Easing Anal Fissures
You noticed blood on your tissue when you used the bathroom. You have pain in your anus. You could have an anal fissure.
An anal fissure is a small tear in the anal canal, which can happen at any age, but is more concentrated in 10-30 age group. They are the most common form of rectal bleeding in infants but blessedly, they heal much quicker at that age.
Anal fissures are usually associated with constipation. However, chronic diarrhea is secondary to laxative abuse is also found to be a cause as well. Although excessive straining is a significant factor in causing anal fissures in many cases, they are probably due to the passage of a hard, dry, bulky stool.
Less often, they may be secondary to childbirth, trauma from a foreign body (e.g. thermometer, enema tip), previous anal surgery, leukemia, or Crohn’s disease. The latter is a chronic inflammation of the gastrointestinal tract of unknown cause, typically affecting the lower end of the small intestine.
Anal fissures are common and can easily become chronic. After the lining of the anal canal is torn for the first time, bowel movements re-injure the area. Underneath the lining of the anal canal is a circular muscle called the sphincter. When it relaxes completely, we have a bowel movement. Most of the time, it’s not relaxed. It’s either clamped down enough or clamped down more than it needs to be.
When the lining of the anal canal is torn, the sphincter muscle beneath the tear goes into spasms, pulling the edges of the tear apart. A cycle of spasm and pain further damages the tissue and prevents healing.
Symptoms of anal fissure usually consists of pain during defecation and muscles of the anus can go into spasms. Other symptoms include pain after bowel movements, a visible crack around the anus, and a small lump or skin tag on the skin near the anal fissure. There may be a small amount of bright red blood on the feces or toilet tissue, which quite often proves alarming to those afflicted.
Once a fissure is present, bowel movements will be very painful and sometimes tinged with fresh blood. Because of the pain, the internal anal sphincter goes into spasms and tightens. This is the circular muscle that helps us maintain continence, or control of our bowels. The muscle spasm squeezes the tissue to the point that blood flow to the area of the fissure is diminished. This in turn impedes healing of the fissure and sets up a vicious cycle of fissure; pain; spasm; nonhealing; more pain, etc. Interestingly, fissures rarely become infected. The anal area is very resistant to infection and even surgical procedures done there rarely become infected.
An acute superficial fissure usually heals spontaneously, in the course of a few days, or with conservative treatment such as use of bulk laxatives (e.g. Metamucil) or warm sitz baths. Recurrent or persistent anal fissures often respond to the regimen of a higher fiber diet (e.g. whole grain products, fruits, vegetables) and liberal fluid intake to soften the stool. Anal dilatation (a procedure to enlarge the anal canal) may also be necessary.
A variety of topical medications are used as suppositories or creams. Many of these contain steroids for their anti-inflammatory effects. Some contain topical anesthetics to reduce the pain and hopefully lessen the spasm of the anal sphincter. The use of steroids and anesthetics is a double-edged sword since these medications can slow the healing process. Topical nitroglycerin, the same medicine used to relieve angina in people with blocked arteries in their hearts, has been found to help heal fissures. It has two beneficial effects that promote healing: it relaxes the muscle and it increases blood circulation to the area.
Injections of botulinum toxin (yes, Botox) into the sphincter muscle heal some fissures. They ease debilitating spasms and pain. Botulinum toxin is more effective than topical nitroglycerin. But because botulinum toxin is invasive, it’s best to try the nitroglycerin first.
If conservative treatment fails, a surgical procedure called sphincterotomy, which involves partially cutting the ring of muscle surrounding the anus and controlling defecation (anal sphincter), is performed. However, long term anal incontinence, as a complication of surgery, has been observed in a small percentage of cases.
The presence of bright red blood on the stool or toilet tissue associated with painful defecation, must not be taken lightly and warrants further investigation.
However, it is due to an anal fissure which, in many cases heals spontaneously or responds to simple conservative treatment. Therefore, in such cases, a prompt visit to your doctor’s office can save you many sleepless nights and needless panic.
