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Anal Fissures
Overview
An anal fissure is a tear in the soft tissue that lines the anus.
Anal fissures can cause pain, bleeding, or other symptoms. Fissures can be small but more painful than you’d expect, given the size of the tear.
The most common symptoms include:
- Pain. This may be felt during a bowel movement. You may feel an ongoing dull ache afterward.
- Bleeding. You may notice a small amount of bright red blood in the stool or when you wipe.
- Itching.
Causes and Risk Factors
The most common cause of anal fissures is constipation. Constipation creates large, hard stools that can cause straining to pass them and can tear the soft tissue of the anal canal.
Other settings in which fissures may arise include:
- Pregnancy. The uterus can put pressure on the rectum and anus at the end of pregnancy. Sometimes the anal canal can tear during delivery.
- Persistent diarrhea.
- Tight muscles. The anal sphincter is a ring of muscles surrounding the anal canal. Tight sphincter muscles increase tension in the anal canal. This can make the skin more likely to tear.
- Anal (or bottom) sex, especially without enough lubricant or before the anal sphincter is relaxed.
- Inflammatory bowel disease such as Crohn’s disease.
- Previous surgery to the anal area. Scarring may make tissues less elastic and more likely to tear.
Diagnosis
Your doctor will ask you about your symptoms and medical history and examine you. Most fissures are located near the opening of the anus. If the fissure is visible, your doctor can confirm the diagnosis immediately.
If we can’t see a fissure, we may recommend additional tests. These include:
- Digital rectal exam. This allows your doctor to feel any abnormalities. They won’t use this method if it’s too painful.
- Anoscopy. Your doctor will use a lighted scope to examine the anal canal.
Sometimes the location of the fissure tells us something about what caused it. Most fissures caused by constipation are located at the back or front of the anal canal.
If the fissure is located to the side, your doctor may consider other medical causes.
Home Treatment
Most tears heal within a few weeks. You can help the healing process by following these recommendations.
Keep stools soft and avoid constipation and straining to pass a bowel movement by:
- Eating fruits, vegetables, beans, and whole grains every day.
- Drinking plenty of water. Urine should be light yellow or clear. Some people with kidney, heart, or liver disease need to limit fluids. Talk to your doctor before increasing fluid intake.
- Exercising. Walk or do other activities for at least 30 minutes most days of the week.
- Taking a fiber supplement (such as Metamucil or psyllium) to ensure regular bowel movements that aren’t too hard or too soft.
- Scheduling time for bowel movements. A daily routine can prevent constipation.
- Placing your feet on a small box or step stool when sitting on the toilet.
- Avoiding straining to pass a bowel movement. If you can’t pass the stool within a minute or 2 without straining, then try again later when you have the urge to poop.
- Listening to your body. If you have the urge to poop, go directly to the bathroom. If you try to override this urge, your body will have a harder time passing the bowel movement.
Use warm water, relax the sphincter, and avoid tears by:
- Taking a sitz bath to ease pain and discomfort. Sit in a few inches of warm water several times a day and after bowel movements.
- Applying a warm, wet compress instead of or in addition to sitz baths. Soak a washcloth in hot water, gently wring it out to remove excess water, then apply to anal area with gentle pressure. Repeat often.
- Using water (bidet toilet seat, shower, squeeze bottle) to rinse the anal area clean after a bowel movement. A small amount of unscented lotion (such as Curel Fragrance Free) on dry toilet paper before you wipe also removes stool without irritating your skin. Avoid commercial wet wipes and dry toilet paper, as they can irritate delicate skin.
- Avoiding rectal douching after anal sex. The regular use of douches with a shower hose or douche kits can dry out the lining of the rectum and make it tear more easily.
- Avoiding anal sex (as bottom) until your symptoms go away. To prevent future fissures, if you have anal sex and you have a tense sphincter muscle, try active relaxation before penetration. Gentle anal dilation can also be helpful to relax the sphincter.
Medical Treatment
Most fissures heal with home treatment. If the fissure doesn’t heal, we may treat it with medications that include:
- Diltiazem, nifedipine, or other topical ointments. These ointments relax the sphincter muscles. More blood can then flow to the tear, which helps it heal.
- Botox. We may recommend injecting botulinum toxin into the anal sphincter muscle. This temporarily paralyzes the muscle, promoting blood flow and healing.
Surgical Treatment
If a fissure doesn’t heal after treatment, we may recommend surgery. The procedure is called a lateral internal sphincterotomy. Before surgery begins, you’ll receive general anesthesia, which will keep you asleep during the procedure. Your surgeon will:
- Place a lighted scope into the anus to see the tear clearly.
- Make a small cut in the anal sphincter muscle. This reduces tension in the anal canal and prevents further fissures from developing.
The procedure doesn’t take long. You’ll be able to go home on the same day.
Risks and benefits
This surgery is very effective. Most fissures heal completely 2 to 4 weeks after surgery. Pain improves within a few days.
A small number of people may experience complications. Around 5 percent may lose some bowel control. This is caused by damage to the anal muscles. Symptoms are usually mild and make it difficult to prevent passing gas. Bowel incontinence usually gets better with time. In rare cases it can be more severe and may cause permanent problems.
Lifestyle Recommendations
You can do several things to prevent fissures from developing again. Keeping stools soft and regular will prevent future injury to the anal canal.
To prevent constipation:
- Eat a high-fiber diet. Slowly add fiber to your diet to reduce gas and bloating.
- Limit low-fiber foods that are high in fat and sugar and low in fiber content, such as ice cream, cheese, and processed foods.
- Drink 8 glasses of water daily.
- Increase physical activity. Walking can stimulate intestinal function.
- Go to the bathroom as soon as you feel the urge to have a bowel movement.
- Try over-the-counter fiber supplements.
Try to avoid taking stimulant laxatives because they can be habit-forming.