Background

A superficial skin tear distal to the dentate border is known as an anal fissure. Anal fissures are frequent in those who have had past anal operations, a history of trauma, a reduced diet with fibers, constipation, and solid stools.

Anal fissures are classified as acute (that can last less than 6 weeks) or chronic (that can last longer than 6 weeks). The anterior or posterior midline is where the bulk of anal fissures are found. To check out alternative reasons, more testing should be done at other places.

This exercise outlines lifestyle changes for preventing the recurrence of anal fissures while describing the causation, clinical characteristics, and types of anal fissures, as well as treatment techniques, including invasive procedures and conservative & postoperative maintenance.

The importance of the interprofessional healthcare professional in treating people with anal fissures and enhancing long-term results is highlighted by this exercise.

Epidemiology

Anal fissures can occur at any age; however, they are more frequently found in children & middle-aged people. Each year throughout the U.S., there are about 250,000 new instances are identified, and both genders are equally impacted.

Anatomy

Pathophysiology

The epithelial portion of the anal canal is referred to as the anoderm. The dentate border is superior to the location. It is a very vulnerable area to microtrauma, and repeated trauma or intense pressure can cause it to rip. Because of the elevated pressures in this region, ischemia-related delayed healing may occur.

Sometimes the tear is severe enough to reveal the sphincter muscle. This causes excruciating discomfort with bowel motions and some rectal blood, along with sphincter spasms. It is well-recognized that the posterior midline, which receives less circulation than the remaining portion of the anal canal, is where anal fissures most frequently occur.

Sphincter tension & anal canal perfusion are mutually exclusive. Other anal fissure locations, including the lateral fissure, are a sign of an underlying cause (ulcerative colitis, Crohn’s disease, HIV, tuberculosis, among others). It is unknown what caused this other site. Rare anterior fissures are linked to dysfunctional and damaged external sphincters.

Etiology

Constipation, tuberculosis, anal tumor, IBD, chronic diarrhea, HIV, STIs, childbirth, past anal surgery, and anal sexual activity are among the important factors of anal fissures. Most acute anal fissures are believed to result from the evacuation of solid stools, STIs, and anal damage from penetration.

Acute anal fissures frequently reoccur, leading to chronic ones. With signs lasting longer than 6 weeks, it is also believed to be brought on by the passage of firm feces against a raised anal sphincter tension pressure.

Both chronic and acute unusual anal fissures can be caused by underlying diseases like TB, bowel disease, anal malignancy, HIV, and previous anal resection. 40 percent of patients who initially have acute anal fissures eventually develop chronic anal fissures.

Genetics

Prognostic Factors

When treated conservatively, acute anal fissures in reduced-risk individuals normally heal within a few days to a week. But a portion of these individuals goes on to acquire CAF, necessitating medication and surgical therapy. Within three to four weeks following surgery, more than 90 percent of patients who need surgical care recover completely.

Clinical History

• Symptoms: Patients may complain of intense pain during or after bowel movements, which can last for several hours. The pain is often described as sharp or burning and may be accompanied by bleeding, itching, or a sensation of incomplete evacuation. 
• Onset: Patients may recall when the symptoms first appeared, which could be sudden or develop gradually over time. 
• Triggers: Patients may identify specific factors that exacerbate their symptoms, such as constipation, diarrhea, straining during bowel movements, or passing large or hard stools. 
• Medical History: Doctors will inquire about the patient’s medical history, including any previous episodes of anal fissures, underlying medical conditions such as inflammatory bowel disease or HIV/AIDS, and any relevant surgical procedures involving the anal area. 
• Diet and Lifestyle: Patients may be asked about their dietary habits, fluid intake, physical activity level, and toileting habits to identify any contributing factors. 
• Pain Severity: Patients may be asked to rate the severity of their pain using a scale, such as the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS), to assess the impact of the fissure on their quality of life. 
• Treatment History: Patients may provide information about any previous treatments they have tried for their anal fissures, such as over-the-counter medications, topical creams, dietary modifications, or medical procedures. 

Physical Examination

• Visual Inspection: The doctor will carefully inspect the anal area to search for any visible evidence of a fissure.This may include observing a small crack or tear in the skin around the anus. The fissure may appear as a linear or oval-shaped ulcer. 
• Location of Fissure: The doctor will note the location of the fissure, as this can provide information about potential causes and guide treatment decisions. Anal fissures are commonly found in the posterior midline, but they can also occur in other locations. 
• Size and Characteristics: The healthcare provider will assess the size and characteristics of the fissure, including its depth and whether it is acute or chronic. Chronic fissures may have associated changes such as skin tags or hypertrophied anal papillae. 
• Digital Rectal Examination (DRE): In order to detect any anomalies, such as soreness or muscular spasms, a gloved finger moistened with oil is inserted into the rectum.This helps assess the internal aspect of the anal canal and the sphincter muscles. 
• Anoscopy or Sigmoidoscopy: In some cases, a more detailed examination may be performed using anoscopy or sigmoidoscopy. Anoscopy involves inserting a short, rigid tube with a light source into the anus to visualize the lower part of the anal canal and rectum. Sigmoidoscopy allows for a more extended examination of the rectum and lower colon. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Hemorrhoids: Swollen blood vessels in the anus can cause bleeding,pain, and discomfort during bowel movements. Hemorrhoids are a common condition that can be mistaken for anal fissures. 
• Perianal Abscess: An infection that results in the formation of a collection of pus near the anus. It can cause pain, swelling, and redness in the affected area. 
• Fistula-in-ano: An abnormal tunnel-like connection between the anal canal and the skin near the anus. It may be associated with recurrent infections and discharge. 

• Proctitis: Rectal lining inflammation is frequently brought on by radiation therapy, inflammatory bowel diseases (such as Crohn’s disorder or ulcerative colitis), or infections. 
• Anal Warts: Caused by human papillomavirus (HPV), anal warts can lead to small growths around the anus, causing itching, discomfort. 
• Rectal Prolapse: The rectum protrudes into the anus, causing pain, discomfort, and occasionally blood during bowel movements. 
• Colorectal Cancer: Colorectal cancer, while less frequent, can cause symptoms like rectal bleeding, stool abnormalities, and abdominal pain. 
• Pruritus Ani: Persistent itching around the anus without an obvious rash or lesion.Infections, skin problems, and irritants can all contribute to this disease. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Dietary and Lifestyle Changes: 

• Increased Fiber Intake: Consuming a high-fiber diet helps soften stools and promotes regular bowel movements, reducing the risk of trauma to the anal canal during defecation. 
• Adequate Hydration: Drinking plenty of water helps maintain soft stools and prevents constipation. 
• Stool Softeners: Over-the-counter stool softeners may be recommended to further soften the stool and ease bowel movements. 

Topical Medications: 

• Nitroglycerin Ointment: Nitroglycerin relaxes the smooth muscles around the anal sphincter, improving blood flow and promoting healing. It is usually applied topically to the anal area. 
• Calcium Channel Blockers: Medications like diltiazem may be prescribed to relax the sphincter muscles and enhance blood flow. 

Pain Management: 

• Topical Anesthetics: Pain and discomfort can be reduced with the use of ointments or creams that include local anaesthetics like lidocaine. 
• Oral Pain Medications: Pain relievers, such as acetaminophen or ibuprofen, may be recommended. 

Warm Sitz Baths: 

• Several times a day, soaking the anal region in hot water for ten to fifteen minutes might help ease discomfort, lessen inflammation, and accelerate recovery. 

Botulinum Toxin Injection: 

• It may be possible to loosen the muscles and increase blood flow in specific situations by injecting a drug called botulinum toxin to the anal sphincter. 

Surgical Procedures: 

• Lateral Internal Sphincterotomy (LIS): a surgical method to relieve pressure and encourage recovery that involves making a tiny incision into the sphincter muscle of the anus. It is often considered for chronic fissures that do not respond to conservative measures. 
• Fissurectomy: Removal of the fissure or associated skin tags may be performed to facilitate healing. 

Botox Injections: 

• It can be used to temporarily relax the sphincter muscles, providing relief and allowing the fissure to heal. 

Management of Underlying Conditions: 

• To ensure long-term care, it is imperative to treat any underlying conditions, such as inflammation of the bowel, that may be contributing to the fissure. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-a-non-pharmacological-approach-for-treating-anal-fissures

Dietary Modifications: 

• Increased Fiber Intake: A high-fiber diet helps soften stools and promotes the regular bowel movements, reducing the risk of trauma to the anal canal during defecation. Fiber-rich foods include fruits, vegetables, whole grains, and legumes. 
• Fluid Intake: It is essential for maintaining soft stools. Drinking plenty of water helps prevent constipation. 

Sitz Baths: 

• Warm Water Soaks: Soaking the anal area in warm water for 10-15 minutes, several times a day, can provide relief from pain and promote relaxation of the anal sphincter muscles. This can help in reducing discomfort and promoting healing. 

Stool Softeners: 

• Natural Stool Softeners: Certain foods, such as prunes, figs, and bran, can act as natural stool softeners. Including these in the diet can help prevent constipation and make bowel movements more comfortable. 

Avoidance of Irritants: 

• Use of Gentle Wipes: Harsh or scented toilet paper and wipes can irritate the anal area. Using soft, unscented wipes or plain, unscented toilet paper can help minimize irritation. 

Proper Toilet Habits: 

• Avoid Straining: Encouraging patients to avoid straining during bowel movements can reduce pressure on the anal canal and promote healing. A footstool placed under the feet during bowel movements can help achieve a more natural position. 
• Timely Bowel Movements: Encouraging regular bowel movements and not delaying them when the urge arises can prevent excessive straining. 

Anal Hygiene: 

• Gentle Cleaning: The anal area should be carefully cleaned with moderate, odorless soap and water by patients after bowel movements. Avoiding aggressive wiping can prevent further irritation. 

Warm Compresses: 

• Application of Warm Compresses: Applying a warm compress to the anal area can provide relief from pain and promote relaxation of the sphincter muscles. 

Lifestyle Modifications: 

• Regular Exercise: Physical activity can help regulate bowel movements and improve overall digestive health. Encouraging regular exercise may contribute to preventing constipation. 

Weight Management: 

• Maintaining a Healthy Weight: Excess body weight can contribute to increased pressure on the anal area during bowel movements.  

Behavioral Modifications: 

• Relaxation Techniques: Stress and anxiety can exacerbate anal fissure symptoms. Encouraging stress-reduction techniques, such as deep breathing or meditation, may be beneficial. 

Use of Topical Nitroglycerin in the treatment of Anal Fissures

Topical nitroglycerin is a commonly used medication in the treatment of anal fissures. Nitroglycerin, when applied topically to the anal area, serves as a vasodilator and smooth muscle relaxant. It is known for its ability to increase blood flow and reduce sphincter spasm, thereby promoting healing and relieving symptoms associated with anal fissures. 

Nitroglycerin relaxes blood vessels, leading to increased blood flow to the affected area. This enhanced blood supply helps in the healing process. It reduces sphincter muscle tone, which is crucial in treating anal fissures, as excessive sphincter spasm can contribute to pain and hinder the healing process. 

Nitroglycerin ointment: It is typically prescribed at a concentration of 0.2%. It is commonly applied two to three times a day to the perianal area. A small amount of the ointment is applied with a finger or applicator to the external anal sphincter and the surrounding tissue. 

Use of Botulinum Toxin Injections in the treatment of Anal Fissures

They are used in the treatment of anal fissures, especially in cases where conservative measures or other medications have not provided sufficient relief. Botulinum toxin, when injected into the anal sphincter muscles, inhibits the release of acetylcholine, leading to temporary paralysis of the muscles. This results in muscle relaxation and reduced spasm. 

Botulinum toxin is injected directly into the anal sphincter muscles. Injections are usually administered in multiple sites around the anal canal. 

OnabotulinumtoxinA: It inhibits the release of acetylcholine at the neuromuscular junction, leading to temporary muscle paralysis. In the context of anal fissures, it helps relax the anal sphincter muscles, reducing spasms and promoting healing. 

Use of topical Calcium Channel Blockers in the treatment of Anal Fissure

Topical calcium channel blockers, such as diltiazem, have been used in the treatment of anal fissures to help relax the anal muscles and promote the healing. Calcium channel blockers cause muscular relaxation by preventing calcium from entering smooth muscle cells.. In anal fissures, this helps reduce spasms in the anal sphincter muscles, which may contribute to pain and hinder the healing process. 

Diltiazem: It is commonly prescribed in compounded formulations at concentrations ranging from 2% to 4%. Commercially available diltiazem creams may also be used. The cream is usually applied to the anal area two to three times a day. A small amount is typically administered using a finger or an applicator. 

use-of-intervention-with-a-procedure-in-treating-anal-fissures

Lateral Internal Sphincterotomy (LIS): 

• Chronic Anal Fissures: LIS is often considered for cases of chronic anal fissures that have not responded to non-surgical treatments. 
• High Resting Anal Sphincter Tone: The procedure is particularly effective for fissures associated with elevated resting anal sphincter tone, as it aims to reduce muscle spasm. 

Procedure: Anal sphincter muscle incisions are made modest during lateral internal sphincterotomy procedures. This incision is usually made in the posterior midline, where most anal fissures are located. The technique seeks to minimize sphincter spasm, improving blood supply to the fissure and aiding healing through severing the anal sphincter muscle.  

Postoperative Care: 

• Sitz Baths: Patients are often advised to take warm sitz baths to promote cleanliness and reduce discomfort. 
• Stool Softeners: Stool softeners or dietary modifications may be recommended to prevent constipation and minimize strain during bowel movements. 
• Pain Management: They may be prescribed to manage postoperative discomfort. 

Recovery and Follow-up: 

• Return to Normal Activities: Patients can usually return to normal activities within a few days to weeks after the procedure. 
• Follow-up Appointments: To track the healing process and handle any issues or complications, follow-up appointments are planned on a regular basis. 

use-of-phases-in-managing-anal-fissures

• Phase 1: Conservative Management 

Symptomatic Relief: 

• Topical Analgesics and Anesthetics: Over-the-counter creams or ointments containing local anesthetics (e.g., lidocaine) may provide pain relief. 
• Warm Sitz Baths: The anal sphincter can be made to relax and lessen pain by bathing in the warm water for ten to fifteen minutes many times a day. 

Dietary and Lifestyle Modifications: 

• High-Fiber Diet: Increased fiber intake softens stools and encourages regular bowel movements, lowering the risk of anal canal damage. 
• Adequate Hydration: Drinking enough of water is critical for keeping stools soft. 
• Stool Softeners: Over-the-counter stool softeners may be recommended to further soften the stool. 

Topical Medications: 

• Topical Nitroglycerin: Nitroglycerin ointment helps relax the anal sphincter muscles and improve blood flow, promoting healing. 

Pain Management: 

• Oral Pain Medications: Pain relievers, such as acetaminophen or ibuprofen, may be recommended for pain control. 
• Phase 2: Pharmacological Treatment 

Topical Calcium Channel Blockers: 

• Diltiazem Ointment: A calcium channel blocker applied topically to relax the anal sphincter muscles and aid in healing. 

Botulinum Toxin Injections: 

• Injections: Botulinum toxin injections into the anal sphincter muscles can temporarily relax the muscles, reducing spasm and promoting healing. 
• Phase 3: Interventional or Surgical Measures 

Lateral Internal Sphincterotomy (LIS): 

• Surgical Procedure: An incision is made in the internal anal sphincter muscle to reduce sphincter spasm and promote healing. 
• Consideration: Typically reserved for cases where conservative and pharmacological treatments have not been successful. 

Fissurectomy: 

• Removal of Fissure: In some cases, the fissure itself may be surgically removed (fissurectomy). 
• Phase 4: Post-Procedure Care and Follow-up 

Postoperative Care: 

• Sitz Baths: Warm sitz baths may continue postoperatively to aid in healing and reduce discomfort. 
• Stool Softeners: Continued use of stool softeners to prevent constipation and strain during bowel movements. 

Regular Follow-up: 

• Monitoring Healing: Regular follow-up appointments to monitor the healing process and address any complications. 
• Adjustment of Treatment: Treatment may be adjusted based on the patient’s response and progress. 

Medication

Future Trends

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References

Anal Fissures:ncbi.nlm.nih.