Wirral Surgeon - An anal fissure is a painful linear tear or crack in the distal anal canal (back passage). Anal fissure develop with equal frequency in both sexes; they tend to occur in younger and middle-aged persons.

Condition treated

The most important point to remember is that everyone with a bowel problem can be helped and many can be completely cured.
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Black and white picture of a woman's back, touching her as. The area of her as is being highlighted in red, representing pain.

Anal fissure

An anal fissure is a painful linear tear or crack in the distal anal canal (back passage).

Anal fissure develop with equal frequency in both sexes; they tend to occur in younger and middle-aged persons.

The exact etiology of anal fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement.

Anal fissure

An anal fissure is a painful linear tear or crack in the distal anal canal (back passage).

Anal fissure develop with equal frequency in both sexes; they tend to occur in younger and middle-aged persons.

The exact etiology of anal fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement.

Black and white picture of a woman's back, touching her as. The area of her as is being highlighted in red, representing pain.

Clinical presentation

Typically, the patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright-red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.

Initial therapy for an anal fissure is medical in nature, and more than 80% of acute anal fissures resolve without further therapy.

Management

First-line medical therapy consists of therapy with stool-bulking agents, such as fiber supplementation and stool softeners. Laxatives are used as needed to maintain regular bowel movements. Sitz baths after bowel movements and as needed provide significant symptomatic relief because they relieve some of the painful internal sphincter muscle spasm. Recurrence rates are in the range of 30-70% if the high-fiber diet is abandoned after the fissure is healed. This range can be reduced to 15-20% if patients remain on a high-fiber diet.
Second-line medical therapy consists of intra-anal application of 0.4% Nitroglycerin (also called glycerol trinitrate - Rectogesic®) ointment directly to the internal sphincter. Unfortunately, many people cannot tolerate the adverse effects of glycerol trinitrate, and as a result, its use is often limited. The main adverse effects are headache and dizziness. Diltiazem ointment is thought to have similar efficacy to Rectogesic but with fewer adverse effects.

Failure of medical therapy is an indication for surgical therapy.

Close up picture of the anus examined by a surgeon wearing purple gloves. It is being highlighted the anal fissure condition where a wall of the anus has splitted.
First-line medical therapy consists of therapy with stool-bulking agents, such as fiber supplementation and stool softeners. Laxatives are used as needed to maintain regular bowel movements. Sitz baths after bowel movements and as needed provide significant symptomatic relief because they relieve some of the painful internal sphincter muscle spasm. Recurrence rates are in the range of 30-70% if the high-fiber diet is abandoned after the fissure is healed. This range can be reduced to 15-20% if patients remain on a high-fiber diet.
Close up picture of the anus examined by a surgeon wearing purple gloves. It is being highlighted the anal fissure condition where a wall of the anus has splitted.
Second-line medical therapy consists of intra-anal application of 0.4% Nitroglycerin (also called glycerol trinitrate - Rectogesic®) ointment directly to the internal sphincter. Unfortunately, many people cannot tolerate the adverse effects of glycerol trinitrate, and as a result, its use is often limited. The main adverse effects are headache and dizziness. Diltiazem ointment is thought to have similar efficacy to Rectogesic but with fewer adverse effects.

Failure of medical therapy is an indication for surgical therapy.

Surgical therapy

Lateral internal sphincterotomy is the current surgical procedure of choice for anal fissure; it can be performed with the patient under general or spinal anesthesia. When treating a chronic anal fissure, the surgeon may elect to perform a fissurectomy in conjunction with the lateral sphincterotomy.

Sometimes, long-standing chronic fissures do not heal, even with an adequate sphincterotomy, and an advancement flap must be performed to cover the defect in the mucosa.

The recurrence or non-healing rates for anal fissures after surgical treatment are in the range of 1-6%.