Anal fissure

Anal fissure is a laceration or crack in the lining of the anus that extends to the circular muscle. Most fissures heal on their own and don’t require treatment, aside from good diaper hygiene. However, some fissures may require medical treatment. The prognosis is very good, especially with fissurectomy and good anal hygiene.

Causes and incidence

Anal fissure results from passage of large, hard stools that stretch the lining beyond its limits. It may also be due to prolonged diarrhea, strain on the perineum during childbirth and, rarely, from scar stenosis. Occasionally, anal fissure is secondary to proctitis, anal tuberculosis, cancer, or Crohn’s disease.

Anal fissures are common in young infants but may occur at any age, with incidence decreasing rapidly with age. Studies suggest that 80% of infants will have had an anal fissure by age 1. Fissures are less common among school-age children than infants. They affect males and females equally.

Signs and symptoms

Onset of an acute anal fissure is characterized by tearing, cutting, or burning pain during or immediately after a bowel movement. A few drops of blood may streak toilet paper or underclothes. Painful anal sphincter spasms result from ulceration of a “sentinel pile” (swelling at the lower end of the fissure). A fissure may heal spontaneously and completely or it may partially heal and break open again. Chronic fissure produces scar tissue that hampers normal bowel evacuation.

Diagnosis

Anoscopy showing a longitudinal tear and typical clinical features help establish the diagnosis. Digital examination that elicits pain and bleeding supports the diagnosis. Gentle traction on perianal skin can create sufficient eversion to visualize the fistula directly.

Treatment

Treatment varies according to the severity of the tear. Conservative treatment measures include stool softeners, dietary adjustment (addition of bulk to absorb water while in the intestinal tract), use of petroleum jelly and sitz baths, and cleaning more gently. Anesthetic ointment may be useful if pain interferes with normal bowel movements. Topical muscle relaxants may also be soothing. These measures generally heal more than 90% of anal fissures. For fissures that don’t heal with these treatments, injection of botulinum toxin into the anal sphincter will temporarily paralyze the anal sphincter muscle, thereby promoting healing. Another option for nonhealing fissures is a minor surgical procedure to relax the sphincter.

For superficial fissures without hemorrhoids, forcible digital dilatation of the anal sphincter under local anesthesia stretches the lower portion of the sphincter. For complicated fissures, treatment includes surgical excision of tissue, adjacent skin, and mucosal tags and division of hypertrophied internal sphincter muscle to release tension.

Special considerations

Care consists of patient education and support.

❑ Prepare the patient for rectal examination; explain the necessity for the procedure.

❑ Provide warm sitz baths, warm soaks, and local anesthetic ointment to relieve pain. A low-residue diet, adequate fluid intake, and stool softeners prevent straining during defecation.

❑ Give diphenoxylate or other antidiarrheals to control diarrhea.

Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Anal symptoms: Introduction (review 274 causes)
• Next Book Extract About Anal symptoms: Anorectal abscess and fistula (Professional Guide to Diseases (Eighth Edition))
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More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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