Anal fissure

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Anal fissure
Other namesFissure in ano, rectal fissure
Anal fissure 2.jpg
An anal fissure
Specialty Gastroenterology   OOjs UI icon edit-ltr-progressive.svg

An anal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper and undergarments, or sometimes in the toilet. If acute they are painful after defecation, [1] but with chronic fissures, pain intensity often reduces and becomes cyclical. [2]

Contents

Causes

Most anal fissures are caused by stretching of the anal mucous membrane beyond its capability. [3]

Superficial or shallow anal fissures look much like a paper cut, and may be hard to detect upon visual inspection; they will generally self-heal within a couple of weeks. However, some anal fissures become chronic and deep and will not heal. The most common cause of non-healing is spasming of the internal anal sphincter muscle which results in impaired blood supply to the anal mucosa. The result is a non-healing ulcer, which may become infected by fecal bacteria.

In adults, fissures may be caused by constipation, the passing of large, hard stools, or by prolonged diarrhea. In older adults, anal fissures may be caused by decreased blood flow to the area. When fissures are found laterally, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, acquired immunodeficiency syndrome (AIDS) or inflammatory bowel disease should be considered as possible causes. [4] Some sexually transmitted infections can promote the breakdown of tissue resulting in a fissure: syphilis, herpes, chlamydia and human papilloma virus. [5]

Other common causes of anal fissures include: childbirth trauma in women, [6] anal sex, [7] [8] Crohn's disease, [6] ulcerative colitis, [9] and poor toileting in young children. [10]

Diagnosing

External anal fissures on the anal verge can be diagnosed by visual inspection.[ citation needed ]

In case of chronic anal fissure the sentinel piles on anal verge, papilla next to dentate line and fissures also commonly referred to in combination as classic fissure triad can also be seen during diagnosis.

Internal anal fissures stretching from anal verge till dentate line in adults on anterior side, posterior side or within any part of the inner circumference of the anal sphincter muscle can be diagnosed with a beak proctoscope of 23 mm diameter, a Hill Ferguson retractor of 23 mm diameter, a Park anal retractor or by digital rectal examination with a finger through the anal sphincter.

Narrow anal fissures might not be felt by finger palpation during the rectal exam due to gloves reducing tactile sensitivity. [11]

Note that colonoscopy, sigmoidoscopy, or normal proctoscopy is for diagnosing internal hemorrhoids and other internal rectal diseases and not for diagnosing anal fissures.[ relevant? ]

Prevention

‹The template Manual is being considered for merging.› 

For adults, the following may help prevent anal fissures:

In infants, frequent diaper change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough fluids (i.e. breastmilk, proper ratios when mixing formulas) is beneficial. In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs. [13]

Treatment

Non-surgical treatments are recommended initially for acute and chronic anal fissures. [14] [15] These include topical nitroglycerin or calcium channel blockers (e.g. diltiazem), or injection of botulinum toxin into the anal sphincter. [16]

Other measures include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners. [17] [18]

Medication

Local application of medication to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment, [19] [20] [21] [22] and then calcium channel blockers in 1999 with nifedipine ointment, [23] [24] and the following year with topical diltiazem. [25] Branded preparations are now available of topical nitroglycerine ointment (Rectogesic (Rectiv) as 0.2% in Australia and 0.4% in UK and US [26] ), topical nifedipine 0.3% with lidocaine 1.5% ointment (Antrolin in Italy since April 2004) and diltiazem 2% (Anoheal in UK, although still in Phase III development). A common side effect drawback of nitroglycerine ointment is headache, caused by systemic absorption of the drug, which limits patient acceptability.

A combined surgical and pharmacological treatment, administered by colorectal surgeons, is the direct injection of botulinum toxin (Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993. However, in many cases involving Botox injections, the patients eventually had to choose another cure as the injections proved less and less potent, spending thousands of dollars in the meantime for a partial cure. Lateral sphincterotomy is the Gold Standard for curing this condition. [27] Combination of medical therapies may offer up to 98% cure rates. [28]

Surgery

Surgical procedures are generally reserved for people with anal fissures who have tried medical therapy for at least one to three months and have not healed. It is not the first option in treatment.

The main concern with surgery is the development of anal incontinence. Anal incontinence can include the inability to control gas, mild fecal soiling, or loss of solid stool. Some degree of incontinence can occur in up to 45 percent of patients in the immediate surgical recovery period. However, incontinence is rarely permanent and is usually mild. The risk should be discussed with one's surgeon.

Surgical treatment, under general anaesthesia, is either anal stretch (Lord's operation) or lateral sphincterotomy where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter spasming and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general or regional anaesthesia. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.

Lateral internal sphincterotomy

Lateral internal sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%). [29] In this procedure the internal anal sphincter is partially divided in order to reduce spasming and thus improve the blood supply to the perianal area.

This improvement in the blood supply helps to heal the fissure, and the weakening of the sphincter is also believed to reduce the potential for recurrence. [30] The procedure is generally performed as a day surgery after the patient is given general anesthesia. The pain from the sphincterotomy is usually mild and is often less than the pain of the fissure itself. Patients often return to normal activity within one week.

LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%). [31]

Though lateral internal sphincterotomy (LIS) is considered safe on a short-term basis, there are concerns about its long-term safety. Pankaj Garg et al. published a systematic review and meta-analysis in which they analyzed the long-term continence disturbance two years after the LIS procedure. They found the incidence of long-term continence disturbance to be 14%, so caution and careful patient selection are needed before undergoing LIS. [32]

Anal dilation

Anal dilation, or stretching of the anal canal (Lord's operation), has fallen out of favour in recent years, primarily due to the unacceptably high incidence of fecal incontinence. [33] In addition, anal stretching can increase the rate of flatus incontinence. [34] The incidence of incontinence is thought to be due to a lack of standardization and that proper technique results in little chance that it will occur. [35]

In the early 1990s, however, a repeatable method of anal dilation proved to be very effective and showed a very low incidence of side effects. [36] Since then, at least one other controlled, randomized study has shown there to be little difference in healing rates and complications between controlled anal dilation and LIS, [37] while another has again shown high success rates with anal dilation coupled with low incidence of side effects. [38]

Fissurectomy

Fissurectomy involves excision of the skin on and around the anal fissure and excision of the sentinel pile if one is present. The surgical wound can be left open. New skin tissue grows and it heals.[ citation needed ]

Epidemiology

The incidence of anal fissures is around 1 in 350 adults. [10] They occur equally common in men and women and most often occur in adults aged 15 to 40. [10]

See also

Related Research Articles

<span class="mw-page-title-main">Hemorrhoid</span> Vascular structures in the anal canal

Hemorrhoids, also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term hemorrhoid is often used to refer to the disease. The signs and symptoms of hemorrhoids depend on the type present. Internal hemorrhoids often result in painless, bright red rectal bleeding when defecating. External hemorrhoids often result in pain and swelling in the area of the anus. If bleeding occurs, it is usually darker. Symptoms frequently get better after a few days. A skin tag may remain after the healing of an external hemorrhoid.

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents — including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Rectal prolapse</span> Protrusion of the walls of the rectum outside the body

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

<span class="mw-page-title-main">Diltiazem</span> Calcium channel blocker medication

Diltiazem, sold under the brand name Cardizem among others, is a nondihydropyridine calcium channel blocker medication used to treat high blood pressure, angina, and certain heart arrhythmias. It may also be used in hyperthyroidism if beta blockers cannot be used. It is taken by mouth or given by injection into a vein. When given by injection, effects typically begin within a few minutes and last a few hours.

<span class="mw-page-title-main">Nitroglycerin (medication)</span> Medication

Nitroglycerin, also known as glyceryl trinitrate (GTN), is a vasodilator used for heart failure, high blood pressure (hypertension), anal fissures, painful periods, and to treat and prevent chest pain caused by decreased blood flow to the heart (angina) or due to the recreational use of cocaine. This includes chest pain from a heart attack. It is taken by mouth, under the tongue, applied to the skin, or by injection into a vein.

<span class="mw-page-title-main">Anal fistula</span> Disease of the anus

Anal fistula is a chronic abnormal communication between the anal canal and the perianal skin. An anal fistula can be described as a narrow tunnel with its internal opening in the anal canal and its external opening in the skin near the anus. Anal fistulae commonly occur in people with a history of anal abscesses. They can form when anal abscesses do not heal properly.

Proctalgia fugax, a variant of levator ani syndrome, is a severe, episodic pain in the regions of the rectum and anus. It can be caused by cramping of the levator ani muscle, particularly in the pubococcygeal part.

<span class="mw-page-title-main">Anal sphincterotomy</span> Surgical cutting of the anal sphincter muscles

Anal sphincterotomy is a surgical procedure that involves treating mucosal fissures from the anal canal/sphincter. The word is formed from sphincter + otomy.

Lateral internal sphincterotomy is an operation performed on the internal anal sphincter muscle for the treatment of chronic anal fissure. The internal anal sphincter is one of two muscles that comprise the anal sphincter which controls the passage of feces. The procedure helps by lowering the resting pressure of the internal anal sphincter, which improves blood supply to the fissure and allows faster healing. The procedure has been shown to be very effective, with 96% of fissures healing at a median of 3 weeks in one trial.

<span class="mw-page-title-main">Human anus</span> External opening of the rectum

In humans, the anus is the external opening of the rectum located inside the intergluteal cleft. Two sphincters control the exit of feces from the body during an act of defecation, which is the primary function of the anus. These are the internal anal sphincter and the external anal sphincter, which are circular muscles that normally maintain constriction of the orifice and which relax as required by normal physiological functioning. The inner sphincter is involuntary and the outer is voluntary. Above the anus is the perineum, which is also located beneath the vulva or scrotum.

Rectal discharge is intermittent or continuous expression of liquid from the anus. Normal rectal mucus is needed for proper excretion of waste. Otherwise, this is closely related to types of fecal incontinence but the term rectal discharge does not necessarily imply degrees of incontinence. Types of fecal incontinence that produce a liquid leakage could be thought of as a type of rectal discharge.

Solitary rectal ulcer syndrome or SRUS is a chronic disorder of the rectal mucosa. It commonly occurs with varying degrees of rectal prolapse. The condition is thought to be caused by different factors, such as long term constipation, straining during defecation, and dyssynergic defecation. Treatment is by normalization of bowel habits, biofeedback, and other conservative measures. In more severe cases various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with rectal cancer or other conditions such as inflammatory bowel disease, even when a biopsy is done.

<span class="mw-page-title-main">Anismus</span> Failure to relax the pelvic floor muscles during defecation

Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

<span class="mw-page-title-main">Anorectal disorder</span> Medical condition

Anorectal disorders include conditions involving the anorectal junction as seen in the image. They are painful but common conditions like hemorrhoids, tears, fistulas, or abscesses that affect the anal region. Most people experience some form of anorectal disorder during their lifetime. Primary care physicians can treat most of these disorders, however, high-risk individuals include those with HIV, roughly half of whom need surgery to remedy the disorders. Likelihood of malignancy should also be considered in high risk individuals. This is why it is important to perform a full history and physical exam on each patient. Because these disorders affect the rectum, people are often embarrassed or afraid to confer with a medical professional.

Dyssynergia is any disturbance of muscular coordination, resulting in uncoordinated and abrupt movements. This is also an aspect of ataxia. It is typical for dyssynergic patients to split a movement into several smaller movements. Types of dyssynergia include Ramsay Hunt syndrome type 1, bladder sphincter dyssynergia, and anal sphincter dyssynergia.

Fistulectomy is a surgical procedure where a surgeon completely removes a fistula, an abnormal tract that connects two hollow spaces of the body. In comparison to other procedural options of treating fistulae such as fistulotomies, where a fistula is cut open but not completely removed, and seton placement, where a rubber band seton is passed through the tract and left post-operation as a means to allow drainage of the fistula, fistulectomies are considered to be a more radical approach. The total removal of a fistula may damage nearby structures in the process.

In fecal incontinence (FI), surgery may be carried out if conservative measures alone are not sufficient to control symptoms. There are many surgical options described for FI, and they can be considered in 4 general groups.

Low anterior resection syndrome is a complication of lower anterior resection, a type of surgery performed to remove the rectum, typically for rectal cancer. It is characterized by changes to bowel function that affect quality of life, and includes symptoms such as fecal incontinence, incomplete defecation or the sensation of incomplete defecation, changes in stool frequency or consistency, unpredictable bowel function, and painful defecation (dyschezia). Treatment options include symptom management, such as use of enemas, or surgical management, such as creation of a colostomy.

A rectal stricture is a chronic and abnormal narrowing or constriction of the lumen of the rectum which presents a partial or complete obstruction to the movement of bowel contents. A rectal stricture is located deeper inside the body compared to an anal stricture. Sometimes other terms with wider meaning are used, such as anorectal stricture, colorectal stricture or rectosigmoid stricture.

References

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