Anal fissure

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

An anal fissure is an unnatural crack or tear in the anus, usually extending from the anal opening and located posteriorly in the midline. This location is probably because of the relatively unsupported nature of the rectal wall in that location.

Contents

Most anal fissures are caused by stretching of the anal mucosa beyond its capability. Various causes of this fissure include:

Anal fissures are common in women after childbirth,[1] and following constipation in infants.[2]

The symptoms of anal fissure include:

In infants under one year old, frequent diaper change can prevent anal fissure. For Adults, the following can help prevent fissure:

  • Treating constipation by eating food rich in dietary fiber, avoiding caffeine (which can cause dehydration), drinking a lot of water and taking stool softener.
  • Treating diarrhea promptly.
  • Lubricating the anal canal with KY Jelly or other water-based lube (petroleum jelly is not recommended because it can harbor harmful bacteria).
  • Avoiding straining or prolonged sitting on the toilet.
  • Using a moist wipe instead of perfumed and harsh toilet paper.
  • Keeping the anus dry and hygienic.

Most anal fissures are shallow or superficial (less than a quarter of inch or 0.64 cm deep). These fissures self-heal within a couple of weeks. While waiting for the fissure to heal, topical or suppository containing anti-inflammatory agents and local anaesthetic can be used. Furthermore, treatment used for hemorrhoid such as eating a high-fiber diet, using stool softener, taking pain killer and having a sitz bath can help.

Anal fissures in infants usually self-heal without anything more than frequently changing diapers and treating constipation if the cause.

Painful deep fissures, on the other hand cut through the sphincter muscle thus making it prone to spasm, which exacerbates the fissure and aborts the healing process. Traditionally surgical operations were required which are both painful and associated with various longterm complication. Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[3][4][5] and in 1999 with nifedipine ointment.[6][7] Botulinum toxin injection, administered by colorectal surgeons, can also be used to relax the sphincter muscle and its use for this condition was first investigated in 1993.[8] These medical treatments are used as first line therapy in treating chronic anal fissures.[9]

Surgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. Procedures include:

  • Internal lateral sphincterotomy or excising a portion of the sphincter
  • Anal dilation or stretching of the anal canal is no longer recommended because of the unacceptably high incidence of fecal incontinence

Despite the high success rate of these surgical procedures (~95%), there are potential side effects, which include: risks from anesthesia, infection, anal leakage or fecal incontinence.

  1. ^ Abramowitz L, Sobhani I, Benifla J, Vuagnat A, Daraï E, Mignon M, Madelenat P (2002). "Anal fissure and thrombosed external hemorrhoids before and after delivery.". Dis Colon Rectum 45 (5): 650-5. PMID 12004215. 
  2. ^ Martínez-Costa C, Palao Ortuño M, Alfaro Ponce B, Núñez Gómez F, Martínez-Rodríguez L, Ferré Franch I, Brines Solanes J (2005). "[Functional constipation: prospective study and treatment response]". An Pediatr (Barc) 63 (5): 418-25. PMID 16266617. 
  3. ^ 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. PMID 7953427. 
  4. ^ 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. PMID 8696736. 
  5. ^ 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. 
  6. ^ 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. PMID 10458123. 
  7. ^ 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. 
  8. ^ Jost W, Schimrigk K (1993). "Use of botulinum toxin in anal fissure". Dis Colon Rectum 36 (10): 974. PMID 8404394. 
  9. ^ 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. 

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