Anal Fissures

It’s common for anal fissures to bleed slightly, which is why many patients assume they have haemorrhoids. An anal fissure is a completely different condition to haemorrhoids and it requires different treatment.

Patients with an anal fissure typically describe a sharp, razor-like pain in the anus, both during and after defecation.  This pain can linger for some time.

Sometimes this pain is so severe, people end up in the emergency department needing strong painkillers and urgent treatment. In other cases, people find they have symptoms that come and go for years.

Anal fissures can happen at any age to men and women, although they tend to be more common in younger people.

The most common cause of an anal fissure is straining to pass a hard stool.

Straining creates pressure, and this combined with a large, hard stool can lead to tearing of the lining (mucosa) of the anal canal. It’s not uncommon for a patient to have experienced years of constipation or frequent hard stool before developing an anal fissure.

It’s not fully understood why these fissures can take so long to heal and become a chronic condition, which is when symptoms last for more than three months. While some people find their fissures heal within three months, they might be at risk of developing them again. This is called a recurrent acute fissure.

What we do know is patients with anal fissures have a very high resting “tone” in the anal canal. This is likely caused by a reflex contraction of the internal anal sphincter. Therapies therefore focus on reducing this high resting tone.

Whether or not people with a high resting tone in the anus are more prone to developing fissures is unclear.

There are other causes of anal fissures too.

Some women can develop an anal fissure in the first few months after a traumatic vaginal delivery, and this can be very problematic. The patient can also experience other problems such as rectal evacuation or anal continence. Rehabilitation of the whole pelvis from such an injury takes time, care and support.

It’s also common for older women to develop an anal fissure due to internal pelvic organ prolapse. This also tends to be caused by traumatic vaginal delivery or pelvic surgery, such as hysterectomy.

Usually in these situations, patients will describe other symptoms. These might include defecatory difficulties, a feeling of pressure in the rectum, anal leakage or coexisting vaginal prolapse. Treatment is directed at the underlying pelvic organ prolapse, which usually leads to improvement in the anal fissure.

There are other causes of anal fissures that are less common, but important.

Anal Crohn’s disease is one of them. In these cases, anal fissures tend to be less painful, but more inflamed. The patient may present with anal fissures before receiving a diagnosis of Crohn’s, so they are unaware they have the disease.

Other causes include infections such as herpes, syphilis, HIV and tuberculosis of the anus. Pelvic radiotherapy treatment (for example for cervical cancer) and anal cancer are other causes.

It’s important to receive evaluation by a specialist colorectal surgeon, which we offer at Brisbane Colorectal. Treatment can range from simple measures such as topical creams, through to surgery.

Since the fissure is usually just inside the anal canal, it won’t be visible to the patient.

Sometimes they’re even difficult for a colorectal surgeon to see, particularly when the pain causes anal spasm.

Most anal fissures are located at “6 o’clock” which is at the back of the anal canal. In cases of pelvic organ prolapse it can be at “12 o’clock” – which is at the front.

Anal fissures located on the side of the anal canal are more unusual. These will usually need a further assessment to ascertain if there is a less common cause.

Like all anal conditions, treatment for anal fissures focuses on the underlying cause, as well as the fissure itself.

An assessment by a specialist colorectal surgeon is important, especially since they will be able to identify what the underlying causes are. This may include a pelvic floor assessment, a colonoscopy, an examination under general anaesthetic or a referral to other therapists such as a pelvic floor physiotherapist.

Basic treatment aims to achieve a routine soft stool, which is easily passed without excessive pushing. This often involved fibre supplements, a stool softener and support to utilise the correct defecatory technique. Pain can be relieved with medication and warm, salt baths.

Topical creams can be very effective in reducing the resting anal tone, with around 50% of patients’ symptoms being resolved using these basic measures. One popular over-the-counter treatment is Rectogesic ointment, although it can cause severe headaches. At Brisbane Colorectal, we can prescribe patients with another cream that is even more effective, with no associated headaches.

A Botox injection into the internal anal sphincter can provide relief for people with intense pain and anal spasm. It is a low risk and well tolerated treatment that is effective in around 80% of patients. However it does need to be given under general anaesthetic.

The Botox usually lasts around three months, and in cases where the underlying cause has not been properly addressed, the symptoms can return. This treatment can be repeated if needed.

Unfortunately, many health funds do not cover, or only partially cover, the cost of the Botox ($500).

Another surgical treatment for anal fissures is an advancement flap.

Like a Botox injection, this is also a day case operation. The defect in the anal lining from the fissure is filled with adjacent skin or mucosa, using small absorbable sutures. The operation is tolerated quite well, and has a reasonable success rate. Again, it is important for the underlying cause of the anal fissure to be treated.

For those with severe pain or symptoms that are difficult to manage, there is another surgical option called a lateral sphincterotomy.

This is another day case surgery, where the lower fibres of the internal sphincter are permanently divided. It is another well tolerated procedure that’s very effective, with a success rate of over 90%.

There is, however, a very small risk of future anal leakage. That’s why this operation is generally performed more in males as there is no potential for obstetric injury, but it is an option for females with severe symptoms.

Every case is different. At Brisbane Colorectal we recommend a formal assessment with one of our colorectal surgeons to discuss which treatment(s) would be best for your symptoms.