Anal Fissures

November 2020

What is an anal fissure?

An anal fissure is a tear in the lining of the anus or anal canal (the opening through which stool

passes out of the body). The fissure can be painful and may bleed, especially with bowel movements.

What causes an anal fissure?

Anal fissures can be caused by trauma to the anus and anal canal. Trauma can be caused by:

• Chronic (long-term) constipation

• Straining to have a bowel movement

• Prolonged diarrhea

• Anal intercourse, anal stretching

• Insertion of foreign objects into the anus

Other causes include:

• Longstanding poor bowel habits

• Overly tight or spastic anal sphincter muscles (muscles that control the closing of the anus)

• Scarring in the anorectal area

• An underlying medical problem, such as Crohn’s disease, ulcerative colitis, anal cancer, leukemia, and sexually transmitted diseases

• Decreased blood flow to the anorectal area

Anal fissures are also common in young infants and in women after childbirth.

What are the signs and symptoms of an anal fissure?

• Pain during, and even hours after, a bowel movement

• Constipation

• Blood on the outside surface of the stool

• Blood on toilet tissue or wipes

• A visible crack or tear in the anus or anal canal

• Burning and itching that may be painful

• Discomfort when urinating, frequent urination, or inability to urinate

• Foul-smelling discharge

Who is at risk for anal fissures?

Anal fissures can occur at any age, but the chance of having an anal fissure decreases as people get older. People who have had one in the past are more likely to have them in the future.

How is an anal fissure diagnosed?

A doctor can usually diagnose an anal fissure by visual inspection of the anus or be a gentle exam with the tip of the finger.

How are anal fissures treated?

The goal of treatment is to lower the pressure on the anal canal by making the stools soft, to ease discomfort, and to ease bleeding. Conservative treatments are

typically tried first and include:

• Preventing constipation – using stool softeners, drinking more fluids while avoiding caffeine products, and increase intake of higher fiber foods or supplements.

• Soaking in a sitz bath (a warm, shallow bath that cleanses the perineum) 10-20 minutes several times a day to help relax the anal muscles

• Cleansing the anorectal area more gently

• Avoiding straining or prolonged sitting on the toilet

• Using petroleum jelly to help lubricate the anorectal area.

Conservative treatments heal approximately 80-90% of fissures within several week to several months. However, if these treatments fail and anal fissures persist

or come back, other treatments can include:

• Using hydrocortisone-containing suppositories or creams to reduce inflammation

• Applying other creams or ointments – nitroglycerin or calcium channel blockers (to promote healing), a topical muscle relaxant, or an anesthetic ointment

• Compounded creams or ointments – Compounding multiple ingredients together can help with healing and pain.

• Injecting Botox into the anal sphincter. This can temporarily paralyze the anal sphincter muscle, relieving pain and promote healing

• Surgery

What compounded options are available for treating anal fissures?

Compounded options are available to treat anal fissures. By combining multiple ingredients into 1 cream or ointment, multiple symptoms may be treated using 1 cream. Examples of common ingredients used in treatment include:

Diltiazem, Nifedipine, or Nitroglycerin – These medications help relax the

anal muscles and increase blood flow to the area, which promotes healing.

Lidocaine or Benzocaine – These are anesthetics which reduce pain.

Hydrocortisone – A steroid that helps reduce swelling and inflammation.

Can anal fissures be prevented?

For infants:

• Change diapers frequently

• Treat constipation, if that is the cause

For adults:

• Keep the anorectal area dry

• Wipe the area with soft materials, a moistened cloth, or cotton pad. Avoid using scented toilet paper.

• Promptly treat constipation and diarrhea

• Avoid irritating the rectum.