which results in impaired
blood supply to the anal mucosa. The result is a non-healing ulcer, which may become
infected by fecal bacteria.

Anal fissure may cause painful bowel movements and bleeding. There may be blood on the outside of the stool or on the toilet tissue (or baby wipes) following a bowel
movement.
Other symptoms may include:

• A crack in the skin that can be seen when the area is stretched slightly (the fissure

is almost always in the middle)

• Constipation

Call your doctor promptly whenever you have rectal bleeding or any bloody discharge
from the anus. Even if you have been treated for a bleeding fissure in the past, it is always
safer for your doctor to determine the best course of action. This is especially true if you
are over age 40, when there is an increase in the risk of rectal bleeding from colorectal
cancer and other serious digestive diseases.
Also, call your doctor if you have:

• Severe pain in the anal area
• A tender mass or swelling near the anus, with or without a fever
• Pus or a foul-smelling discharge from the anus
• Discomfort or tightness in the anal area that interferes with bowel movements

A careful history usually suggests that an anal fissure is present, and gentle inspection of
the anus can confirm the presence of a fissure. If gentle eversion (pulling apart) the edges
of the anus by separating the buttocks does not reveal a fissure, a more vigorous
examination following the application of an anesthetic to the anus and anal canal may be
necessary. A cotton-tipped swab may be inserted into the anus to gently localize the
source of the pain.
An acute anal fissure looks like a linear tear. A chronic anal fissure frequently is
associated with a triad of findings that includes a tag of skin at the edge of the anus
(sentinel pile), thickened edges of the fissure with muscle fibers of the internal sphincter
visible at the base of the fissure, and an enlarged anal papilla at the upper end of the
fissure in the anal canal.
If rectal bleeding is present, an endoscopic evaluation using a rigid or flexible viewing
tube is necessary to exclude the possibility of a more serious disease of the anus and
rectum. A sigmoidoscopy that examines only the distal part of the colon may be
reasonable in patients younger than 50 years of age who have a typical anal fissure. In
patients with a family history of colon cancer or age greater than 50 (and, therefore, at
higher risk for colon cancer), a colonoscopy that examines the entire colon is
recommended. Atypical fissures that suggest the presence of other diseases, as discussed
previously, require other diagnostic studies including colonoscopy and upper
gastrointestinal (UGI) and small bowel x-rays.

Self-help
Changes to your diet will help your anal fissure to heal. The main aims are to prevent
constipation and make your faeces (stools) smaller and softer.

• You should eat a diet that is rich in fibre, including plenty of fruit, vegetables and wholegrain cereals such as brown rice, bread and pasta. You should aim to eat 25 to 30g of fibre per day in your food or by taking a supplement. For example, two slices of whole meal bread has 6g fibre and a serving of wholegrain pasta has 5g fibre.
• You should drink enough water so that you don't become dehydrated, which can make your faeces harder.
• Over-the-counter remedies available from your pharmacy can also help to treat constipation. These include a bulk-forming laxative (e.g. Fybogel) or a laxative that softens the faeces (e.g. lactulose syrup). However, don't give bulk-forming

Laxatives to children

Always read the patient information leaflet that comes with your medicine and if you
have any questions, ask your pharmacist for advice.
It may help to use a lubricant such as petroleum jelly around your anus before you have a
bowel movement. Sitting in a warm bath after a bowel movement may relieve your
discomfort.
If your anal fissure doesn't heal despite these home treatments, or if you are worried
about it, you should see your GP.
You should also see your GP if you have:

• Blood in your faeces (rather than some spotting on toilet paper or in the toilet)

• Altered bowel habits, for example passing faeces more often than usual

• Been losing weight without trying to

These symptoms may be caused by problems other than an anal fissure. You should visit
your GP for advice.
Medicines

Acute anal fissure
If necessary you can take over-the-counter painkillers such as paracetamol, ibuprofen or
aspirin.
Your GP may prescribe you a cream, ointment or suppository that contains a local
anesthetic, such as lidocaine, and/or steroids, such as hydrocortisone (e.g. Perinal).
These medicines will help to relieve the spasm of an anal fissure. Your GP may also
prescribe laxatives and will give you advice about preventing constipation.
Always ask your GP for advice and read the patient information leaflet that comes with
your medicine.

Chronic Anal Fissure
Medicines for chronic anal fissure aim to reduce spasms and reduce the pressure in the
anus.
As well as the medicines and self-help for acute anal fissure your GP may also prescribe
glyceryl trinitrate (e.g. Rectogesic). This is a rectal ointment that relaxes the internal anal
sphincter muscle. This reduces the spasm and improves the blood flow to the anus,
helping the fissure heal. Using the ointment may mean that you won't need more invasive
treatment such as surgery.
A number of other medicines for anal fissure are sometimes used, such as botulinum, a
toxin (e.g. Botox) or calcium channel blockers (e.g. topical Nifedipine). These medicines
act by relaxing part of the sphincter to reduce the spasm and the pressure in the anus.
Studies of these treatments have produced mixed results so you should ask your GP for
advice.
Ask your GP for more information about medicines for anal fissure.

Surgery
Most anal fissures heal with the use of medicines or by changing your diet. You may
need surgery if you have a chronic anal fissure that doesn't get better.
The aim of surgery is similar to that of medicines - to relieve the pressure within the anus.
The most common operation is called a lateral internal sphincterotomy (LIS). You can
have this as a day case under local or general anesthetic. Local anesthetic completely
blocks feeling from the anal area and you will stay awake during the operation. General
anesthetic means you will be asleep during the operation and feel no pain.
In a LIS procedure your surgeon will make a small cut to access the internal sphincter.
He or she will then make a small cut in the internal sphincter to relieve the spasm
associated with anal fissures.
LIS is a very effective treatment with a success rate of about 95 percent, but there's a
small risk you might have some incontinence - mainly to wind. It's also possible that your
anal fissure may re-occur after surgery.

The following lifestyle changes may help relieve discomfort and promote healing of an
anal fissure, as well as prevent recurrences:

• Add fiber to your diet. You can increase your fiber intake by eating more fruits, vegetables, nuts and whole grains. The recommended amount of fiber is 20 to 35 grams of fiber daily. Most people don't get that much, so you may want to take a fiber supplement. Bulk-forming laxatives, such as psyllium (Fiberall, Metamucil, others), soften stools and allow them to pass more easily. Adding fiber through either diet or supplementation may cause gas and bloating, so increase your fiber intake gradually.

• Drink adequate fluids. Fluids also help prevent constipation, so it's important to get enough. However, it may be difficult to determine how much enough for you is. If you're rarely thirsty and your urine looks colorless or very light yellow, you're probably drinking enough.

• Exercise regularly. You can experience a host of benefits by walking or engaging in 30 minutes of another moderate activity most days of the week. Among those benefits are promoting regular bowel movements and increasing blood flow to all parts of your body, which may promote healing of an anal fissure.
• Take a bath or a sitz bath. Soaking in warm water for 10 to 20 minutes one or more times a day, especially after bowel movements, will help ease pain and itching. Don't use soap or bubble bath, as this may irritate the area. Also, avoid using medicated or perfumed wipes because these also may irritate the area.

• Avoid straining during bowel movements. Straining creates pressure, which can open a healing tear or cause a new tear.

Anal fissures are not associated with more serious diseases, such as bowel cancer. Some of
the possible complications of an anal fissure can include:

• Chronic anal fissure - the tear fails to heal. Over time, this can cause extensive scar tissue at the site of the fissure (sentinel pile).

• Anal fistulas - abnormal ‘tunnels’ join the anal canal to surrounding organs, usually other parts of the bowel.

• Anal stenosis - the anal canal becomes abnormally narrowed either due to spasm of the anal sphincter or contraction of the resultant scar tissue.