Definition - What is an Anal Fissure?

An anal fissure is a painful tear in the lining of the anal canal.

Cause

Constipation accompanied by dry or hard stools can cause a tear in the lining of the anal canal. Frequent diarrhea or irritation of the anal and rectal area can also lead to a fissure.

Risk Factors for Developing an Anal Fissure

• Constipation
• Straining during bowel movements
• Previous surgery in the anal canal, which can cause scarring and reduced elasticity of the tissue
• Chronic diarrhea

Symptoms

The symptoms of an anal fissure are similar to those of more severe conditions. Therefore, it is essential to consult a doctor if you experience the following symptoms:
• Pain during or after bowel movements
• A burning sensation during bowel movements
• Bleeding with bowel movements
• Bright red blood on toilet paper or in the toilet bowl
• Itching around the anal area
• A small amount of mucus in the stool

Diagnosis

The doctor will ask about your symptoms and medical history.
The physical examination will also include an inspection of the anal canal.
• Typically, an external examination is sufficient to see the fissure.
• If the fissure has been present for three months or more, additional changes may be seen. These changes may include a fold or thickening of the skin, granulation tissue, or a change in color to white around the fissure due to scar tissue formation.

Treatment

The goal of treatment is to heal the fissure and prevent future problems around the anal canal. About half of the fissures can heal on their own or with self-care. A relatively new fissure usually heals quite easily compared to those existing for more than three months.
Conservative treatments for an anal fissure include:
• Avoiding hard or dry stools
• Drinking at least eight cups of water a day
• Eating a high-fiber diet
• Using stool softeners or laxatives as prescribed by a doctor
• Regular physical activity
• Applying cream or ointment to the anal area as prescribed by a doctor
• Sitz baths, especially after bowel movements, to relieve pain and increase blood flow to the area
• Injection of botox, causing temporary weakening of the anal sphincter muscle, allowing the fissure to heal

It is generally accepted to try conservative treatment for about a month, and if there is no improvement, surgical treatment may be considered.

Surgical Options

In some cases, surgery may be necessary, for example, if the fissure does not heal or recurs and changes. Scar tissue or distortion of the sphincter muscle, which opens and closes the anal canal, may also delay natural healing and require surgery.
Several surgical options involve the principle of weakening the sphincter muscle of the anal canal to reduce the intensity of contractions during efforts to pass bowel movements. The most common surgery is called sphincterotomy. During this procedure, the doctor makes a small incision and divides certain fibers of the sphincter muscle. This will reduce the intensity of the contractions of the anal sphincter during efforts to pass bowel movements, reducing pain, and allowing the fissure to heal.

The surgery usually takes a few minutes and is performed under regional anesthesia (spinal). The procedure requires only a day of hospitalization, and a few hours afterward, the patient can be discharged to rest at home.
The pain in the area may persist for several days to weeks, gradually decreasing.

It should be noted that even after surgery, a recurrence of the condition is possible, and following the instructions to prevent the development of a fissure is essential.

Prevention

Most anal fissures are caused by constipation with dry and hard stools. Here are some recommendations on how to avoid constipation:
• Drink at least eight cups of water a day.
• Engage in regular physical activity.
• Eat fiber-rich foods, such as fruits, vegetables, legumes, and whole grains.
• Avoid straining during bowel movements.

Wishing you a full recovery and speedy healing!
The Surgical Department Team, Shaare Zedek Medical Center