What is an anal fissure?
An anal fissure is a tear or split in the anal mucosa. It is a painful condition and can cause bright red per rectal (PR)bleeding. A fissure can be caused by the passage of a firm or hard stool or by trauma sustained to the anus. More than half of fissures heal by themselves.
When the pain is persistent and lasts for over 6 weeks, spontaneous healing is unlikely. The pain is caused by irritation of the exposed internal anal sphincter combined with spasm of the internal anal sphincter.
Treatment Options:
Non Surgical:
- Address stool consistency: Ensure stools are soft with laxative use – Movicol sachet and lactulose – speak to your specialist regarding dosage and duration
- Address blood flow: Topical vasodilators such as rectogesic can be used. Systemic absorption can lead to headaches, which is a common reason for poor compliance. Using a glove can help prevent absorption through the fingertips
- Address sphincter spasm: topical muscle relaxant creams such as diltizem or nifedipine can be prescribed by Dr Petrushnko to help address the spasm which will help with pain.
- Address pain: Opiod medication will only work for short periods of time and may lead to constipation which further precipitate the fissure. Topical analgesia such as lidnocaine gel can be applied to sooth the pain
Surgical:
- Fissurectomy: this involves debridement of the fissure base to remove the biofilm that is preventing healing. Anal tags known as sentinel tags can also be excised at the same time which may help healing
- Botox: Injection of botox into the sphincter complex allows relaxation of the sphincter muscle to reduce spasm and improve healing
- Sphincterotomy: This is a last resort for patients with debilitating fissures that have not responded to all other treatment modalities. Careful selection of patients is required to prevent fecal incontinence.
When PR bleeding is experienced, it is also important to exclude other sinister causes and a colonoscopy in some circumstances may be needed. Furthermore, some fissures are atypical in nature and will require an examination under anaesthesia to ensure an underlying tumor or growth is not missed.
