Anal Fissure - Symptoms, Causes, Prevention, Treatment

1. The anus is the outer end of our body’s digestive system through which stool passes out of the body. It is surrounded by the sphincter muscles, which open and close for passing the stools. Our anus also contains a network of blood vessels and nerve cells
2. . A fissure in Ano also called an anal fissure, is a condition that affects the anal region. It is characterised by the development of an open sore or a tear in the anal skin. An anal fissure also causes painful bleeding, unlike piles which cause painless bleeding. If fissures do not settle with home

The anus is the outer end of our body’s digestive system through which stool passes out of the body. It is surrounded by the sphincter muscles, which open and close for passing the stools. Our anus also contains a network of blood vessels and nerve cells. Fissure in Ano also called an anal fissure, is a condition that affects the anal region. It is characterised by the development of an open sore or a tear in the anal skin. An anal fissure also causes painful bleeding, unlike piles which cause painless bleeding. If fissures do not settle with home

The anus is the outer end of our body’s digestive system through which stool passes out of the body. It is surrounded by the sphincter muscles, which open and close for passing the stools. Our anus also contains a network of blood vessels and nerve cells. Fissure in Ano also called an anal fissure, is a condition that affects the anal region. It is characterised by the development of an open sore or a tear in the anal skin. An anal fissure also causes painful bleeding, unlike piles which cause painless bleeding. If fissures do not settle with home

Causes

You can get anal fissures because of tearing or damage to your anus.

The following reasons can cause this tearing:

1. Conditions associated with the digestive system such as persistent diarrhoea, long-term constipation, and inflammatory bowel disease, such as ulcerative colitis (ulcers in the digestive tract).
2. Passage of hard stools.
3. Syphilis, HIV (Human Immunodeficiency Virus), and herpes, among other sexually transmitted diseases (STD). STDs can sometimes spread to and cause damage to the anal region, thereby resulting in fissures.
4. Anal intercourse or sodomy.
5. Anal cancer and leukaemia.
6. Pregnancy or childbirth, leads to constipation.
7. Decrease in the blood flow to the anus. When the sphincter muscle is under pressure, it causes spasms and reduces the blood flow.

This common condition can affect all genders; however, children and adults between 10 and 30 years are more prone to anal fissures.

When to Seek Advice?

If you have the symptoms stated earlier, you must consult a proctologist. An anal fissure can quickly become a chronic condition. While passing stools, the anal area can get reinjured because of contractions of the sphincter muscles. This cycle of sphincter muscle contraction pulls the tear apart and further increases the damage.

Symptoms and Signs

1. If you have an anal fissure, you might experience the following symptoms while passing stools: 
2. Painful motion or intense anal pain that lasts several minutes to hours.
3. (Do not confuse this symptom with piles or haemorrhoids. If you have an anal fissure, this pain will be intense and make you uncomfortable. On the other hand, piles only cause pain when the condition exacerbates.
4. Bleeding from the anus with drops of blood, or blood stuck to stools (bleeding stools).
5. Dark coloured stools or blood mixed stools.
6. Intense burning, pricking, or itching sensation in the anus.
7. Foul discharge or pus from the anus.
8. An anal fissure can be acute (lasts for a short while) or chronic (lasts longer). If you have an acute anal fissure, you will experience spasms, pain in the anal region, and bleeding during passing stool. This condition lasts for less than six weeks. Acute fissures can progress to chronic fissures that last for more than six weeks.
9. You can get chronic anal fissure due to repeated injury to the anus and passing hard stools for a long time. Also, in chronic fissures, you might develop a large and deep anal tear. Repeated injury and healing in the anal region further cause a sentinel pile, also known as a skin tag, which is an outgrowth of skin at the ends of the fissure. A skin tag is painless and does not cause any bleeding.

Diagnosis

Your proctologist will ask you about the kind of pain you are experiencing and your toilet habits. They need to perform a rectal examination to check for the presence of an anal fissure. Your proctologist will examine your anal region visually or by gently touching the anal region with the tip of the finger. If you have excruciating pain, please inform your surgeon, and they will not do a proctoscopy. A proctoscopy is done to assess anal disease and find the reason for anal bleeding

Treatment

The treatment of anal fissures focuses on reducing the pain and discomfort while passing stools and breaking the cycle of poor healing by increasing the blood flow to the fissure. Your proctologist will first recommend conservative treatments followed by medications. If these treatments do not work, the proctologist will suggest you undergo surgery.[4,9]

Home remedies

1. The home remedies listed below would help you get rid of existing fissures and prevent any fissures in the future.
2. Sitz bath: Soaking your anal region in a warm tub of water for 15 to 20 min at least twice a day with or without potassium permanganate (KMO4) or Epsom salts helps increase the blood supply to your anal region and relax your anal muscles. This provides pain relief to a great extent, and you must do this regularly to seek pain relief.
3. It is important to have a fibre-rich diet. Aim to eat a minimum of 30 grams of fibre in a day, equal to almost two cups of boiled lentils. Consume vegetables, fruits, lentils, and wholegrain products to obtain sufficient fibre.[1,2,18]
4. Drink a minimum of eight glasses of water to remain hydrated. Avoid caffeine as it can cause dehydration.
5. Exercise regularly.
6. Do not hold your stools when you want to go to the toilet. This causes drying or hardening of stools.

Medications

1. If the conventional treatments do not work and the fissures recur or do not get treated, your proctologist would recommend the following:
2. Over-the-counter medicines like paracetamol or ibuprofen to lessen the pain. These medications work by preventing the nerve cells from sending the pain signal to your brain. So, if your brain does not receive any pain signal, you will not feel the pain.
3. Laxatives so that softer stools are formed that are easy to pass.
4. Suppositories (medicines inserted into the anus) that will help to reduce any swelling due to fissures.
5. Creams or ointments containing nitroglycerine and calcium channel blockers (e.g., diltiazem). These ointments help relax the anal sphincter muscles and increase the blood flow to the fissure region ultimately treating the fissures.
6. An ointment containing a local anaesthetic such as lidocaine. This ointment helps to decrease the pain experienced while passing stools.
7. Botox injection that contains botulinum toxin type A. When injected in the anal region, Botox injection temporarily paralyses the muscles in the anal area. This helps to reduce the pain and heal the fissure.

Your proctologist may recommend a follow-up after a few weeks of treatment. Depending on the improvement in the condition, your proctologist would take further steps.[

What does Ayurveda have to offer?

1. The symptoms and signs of anal fissures mirror those of the Bhagandara condition described in the Ayurvedic literature. There are several Ayurvedic medicines or churns available to soften the stools and reduce constipation. 
2. Different ayurvedic formulations available to treat constipation are Avipatti churnam, Triphala churna, Pancha Sakar churna, Kalyan guide, and dashmula tail, hingvastaka churna, Sukumaran ghrita, etc.
3. Medicinal plants like Isabgol Husk, Sonamukhi (Cassia Angustifolia vahl), and Haritaki (Terminalia Chebula Retz) help to have soft stools when consumed with warm water.[20] 
4. For managing chronic anal fissures, Ksharsutra therapy is recommended, which contains a mixture of Snuhi latex (Euphorbia nerifolia), Apamarga Kshara (Achyranthes Aspera) and Haridra Churna (Curcuma long). This therapy is considered a gold standard treatment as it is safe, cost-effective, and treats chronic fissures.

Surgery

1. When conservative attempts fail, or the fissure is chronic, your proctologist may recommend surgery. The following types of surgeries are available to get rid of anal fissures:
2. Anal dilation: In this surgery, the surgeon will manually stretch your anal sphincter muscle. This will help relieve pressure in your anal region and get rapid relief from pain.
3. Lateral internal sphincterotomy: In this surgery, the surgeon will make several cuts in the anal sphincter muscles, which help reduce the pressure in the anal region. This facilitates the healing of anal fissures. This surgery is one of the most efficient treatments and causes complete relief within two to four weeks.
4. Fissurectomy: In this surgery, the surgeon will remove the edges of fissures and skin tags. Fissurectomy has a high success rate and provides rapid relief from the discomfort due to fissures. Complete healing may take more time than lateral internal sphincterotomy.
5. Damage to the anal sphincter muscle during lateral sphincterotomy can cause temporary loss of bowel control. But this is extremely rare, and you will be fully healed within a few weeks after the surgery.

What to Ask and Tell Your Doctors?

1. You can ask your proctologist the following questions:
2. What are the alternative treatment options for surgery?
3. How would it feel after the surgery?
4. How many days will it take to recover from the surgery?
5. What medications or therapy to continue post-surgery?
6. Are there any risks with anal fissure surgery?
7. It is crucial that you inform your surgeon of the following before surgery:
8. Prescription or non-prescription medicines that you are using
9. Your current health issues other than a fissure
10. Any history of illness or surgery
11. Allergies to any medicine
12. Problems that occurred in the previous surgery.

Surgery

Before surgery, the surgeon will administer spinal anaesthesia to you. Spinal anaesthesia helps to numb the anal region. After the surgery, the surgeon will apply a loose outer dressing to your anal area.

1. Relief from pain in the anal region
2. Respite  from blood loss, while passing stool
3. Surgical procedure Like Lateral internal sphincterotomy-  It helps reduce pressure inside the anus that can cause spasms and increases blood flow to the area to help the tissue heal.
4. A Fissurectomy for the treatment of patients with an idiopathic noninfected fissure is associated with rapid pain relief and a high success rate even though complete healing may often be delayed
5. Laser Sphincterotomy or LASER treatment opts when a patient suffers from a chronic fissure. The advantage of this surgical process is it  is minimal -invasive, same day discharge from the hospital, shorter recovery  with minimal blood loss

1. Delay in diagnosis may lead an acute fissure becoming a chronic one and, thus, becomes more difficult to treat.
2.  Misdiagnosis of an anal fissure may also allow other conditions to go undetected and untreated, such as serious infections or even cancer.