04/10/2020
What is an a**l fissure?
An a**l fissure is a tear in the lining of the lower re**um (a**l ca**l) that causes pain during bowel movements. A**l fissures don’t lead to more serious problems.
Most a**l fissures heal with home treatment after a few days or weeks. These are called short-term (acute) a**l fissures. If you have an a**l fissure that hasn’t healed after 8 to 12 weeks, it is considered a long-term (chronic) fissure. A chronic fissure may need medical treatment. A**l fissures are a common problem. They affect people of all ages, especially young and otherwise healthy people.
Pathophysiology and Etiology
The exact etiology of a**l fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement. Low-fiber diets (eg, those lacking in raw fruits and vegetables) are associated with the development of a**l fissures. No occupations are associated with a higher risk for the development of a**l fissures. Prior a**l surgery is a predisposing factor because scarring from the surgery may cause either stenosis or tethering of the a**l ca**l, which makes it more susceptible to trauma from the hard stool.
Initial minor tears in the a**l mucosa due to a hard bowel movement probably occur often. In most people, these heal rapidly without long-term sequelae. In patients with underlying abnormalities of the internal sphincter, however, these injuries progress to acute and chronic a**l fissures. Studies of the internal a**l sphincter and of a**l ca**l physiology have been performed with varied results, but at least one abnormality is likely to present in the internal a**l sphincter of many a**l fissure patients.
The most commonly observed abnormalities are hypertonicity and hypertrophy of the internal a**l sphincter, leading to the elevated a**l ca**l and sphincter resting pressures. The internal sphincter maintains the resting pressure of the a**l ca**l; a**l-rectal manometry can be used to measure this pressure. Most patients with a**l fissures have elevated resting pressure, which returns to normal levels after surgical sphincterotomy.
The posterior a**l commissure is the most poorly perfused part of the a**l ca**l. In patients with hypertrophied internal a**l sphincters, this delicate blood supply is further compromised, thus rendering the posterior midline of the a**l ca**l relatively ischemic. This relative ischemia is thought to account for why many fissures do not heal spontaneously and may last for several months.
Pain accompanies each bowel movement as this raw area is stretched and the injured mucosa is abraded by the stool. The internal sphincter also begins to spasm when a bowel movement is passed. This spasm has two effects: First, it is painful in itself, and second, it further reduces the blood flow to the posterior midline and the a**l fissure, contributing to the poor healing rate.
What causes an a**l fissure?
A**l fissures can be caused by trauma to the a**s and a**l ca**l. The trauma can be caused by one or more of the following:
Chronic (long-term) constipation
Straining to have a bowel movement, especially if the stool is large, hard and/or dry
Prolonged diarrhea
A**l s*x, a**l stretching
Insertion of foreign objects into the a**s
Causes other than trauma include:
Longstanding poor bowel habits
Overly tight or spastic a**l sphincter muscles (muscles that control the closing of the a**s)
Scarring in the anorectal area
An underlying medical problem, such as Crohn’s disease and ulcerative colitis (types of inflammatory bowel disease); a**l cancer; leukemia; infectious diseases (such as tuberculosis); and s*xually transmitted diseases (such as syphilis, gonorrhea, Chlamydia, chancroid, HIV)
Decreased blood flow to the anorectal area
A**l fissures are also common in young infants and in women after childbirth.
Risk factors of a**l fissure
Factors that may increase your risk of developing an a**l fissure include:
Straining during bowel movements and passing hard stools increase the risk of tearing.
A**l fissures are more common in women after they give birth.
Crohn’s disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the a**l ca**l more vulnerable to tearing.
A**l in*******se.
A**l fissures can occur at any age but are more common in infants and middle-aged adults.
What are the signs and symptoms of a**l fissures?
People with a**l fissures almost always experience a**l pain that worsens with bowel movements.
The pain following a bowel movement may be brief or long-lasting; however, the pain usually subsides between bowel movements.
The pain can be so severe that patients are unwilling to have a bowel movement, resulting in constipation and even f***l impaction. Moreover, constipation can result in the passage of a larger, harder stool that causes further trauma and makes the fissure worse.
The pain also can affect urination by causing discomfort when urinating (dysuria), frequent urination, or the inability to urinate.
Bleeding in small amounts, itching (pruritus ani), and a malodorous discharge may occur due to the discharge of pus from the fissure.
As previously mentioned, a**l fissures commonly bleed in infants.
Complications of a**l fissure
Complications seen with a**l fissures include:
Pain and discomfort
Reduced quality of life
Difficulty with bowel movements. Many people even avoid going to the bathroom because of the pain and discomfort it causes
Possible recurrence even after treatment
Clotting
Uncontrolled bowel movements and gas
Diagnosis
Your doctor will likely ask about your medical history and perform a physical exam, including a gentle inspection of the a**l region. Often the tear is visible. Usually, this exam is all that’s needed to diagnose an a**l fissure.
An acute a**l fissure looks like a fresh tear, somewhat like a paper cut. A chronic a**l fissure likely has a deeper tear and may have internal or external fleshy growths. A fissure is considered chronic if it lasts more than eight weeks.
The fissure’s location offers clues about its cause. A fissure that occurs on the side of the a**l opening, rather than the back or front, is more likely to be a sign of another disorder, such as Crohn’s disease. Your doctor may recommend further testing if he or she thinks you have an underlying condition:
Anoscopy. An anoscope is a tubular device inserted into the a**s to help your doctor visualize the re**um and a**s.
Flexible sigmoidoscopy. Your doctor will insert a thin, flexible tube with a tiny video into the bottom portion of your colon. This test may be done if you’re younger than 50 and have no risk factors for intestinal diseases or colon cancer.
Colonoscopy. Your doctor will insert a flexible tube into your re**um to inspect the entire colon. This test may be done if you are older than age 50 or you have risk factors for colon cancer, signs of other conditions, or other symptoms such as abdominal pain or diarrhea.
Treatment
A**l fissures often heal within a few weeks if you take steps to keep your stool soft, such as increasing your intake of fiber and fluids. Soaking in warm water for 10 to 20 minutes several times a day, especially after bowel movements, can help relax the sphincter and promote healing.
If your symptoms persist, you’ll likely need further treatment.
Nonsurgical treatments
Your doctor may recommend:
Externally applied nitroglycerin (Rectiv), to help increase blood flow to the fissure and promote healing and to help relax the a**l sphincter. Nitroglycerin is generally considered the medical treatment of choice when other conservative measures fail. Side effects may include headaches, which can be severe.
Topical anesthetic creams such as lidocaine hydrochloride (Xylocaine) may be helpful for pain relief.
Botulinum toxin type A (Botox) injection, to paralyze the a**l sphincter muscle and relax spasms.
Blood pressure medications, such as oral nifedipine (Procardia) or diltiazem (Cardizem) can help relax the a**l sphincter. These medications may be taken by mouth or applied externally and may be used when nitroglycerin is not effective or causes significant side effects.
Surgery
If you have a chronic a**l fissure that is resistant to other treatments, or if your symptoms are severe, your doctor may recommend surgery. Doctors usually perform a procedure called lateral internal sphincterotomy (LIS), which involves cutting a small portion of the a**l sphincter muscle to reduce spasm and pain and promote healing.
Studies have found that for chronic fissure, surgery is much more effective than any medical treatment. However, surgery has a small risk of causing incontinence.
Self-help for a**l fissures
Be guided by your health care professional, but general suggestions include:
Apply petroleum jelly to the a**s.
See your chemist for advice on ointments specific for a**l pain.
Take regular sitz (salt bath) baths, which involves sitting in a shallow bath of warm water for around 20 minutes.
Use baby wipes instead of toilet paper.
Shower or bathe after every bowel motion.
Drink six to eight glasses of water every day.
How can an a**l fissure be prevented?
An a**l fissure can’t always be prevented, but you can reduce your risk of getting one by taking the following preventive measures:
Keeping the a**l area dry
Cleansing the a**l area gently with mild soap and warm water
Drinking plenty of fluids, eating fibrous foods, and exercising regularly to avoid constipation
Treating diarrhea immediately
Changing infants’ diapers frequently
What is an a**l fissure?
An a**l fissure is a tear in the lining of the lower re**um (a**l ca**l) that causes pain during bowel movements. A**l fissures don’t lead to more serious problems.
Most a**l fissures heal with home treatment after a few days or weeks. These are called short-term (acute) a**l fissures. If you have an a**l fissure that hasn’t healed after 8 to 12 weeks, it is considered a long-term (chronic) fissure. A chronic fissure may need medical treatment. A**l fissures are a common problem. They affect people of all ages, especially young and otherwise healthy people.
Pathophysiology and Etiology
The exact etiology of a**l fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement. Low-fiber diets (eg, those lacking in raw fruits and vegetables) are associated with the development of a**l fissures. No occupations are associated with a higher risk for the development of a**l fissures. Prior a**l surgery is a predisposing factor because scarring from the surgery may cause either stenosis or tethering of the a**l ca**l, which makes it more susceptible to trauma from the hard stool.
Initial minor tears in the a**l mucosa due to a hard bowel movement probably occur often. In most people, these heal rapidly without long-term sequelae. In patients with underlying abnormalities of the internal sphincter, however, these injuries progress to acute and chronic a**l fissures. Studies of the internal a**l sphincter and of a**l ca**l physiology have been performed with varied results, but at least one abnormality is likely to present in the internal a**l sphincter of many a**l fissure patients.
The most commonly observed abnormalities are hypertonicity and hypertrophy of the internal a**l sphincter, leading to the elevated a**l ca**l and sphincter resting pressures. The internal sphincter maintains the resting pressure of the a**l ca**l; a**l-rectal manometry can be used to measure this pressure. Most patients with a**l fissures have elevated resting pressure, which returns to normal levels after surgical sphincterotomy.
The posterior a**l commissure is the most poorly perfused part of the a**l ca**l. In patients with hypertrophied internal a**l sphincters, this delicate blood supply is further compromised, thus rendering the posterior midline of the a**l ca**l relatively ischemic. This relative ischemia is thought to account for why many fissures do not heal spontaneously and may last for several months.
Pain accompanies each bowel movement as this raw area is stretched and the injured mucosa is abraded by the stool. The internal sphincter also begins to spasm when a bowel movement is passed. This spasm has two effects: First, it is painful in itself, and second, it further reduces the blood flow to the posterior midline and the a**l fissure, contributing to the poor healing rate.
What causes an a**l fissure?
A**l fissures can be caused by trauma to the a**s and a**l ca**l. The trauma can be caused by one or more of the following:
Chronic (long-term) constipation
Straining to have a bowel movement, especially if the stool is large, hard and/or dry
Prolonged diarrhea
A**l s*x, a**l stretching
Insertion of foreign objects into the a**s
Causes other than trauma include:
Longstanding poor bowel habits
Overly tight or spastic a**l sphincter muscles (muscles that control the closing of the a**s)
Scarring in the anorectal area
An underlying medical problem, such as Crohn’s disease and ulcerative colitis (types of inflammatory bowel disease); a**l cancer; leukemia; infectious diseases (such as tuberculosis); and s*xually transmitted diseases (such as syphilis, gonorrhea, Chlamydia, chancroid, HIV)
Decreased blood flow to the anorectal area
A**l fissures are also common in young infants and in women after childbirth.
Risk factors of a**l fissure
Factors that may increase your risk of developing an a**l fissure include:
Straining during bowel movements and passing hard stools increase the risk of tearing.
A**l fissures are more common in women after they give birth.
Crohn’s disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the a**l ca**l more vulnerable to tearing.
A**l in*******se.
A**l fissures can occur at any age but are more common in infants and middle-aged adults.
What are the signs and symptoms of a**l fissures?
People with a**l fissures almost always experience a**l pain that worsens with bowel movements.
The pain following a bowel movement may be brief or long-lasting; however, the pain usually subsides between bowel movements.
The pain can be so severe that patients are unwilling to have a bowel movement, resulting in constipation and even f***l impaction. Moreover, constipation can result in the passage of a larger, harder stool that causes further trauma and makes the fissure worse.
The pain also can affect urination by causing discomfort when urinating (dysuria), frequent urination, or the inability to urinate.
Bleeding in small amounts, itching (pruritus ani), and a malodorous discharge may occur due to the discharge of pus from the fissure.
As previously mentioned, a**l fissures commonly bleed in infants.
Complications of a**l fissure
Complications seen with a**l fissures include:
Pain and discomfort
Reduced quality of life
Difficulty with bowel movements. Many people even avoid going to the bathroom because of the pain and discomfort it causes
Possible recurrence even after treatment
Clotting
Uncontrolled bowel movements and gas
Diagnosis
Your doctor will likely ask about your medical history and perform a physical exam, including a gentle inspection of the a**l region. Often the tear is visible. Usually, this exam is all that’s needed to diagnose an a**l fissure.
An acute a**l fissure looks like a fresh tear, somewhat like a paper cut. A chronic a**l fissure likely has a deeper tear and may have internal or external fleshy growths. A fissure is considered chronic if it lasts more than eight weeks.
The fissure’s location offers clues about its cause. A fissure that occurs on the side of the a**l opening, rather than the back or front, is more likely to be a sign of another disorder, such as Crohn’s disease. Your doctor may recommend further testing if he or she thinks you have an underlying condition.
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