anal fissure

Most anal fissures are caused by stretching of the anal mucous membrane beyond its capability.{{Cite web |date=2022-04-19 |title=Anal Fissures |url=https://www.hopkinsmedicine.org/health/conditions-and-diseases/anal-fissures |access-date=2023-11-02 |website=www.hopkinsmedicine.org |language=en}}

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.

In adults, fissures may be caused by constipation, the passing of large, hard stools, or by prolonged diarrhea. In older adults, anal fissures may be caused by decreased blood flow to the area. When fissures are found laterally, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, acquired immunodeficiency syndrome (AIDS) or inflammatory bowel disease should be considered as possible causes.{{cite journal| title = Common Anorectal Conditions| journal = American Family Physician| date = July 2001| volume = 64| issue = 1| pages = 77–89| url = http://www.aafp.org/afp/2001/0701/p77.html| publisher = American Academy of Family Physicians| url-status = live| archive-url = https://web.archive.org/web/20120805172601/http://www.aafp.org/afp/2001/0701/p77.html| archive-date = 5 August 2012| df = dmy-all| last1 = Pfenninger| first1 = John L.| last2 = Zainea| first2 = George G.}} Some sexually transmitted infections can promote the breakdown of tissue resulting in a fissure: syphilis, herpes, chlamydia and human papilloma virus.{{cite web| title = Anal Fissure – Causes| url = http://www.nhs.uk/Conditions/Anal-fissure/Pages/Causes.aspx| publisher = NHS Choices| url-status = live| archive-url = https://web.archive.org/web/20130204052504/http://www.nhs.uk/Conditions/Anal-fissure/Pages/Causes.aspx| archive-date = 4 February 2013| df = dmy-all}}

Other common causes of anal fissures include: childbirth trauma in women,{{cite journal|last=Collins|first=E. E.|author2=Lund, J. N.|title=A Review of Chronic Anal Fissure Management|journal=Techniques in Coloproctology|date=September 2007|volume=11|issue=3|pages=209–223|doi=10.1007/s10151-007-0355-9|pmid=17676270|s2cid=8520860 }} anal sex,{{cite web |title=What Causes Anal Fissures? |url=http://www.webmd.com/digestive-disorders/anal-fissure-causes |website=WebMD |access-date=July 20, 2017 |url-status=live |archive-url=https://web.archive.org/web/20170727093631/http://www.webmd.com/digestive-disorders/anal-fissure-causes |archive-date=27 July 2017 |df=dmy-all }}{{cite book |last1=Ferri |first1=Fred F. |title=Ferri's Clinical Advisor 2016 |date=2015 |publisher=Elsevier Health Sciences |isbn=9780323378222 |page=108 |url=https://books.google.com/books?id=bbLSCQAAQBAJ&pg=PA108 |language=en}} Crohn's disease, ulcerative colitis,{{cite web|url=http://my.clevelandclinic.org/disorders/anal_fissures/hic_anal_fissures.aspx|title=Anal Fissure Treatment, Symptoms & Surgery - Cleveland Clinic: Health Library|website=Cleveland Clinic|url-status=live|archive-url=https://web.archive.org/web/20130822215054/http://my.clevelandclinic.org/disorders/Anal_Fissures/hic_Anal_Fissures.aspx|archive-date=22 August 2013|df=dmy-all}} and poor toileting in young children.{{cite web|title=Anal Fissure – Basics – Epidemiology|url=http://bestpractice.bmj.com/best-practice/monograph/563/basics/epidemiology.html|work=Best Practice|publisher=British Medical Journal|access-date=30 June 2012|date=23 April 2012|df=dmy-all}}

External anal fissures on the anal verge can be diagnosed by visual inspection.{{citation needed|date=July 2022}}

In case of chronic anal fissure the sentinel piles on anal verge, papilla next to dentate line and fissures also commonly referred to in combination as classic fissure triad can also be seen during diagnosis.

Internal anal fissures stretching from anal verge till dentate line in adults on anterior side, posterior side or within any part of the inner circumference of the anal sphincter muscle can be diagnosed with a beak proctoscope of 23 mm diameter, a Hill Ferguson retractor of 23 mm diameter, a Park anal retractor or by digital rectal examination with a finger through the anal sphincter.

Narrow anal fissures might not be felt by finger palpation during the rectal exam due to gloves reducing tactile sensitivity.{{Cite journal |last1=Man |first1=Tanita |last2=Jiang |first2=Jun |last3=Schulz |first3=Manuela |last4=Kükrek |first4=Haydar |last5=Betzl |first5=Julia |last6=Machens |first6=Hans-Günther |last7=Erne |first7=Holger C. |last8=Moog |first8=Philipp |date=December 2022 |title=Surgical experience and different glove wearing conditions affect tactile sensibility |journal=Heliyon |language=en |volume=8 |issue=12 |pages=e12550 |doi=10.1016/j.heliyon.2022.e12550 |doi-access=free |pmc=9803715 |pmid=36593852|bibcode=2022Heliy...812550M }}

Note that colonoscopy, sigmoidoscopy, or normal proctoscopy is for diagnosing internal hemorrhoids and other internal rectal diseases and not for diagnosing anal fissures.{{relevance inline|date=July 2024}}

{{how-to|section|date=July 2024}}

For adults, the following may help prevent anal fissures:

• Avoiding straining when defecating. 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.{{cite web|last=Basson|first=Marc D.|url=http://emedicine.medscape.com/article/184704-overview|title=Constipation|work=eMedicine|date=28 January 2010|publisher=WebMD|location=New York, NY|access-date=5 April 2010|url-status=live|archive-url=https://web.archive.org/web/20100215035435/http://emedicine.medscape.com/article/184704-overview|archive-date=15 February 2010|df=dmy-all}} Similarly, prompt treatment of diarrhea may reduce anal strain.
• Careful anal hygiene after defecation, including using soft toilet paper and cleaning with water, plus the use of sanitary wipes.
• In cases of pre-existing or suspected fissure, use of a lubricating ointment (It is important to note that hemorrhoid ointment is contraindicated because it constricts small blood vessels, thus causes a decrease in blood flow, which prevents healing).

In infants, frequent diaper change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough fluids (i.e. breastmilk, proper ratios when mixing formulas) is beneficial. In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.{{Cite book |title=Nelson Textbook of Pediatrics |date=2011 |publisher=Saunders, Elsevier |isbn=978-0-8089-2420-3 |editor-last=Kliegman |editor-first=Robert M. |edition=19 |location=Philadelphia, Pa |editor-last2=Abramson |editor-first2=Jon S.}}

Non-surgical treatments are recommended initially for acute and chronic anal fissures.{{cite journal |vauthors=Nelson RL, Thomas K, Morgan J, Jones A |title=Non surgical therapy for anal fissure |journal=Cochrane Database of Systematic Reviews |volume=2 |pages=CD003431 |year=2012 |issue=2 |pmid=22336789 |doi=10.1002/14651858.CD003431.pub3|pmc=7173741 }}{{cite journal |last=Haq. |first=Z. |author2=Rahman, M.|author3= Chowdhury, R.|author4= Baten, M.|author5= Khatun, M. |title=Chemical Sphincterotomy—First Line of Treatment for Chronic Anal Fissure |journal=Mymensingh Medical Journal |volume=14 |issue=1 |pages=88–90 |year=2005 |pmid=15695964}} These include topical nitroglycerin or calcium channel blockers (e.g. diltiazem), or injection of botulinum toxin into the anal sphincter.{{cite journal|last1=Shao|first1=WJ|last2=Li |first2=GC |last3=Zhang |first3=ZK|title=Systematic review and meta-analysis of randomized controlled trials comparing botulinum toxin injection with lateral internal sphincterotomy for chronic anal fissure|journal=International Journal of Colorectal Disease|date=September 2009|volume=24|issue=9|pages=995–1000|pmid=19266207|doi=10.1007/s00384-009-0683-5|s2cid=21869421}}

Other measures include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.{{cite web|title=Anal Fissure – Treatment Overview|url=http://www.webmd.com/digestive-disorders/tc/anal-fissure-treatment-overview|publisher=WebMD|access-date=27 September 2011|url-status=live|archive-url=https://web.archive.org/web/20111005161059/http://www.webmd.com/digestive-disorders/tc/anal-fissure-treatment-overview|archive-date=5 October 2011|df=dmy-all}}{{cite web|last=Poritz|first=Lisa Susan|title=Anal Fissure Treatment & Management|url=http://emedicine.medscape.com/article/196297-treatment|publisher=Medscape|access-date=27 September 2011|url-status=live|archive-url=https://web.archive.org/web/20111031164029/http://emedicine.medscape.com/article/196297-treatment|archive-date=31 October 2011|df=dmy-all}}

Local application of medication to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,{{cite journal |last=Loder |first=P. |author2=Kamm, M.|author3= Nicholls, R.|author4= Phillips, R. |title='Reversible Chemical Sphincterotomy' by Local Application of Glyceryl Trinitrate |journal=British Journal of Surgery |volume=81 |issue=9 |pages=1386–1389 |year=1994 |pmid=7953427 |doi=10.1002/bjs.1800810949|s2cid=45517748 }}{{cite journal |last=Watson |first=S. |author2=Kamm, M.|author3= Nicholls, R.|author4= Phillips, R. |title=Topical Glyceryl Trinitrate in the Treatment of Chronic Anal Fissure |journal=British Journal of Surgery |volume=83 |issue=6 |pages=771–775 |year=1996 |pmid=8696736 |doi=10.1002/bjs.1800830614|s2cid=27460928 |doi-access=free }}{{cite journal |last=Simpson |first=J. |author2=Lund, J.|author3= Thompson, R.|author4= Kapila, L.|author5= Scholefield, J. |title=The Use of Glyceryl Trinitrate (GTN) in the Treatment of Chronic Anal Fissure in Children |journal=Medical Science Monitor |volume=9 |issue=10 |pages=PI123–126 |year=2003 |pmid=14523338|url= http://www.medscimonit.com/index.php?/archives/article/13258}}{{cite journal|last=Lund |first=J. N. |author2=Scholefield, J.H. |title=A Randomised, Prospective, Double-blind, Placebo-controlled Trial of Glyceryl Trinitrate Ointment in Treatment of Anal Fissure |journal=The Lancet|date=4 January 1997|volume=349|issue=9044|pages=11–14|doi=10.1016/S0140-6736(96)06090-4 |pmid=8988115|s2cid=8780826 }}

and then calcium channel blockers in 1999 with nifedipine ointment,{{cite journal |last=Antropoli |first=C. |author2=Perrotti, P.|author3=Rubino, M.|author4=Martino, A.|author5=De Stefano, G.|author6=Migliore, G.|author7=Antropoli, M.|author8= Piazza, P. |title=Nifedipine for Local Use in Conservative Treatment of Anal Fissures: Preliminary Results of a Multicenter Study |journal=Diseases of the Colon and Rectum |volume=42 |issue=8 |pages=1011–1015 |year=1999 |pmid=10458123 |doi=10.1007/BF02236693|s2cid=29343690 }}{{cite journal|last=Katsinelos |first=P. |author2=Kountouras, J. |author3=Paroutoglou, G. |author4=Beltsis, A. |author5=Chatzimavroudis, G. |author6=Zavos, C. |author7=Katsinelos, T. |author8=Papaziogas, B. |title=Aggressive Treatment of Acute Anal Fissure with 0.5% Nifedipine Ointment Prevents Its Evolution to Chronicity |journal=World Journal of Gastroenterology |volume=12 |issue=38 |pages=6203–6206 |year=2006 |doi=10.3748/wjg.v12.i38.6203 |pmid=17036396 |pmc=4088118 |doi-access=free }}

and the following year with topical diltiazem.{{cite journal |last=Carapeti |first=E. |author2=Kamm, M.|author3= Phillips, R. |title=Topical Diltiazem and Bethanechol Decrease Anal Sphincter Pressure and Heal Anal Fissures without Side Effects |journal=Diseases of the Colon and Rectum |volume=43 |issue=10 |pages=1359–1362 |year=2000 |pmid=11052511 |doi=10.1007/BF02236630|s2cid=25450627 }}

Branded preparations are now available of topical nitroglycerine ointment (Rectogesic (Rectiv) as 0.2% in Australia and 0.4% in UK and US{{cite web|title=Rectiv|url=https://www.drugs.com/rectiv.html|publisher=drugs.com|access-date=27 September 2011|url-status=live|archive-url=https://web.archive.org/web/20110902033155/http://www.drugs.com/rectiv.html|archive-date=2 September 2011|df=dmy-all}}), topical nifedipine 0.3% with lidocaine 1.5% ointment (Antrolin in Italy since April 2004) and diltiazem 2% (Anoheal in UK, although still in Phase III development). A common side effect drawback of nitroglycerine ointment is headache, caused by systemic absorption of the drug, which limits patient acceptability.

A combined surgical and pharmacological treatment, administered by colorectal surgeons, is the direct injection of botulinum toxin (Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993. However, in many cases involving Botox injections, the patients eventually had to choose another cure as the injections proved less and less potent, spending thousands of dollars in the meantime for a partial cure. Lateral sphincterotomy is the Gold Standard for curing this condition.{{cite journal |last=Jost |first=W. |author2=Schimrigk, K. |title=Use of Botulinum Toxin in Anal Fissure |journal=Diseases of the Colon and Rectum |volume=36 |issue=10 |page=974 |year=1993 |pmid=8404394 |doi=10.1007/BF02050639|s2cid=44959287 }}

Combination of medical therapies may offer up to 98% cure rates.{{cite journal |last=Tranqui |first=P. |author2=Trottier, D. |author3=Victor, C. |author4=Freeman, J. |title=Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin |journal=Canadian Journal of Surgery |volume=49 |issue=1 |pages=41–45 |year=2006 |pmid=16524142 |url=https://www.canjsurg.ca/content/cjs/49/1/41.full.pdf |access-date=14 December 2023 |pmc=3207506 |url-status=live |archive-url=https://web.archive.org/web/20231214094957/https://www.canjsurg.ca/content/cjs/49/1/41.full.pdf |archive-date=14 December 2023 |df=dmy-all }}

Surgical procedures are generally reserved for people with anal fissures who have tried medical therapy for at least one to three months and have not healed. It is not the first option in treatment.

The main concern with surgery is the development of anal incontinence. Anal incontinence can include the inability to control gas, mild fecal soiling, or loss of solid stool. Some degree of incontinence can occur in up to 45 percent of patients in the immediate surgical recovery period. However, incontinence is rarely permanent and is usually mild. The risk should be discussed with one's surgeon.

Surgical treatment, under general anaesthesia, is either anal stretch (Lord's operation) or lateral sphincterotomy where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter spasming and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general or regional anaesthesia. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.

Lateral internal sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%).{{cite web |url= https://www.lecturio.com/concepts/anal-fissure/ | title= Anal Fissure |website=The Lecturio Medical Concept Library | date= 16 October 2020 |access-date= 28 June 2021}} In this procedure the internal anal sphincter is partially divided in order to reduce spasming and thus improve the blood supply to the perianal area.

This improvement in the blood supply helps to heal the fissure, and the weakening of the sphincter is also believed to reduce the potential for recurrence.{{cite journal |url= https://www.ncbi.nlm.nih.gov/books/NBK493213/

| title= Internal Anal Sphincterotomy | website= National Center for Biotechnology Information, U.S. National Library of Medicine | year= 2022 | pmid= 29630265 |access-date= 28 June 2021| last1= Villanueva Herrero | first1= J. A. | last2= Henning | first2= W. | last3= Sharma | first3= N. | last4= Deppen | first4= J. G. }} The procedure is generally performed as a day surgery after the patient is given general anesthesia. The pain from the sphincterotomy is usually mild and is often less than the pain of the fissure itself. Patients often return to normal activity within one week.

LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%).{{cite book |last=Wolff |first=B. G. |author2=Fleshman, J.W.|author3= Beck, D. E.|author4= Church, J. M. |title=The ASCRS Textbook of Colon and Rectal Surgery|page=180|url= https://books.google.com/books?id=3dDYW2tbx6UC&q=sphincterotomy+incontinence&pg=PA180|access-date=15 July 2009 |year= 2007|publisher= Springer|isbn=978-0-387-24846-2}}

Though lateral internal sphincterotomy (LIS) is considered safe on a short-term basis, there are concerns about its long-term safety. Pankaj Garg et al. published a systematic review and meta-analysis in which they analyzed the long-term continence disturbance two years after the LIS procedure. They found the incidence of long-term continence disturbance to be 14%, so caution and careful patient selection are needed before undergoing LIS.{{cite journal |vauthors=Garg P, Garg M, Menon GR |title=Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis |journal=Colorectal Disease |volume=15 |issue=3 |pages=e104–17 |date=March 2013 |pmid=23320551 |doi=10.1111/codi.12108|s2cid=23739830 }}

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.{{cite book |last1=Becker |first1=Horst Dieter |title=Urinary and Fecal Incontinence: An Interdisciplinary Approach |year=2005 |publisher=Springer Science & Business Media |isbn=9783540222255 |oclc=185042351 |page=105 |url=https://books.google.com/books?id=lTBDylTih0kC&pg=PA105 |access-date=17 August 2014}} In addition, anal stretching can increase the rate of flatus incontinence.{{cite journal |last=Sadovsky |first=R. |title=Diagnosis and management of patients with anal fissures – Tips from Other Journals |journal=American Family Physician |date=1 April 2003 |volume=67 | issue=7 |page=1608 |url=http://findarticles.com/p/articles/mi_m3225/is_7_67/ai_99410474 |archive-url=https://web.archive.org/web/20060129104317/http://www.findarticles.com/p/articles/mi_m3225/is_7_67/ai_99410474 |url-status=dead |archive-date=29 January 2006 |format=Reprint |access-date=12 May 2009 }} The incidence of incontinence is thought to be due to a lack of standardization and that proper technique results in little chance that it will occur.{{cite journal| pmc=2141661 | pmid=15126193 | volume=4 | title=Treatment of fissure in ano- revisited | year=2004 | author=Gupta PJ | journal=Afr Health Sci | issue=1 | pages=58–62}}

In the early 1990s, however, a repeatable method of anal dilation proved to be very effective and showed a very low incidence of side effects.{{cite journal |last1=Sohn |first1=N |last2=Weinstein |first2=M.A. |title=Anal dilatation for anal fissures |journal=Seminars in Colon and Rectal Surgery |date=January 1997 |volume=8 |pages=17–23 |url=https://www.researchgate.net/publication/285916550}} Since then, at least one other controlled, randomized study has shown there to be little difference in healing rates and complications between controlled anal dilation and LIS,{{cite journal |last=Yucel |first=T. |author2=Gonullu, D.|author3= Oncu, M.|author4= Koksoy, F. N.|author5= Ozkan, S. G.|author6= Aycan, O.|title=Comparison of Controlled-intermittent Anal Dilatation and Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissures: A Prospective, Randomized Study|journal=International Journal of Surgery|date=June 2009|volume=7|issue=3|pages=228–231|pmid=19361582 |doi=10.1016/j.ijsu.2009.03.006|doi-access=free}}

while another has again shown high success rates with anal dilation coupled with low incidence of side effects.{{cite journal |last=Renzi |first=A. |author2=Brusciano, L.|author3=Pescatori, M.|author4=Izzo, D.|author5=Napolitano, V.|author6=Rossetti, G.|author7=del Genio, G.|author8= del Genio, A.|title=Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study|journal=Diseases of the Colon and Rectum|date=January 2005|volume=48|issue=1|pages=121–126|pmid=15690668 |doi=10.1007/s10350-004-0780-z|s2cid=42818812 }}

Fissurectomy involves excision of the skin on and around the anal fissure and excision of the sentinel pile if one is present. The surgical wound can be left open. New skin tissue grows and it heals.{{citation needed|date=July 2022}}

File:Fissurektomie Wunde - Anfangsstadium.jpg|Fissurectomy wound 1.5 weeks after the OP

File:Fissurektomie Wunde nach 3 Wochen.jpg|Fissurectomy wound 3.5 weeks after the OP

File:Fissurektomie Wunde nach 12 Wochen.jpg|Fissurectomy wound 12.5 weeks after the OP

The incidence of anal fissures is around 1 in 350 adults. They occur equally common in men and women and most often occur in adults aged 15 to 40.

{{Portal|Medicine}}

• Anal fistula
• Hemorrhoid
• Pruritus ani

{{Reflist}}

{{Refbegin}}

• {{cite journal |last=Lund |first=J. N. |author2=Nyström, P. O.|author3=Coremans, G.|author4=Herold, A.|author5=Karaitianos, I.|author6=Spyrou, M.|author7=Schouten, W. R.|author8=Sebastian, A. A.|author9= Pescatori, M.|journal=Techniques in Coloproctology|date=October 2006|volume=10|issue=3|pages=177–180 |doi=10.1007/s10151-006-0276-z |pmid=16969620 |title=An evidence-based treatment algorithm for anal fissure |s2cid=5736917 }}

{{Refend}}

{{Commons}}

{{Medical resources

| DiseasesDB = 673

| ICD10 = {{ICD10|K|60|0|k|55}}-{{ICD10|K|60|2|k|55}}

| ICD9 = {{ICD9|565.0}}

| ICDO =

| OMIM =

| MedlinePlus = 001130

| eMedicineSubj = med

| eMedicineTopic = 3532

| eMedicine_mult = {{eMedicine2|ped|2938}} {{eMedicine2|emerg|495}}

| MeshID = D005401

}}

{{Gastroenterology}}

{{Authority control}}

{{DEFAULTSORT:Anal Fissure}}

Category:Diseases of intestines

Category:Anal diseases