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Anal fissure
Classification and external resources
ICD-10 K60.0-K60.2
ICD-9 565.0
DiseasesDB 673
MedlinePlus 001130
eMedicine med/3532 ped/2938 emerg/495
MeSH D005401

An anal fissure is a natural crack or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on the toilet paper, sometimes in the toilet. If acute they may cause severe periodic pain after defecation [1] but with chronic fissures pain intensity is often less. Anal fissures usually extend from the anal opening and are usually located posteriorly in the midline, probably because of the relatively unsupported nature of the anal wall in that location. Fissure depth may be superficial or sometimes down to the underlying sphincter muscle.

anal fissure
anal fissure

Contents

Causes

Most anal fissures are caused by stretching of the anal mucosa beyond its capability. For example, anal fissures are common in women after childbirth[2], after difficult bowel movements, and in infants following constipation.[3]

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.[4]

Prevention

For adults, the following may help prevent anal fissure:

  • 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 such as caffeine.[5] Similarly, prompt treatment of diarrhea may reduce anal strain.
  • Careful anal hygiene after defecation, including using soft toilet paper and/or cleaning with water.
  • In cases of pre-existing or suspected fissure, use of a lubricating ointment (e.g. hemorrhoid ointments) can be helpful.
  • In infants, frequent nappy/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. NOTE: See physician before giving infants any fluids outside breastmilk and/or formula) may thus help avoid fissures. In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.

Treatment

Non-surgical treatment is recommended as first-line treatment of acute and chronic anal fissures.[6][7] Customary treatments include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.

Surgical treatment, under general anaesthesia, was 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 anaesthetic and can be painful postoperatively. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.

A new medical/surgical development came in 1993 when researchers reported injecting botulinum toxin into the anal sphincter to relax the sphincter and promote fissure healing.[1]

Chemical sphincterotomy

Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[8][9][10][11] and then calcium channel blockers with in 1999 nifedipine ointment,[12][13] and the following year with topical diltiazem.[14] Branded preparations are now available of topical nitroglycerine ointment (Rectogesic as 0.2% in Australia and 0.4% in UK), 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 direct injection of Botulinum toxin (Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993.[15] Combination of medical therapies may offer up to 98% cure rates.[16]

Surgical Procedures

Surgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. Despite their high success rate (~95%), they are used only after medical treatment has failed due to their potential complications. These include general risks from anesthesia, infection and anal leakage (fecal incontinence). Surgical procedures include:

Lateral Internal Sphincterotomy

Lateral Internal Sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%). 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.

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%[17]).

Anal Dilation (or Dilatation)

Anal dilation, or stretching of the anal canal, (Lord's operation) has fallen out of favour in recent years, primarily due to the perceived unacceptably high incidence of fecal incontinence.[18] In addition, anal stretching can increase the rate of flatus incontinence.[19]

In the early 1990s however Norman Sohn and Michael A. Weinstein of Somerset Surgical Associates pioneered a repeatable method of anal dilation which proved to be very effective and showed a very low incidence of side effects[20]. 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[21], whilst another has again shown high success rates with anal dilation coupled with low incidence of side effects[22].

See also

References

  1. ^ a b Gott M.D., Peter H. (March 5, 1998) The Fresno Bee New therapy coming for anal fissures. Section:Life; Page E2
  2. ^ Abramowitz L, Sobhani I, Benifla JL, et al. (2002). "Anal fissure and thrombosed external hemorrhoids before and after delivery,". Dis. Colon Rectum 45 (5): 650–5. doi:10.1007/s10350-004-6262-5. PMID 12004215. 
  3. ^ Martínez-Costa C, Palao Ortuño MJ, Alfaro Ponce B, et al. (2005). "[Functional constipation: prospective study and treatment response]" (in Spanish; Castilian). Anales de pediatría (Barcelona, Spain) 63 (5): 418–25. PMID 16266617. 
  4. ^ Collins EE, Lund JN.A review of chronic anal fissure management.Tech Coloproctol. 2007 Sep;11(3):209-23.
  5. ^ Basson, Marc D., "Constipation" @ emedicine
  6. ^ Nelson R.Non surgical therapy for anal fissure.Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003431
  7. ^ Haq Z, Rahman M, Chowdhury R, Baten M, Khatun M (2005). "Chemical sphincterotomy--first line of treatment for chronic anal fissure". Mymensingh Med J 14 (1): 88–90. PMID 15695964. 
  8. ^ Loder P, Kamm M, Nicholls R, Phillips R (1994). "'Reversible chemical sphincterotomy' by local application of glyceryl trinitrate". Br J Surg 81 (9): 1386–9. doi:10.1002/bjs.1800810949. PMID 7953427. 
  9. ^ Watson S, Kamm M, Nicholls R, Phillips R (1996). "Topical glyceryl trinitrate in the treatment of chronic anal fissure". Br J Surg 83 (6): 771–5. doi:10.1002/bjs.1800830614. PMID 8696736. 
  10. ^ Simpson J, Lund J, Thompson R, Kapila L, Scholefield J (2003). "The use of glyceryl trinitrate (GTN) in the treatment of chronic anal fissure in children". Med Sci Monit 9 (10): PI123–6. PMID 14523338. 
  11. ^ Lund JN, Scholefield JH.A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure.Lancet. 1997 Jan 4;349(9044):11-4.
  12. ^ Antropoli C, Perrotti P, Rubino M, Martino A, De Stefano G, Migliore G, Antropoli M, Piazza P (1999). "Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study". Dis Colon Rectum 42 (8): 1011–5. doi:10.1007/BF02236693. PMID 10458123. 
  13. ^ Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Chatzimavroudis G, Zavos C, Katsinelos T, Papaziogas B (2006). "Aggressive treatment of acute anal fissure with 0.5% nifedipine ointment prevents its evolution to chronicity". World J Gastroenterol 12 (38): 6203–6. PMID 17036396. http://www.wjgnet.com/1007-9327/12/6203.asp. Retrieved 2009-05-12. 
  14. ^ Carapeti E, Kamm M, Phillips R (2000). "Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects". Dis. Colon Rectum 43 (10): 1359–62. doi:10.1007/BF02236630. PMID 11052511. 
  15. ^ Jost W, Schimrigk K (1993). "Use of botulinum toxin in anal fissure". Dis Colon Rectum 36 (10): 974. doi:10.1007/BF02050639. PMID 8404394. 
  16. ^ Tranqui P, Trottier D, Victor C, Freeman J (2006). "Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin" (PDF). Canadian journal of surgery. Journal canadien de chirurgie 49 (1): 41–5. PMID 16524142. http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/cjs/vol-49/issue-1/pdf/pg41.pdf. Retrieved 2009-05-12. 
  17. ^ Wolff BG, Fleshman JW, ASCRS, Beck DE, Church JM. The ASCRS Textbook of Colon and Rectal Surgery. p. 180. http://books.google.co.uk/books?id=3dDYW2tbx6UC&pg=PA180&dq=sphincterotomy+incontinence. Retrieved 2009-07-15. 
  18. ^ Kotlarewsky M, Freeman JB, Cameron W, Grimard LJ (2001). "Anal intraepithelial dysplasia and squamous carcinoma in immunosuppressed patients" (PDF). Canadian journal of surgery. Journal canadien de chirurgie 44 (6): 450–4. PMID 11764880. http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/cjs/vol-44/issue-6/pdf/pg450.pdf. Retrieved 2009-05-12. 
  19. ^ Sadovsky R (1 April 2003). "Diagnosis and management of patients with anal fissures - Tips from Other Journals" (Reprint). American Family Physician 67 (7): 1608. http://web.archive.org/web/20080209180657/http://findarticles.com/p/articles/mi_m3225/is_7_67/ai_99410474. Retrieved 2009-05-12. 
  20. ^ Sohn M, Weinstein MA (PDF). Anal Dilatation for Anal Fissures. http://ssamed.com/pdf/presentation_adaf.pdf. Retrieved 2009-07-15. 
  21. ^ Yucel T, Gonullu D, Oncu M, Koksoy FN, Ozkan SG, Aycan O (June 2009). "Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study". Int J Surg 7(3) (3): 228–31. doi:10.1016/j.ijsu.2009.03.006. PMID 19361582. 
  22. ^ Renzi A, Brusciano L, Pescatori M, Izzo D, Napolitano V, Rossetti G, del Genio G, del Genio A (January 2005). "Pneumatic balloon dilatation for chronic anal fissure: a prospective, clinical, endosonographic, and manometric study". Diseases of the Colon and Rectum 48(1) (1): 121–6. PMID 15690668. 

External links

Anal fissure treatment algorithm - Lund JN, Nyström PO, Coremans G, Herold A, Karaitianos I, Spyrou M, Schouten WR, Sebastian AA, Pescatori M.An evidence-based treatment algorithm for anal fissure.Tech Coloproctol. 2006 Oct;10(3):177-80.


Simple English

An anal fissure, or fissura ani, is a fissure (a small wound) in the skin around the anus. The symptoms are a sharp pain around the anus during defecation (going to the toilet) or by touching it, for example while taking a shower. The small wound can sometimes bleed a little bit during or after defecation.

It's not completely clear what causes an anal fissure. Possible: constipation, to much strain on the anal sphincter (the circular muscle of the anus), reduced blood circulation, the skin is not made dry enough after taking a shower/swimming, the skin has been stretched too much, pregnancy/giving birth, and not changing a baby's diper in time.

After the anal fissure closes, it takes 6 weeks to 3 month before the wound is healed completely. In this period the fissure easily opens again. Therefore the wound can return repeatedly.

Treatment

A doctor can prescribe several products to treat the anal fissure. For example an pain relieving ointment or suppository (an anal pill); a laxative (making it easier to go to the toilet); zinc-ointment (this will protect the skin and contract it, so it will heal faster). Further more a doctor can give advice about taking care of the wound and improve digestion and defecation.

If an anal fissure has become chronic and won't go away, medical surgery can be a solution. The circular muscle of the anus can be cut or stretched. Also an injection with botox can have a positive result.

To prevent the fissure to return

The anal fissure can burst open very easily up to 3 months after healing, for example during defecation. The patient can do several things to reduce the chance that the fissure will return. The advice includes the following tips.

As long as the fissure is open (a painful, small wound next to the anus which can bleed a little) the patient can put an ointment with zinc oxide (protects and contracts) and pramocaïne (relieves pain and itching) on and around the fissure (in Europe available without prescription as Nestosyl). Use toilet paper or tissue paper to spread out the ointment and wash hands afterward with soap. This treatment has to be continued for several weeks to reduce the chance that the fissure will open again.

Besides it is very important to have a good digestion and defecation. The longer the faeces is in the intestine, the more liquid will be withdrawal. Because of this, the faeces will become harder and get more volume, and that gives more chance that the skin around the anus will crack again. Patients are advized to eat fibres every day (for example: unpolished rice, muesli, whole grain bread, dried apricots, figs, dates, prunes, saltless nuts, beans, peas, etc.); to eat the recommended amount of vegetables and fruit every day; to use a little bit of butter or oil every day; to drink enough during the day; and to exercise every day. The patient needs to avoid food that can cause constipation (possible: white bread, white pasta/pizza/noodles, eggs, cheese, sugar, coffee, chocolate, etc.). If necessary, one can take enzymes as food supplement with every meal that includes bread.

Patients should not postpone going to the toilet. While waiting, the faeces will push on the circular muscle of the anus, which causes a pressure. Besides the faeces can become harder and get more volume after a while. When the patient feels the urge to go to the toilet, the best thing is to go immediately. While sitting on the toilet, the patient has to press as little as possible, but instead relax the circular muscle.

As long as the wound is not healed, taking a daily bath with soda (sodium carbonate) can give relief. Further more that will keep the wound clean.

It's very important that the skin around the anus is completely dry before the patients gets dressed. The slightest moisture in the folding of the skin can be the reason that the skin will get damaged easily.

Some patients benefit by putting simple oil around the anus. For example olive oil or sunflower oil. The skin softens and won't tear or crack as easily. Always remind hygiene.

If the tips that are mentioned above do not help enough and the fissure continues to crack open, the cause could be the use of toilet paper after defecation. The paper rubs too strong over the skin and causes the wound to open again. An easy solution to solve this problem is the use of baby ointment (zinc oxide ointment) that is used for a baby's red bottom. Put this, using toilet paper or tissue paper, before defecation around the anus. The skin will be more protected by wiping the anus and the fissure won't open again so easily. If necessary, the baby ointment can be applied again afterward. Furthermore one can try to use another brand of softer toilet paper.

By following all mentioned tips and advice, always follow the normal principles of hygiene. Use toilet paper or tissue paper and wash the hands afterward.

These recommendations only make sense if the patient is sure that the problem is an anal fissure. If there is any doubt, especially when there is blood in the faeces, consult a doctor.








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