This article covers various topics related to anal fissures, including their treatment, symptoms, causes, creams, and information about anal fissures.
Anal fissure is a condition characterized by a non-deep, crack-like injury on the inner surface of the anus. Approximately 7% of the population experiences this issue at some point in their lives. While some cases resolve spontaneously or with medication, others may become chronic and require different forms of treatment.
Why Does Anal Fissure Occur?
The most common cause is known to be hard stools or constipation. Directly hardened feces can injure the inner lining of the anus by causing scratches, tearing the anus by forcing it to stretch, or tearing when attempting to remove hardened feces manually. Constipation is responsible for approximately 90-95% of all anal fissure cases. The remaining 5-10% can be attributed to the following reasons:
- Severe diarrhea (having bowel movements 10-15 times a day)
- Dysentery
- Insertion of a foreign object
- Anal intercourse
Less common causes include:
- Crohn’s disease
- Careless enema use
- Colonoscopy
- Ulcerative colitis
What Are the Symptoms of Anal Fissure?
The most commonly felt symptom by patients is pain during bowel movements, which patients describe as feeling like “glass cutting” or “as if a barbed wire is causing pain.” When it becomes chronic, there may be a lingering pain resembling cramps around the anus for hours after a bowel movement. Multiple symptoms can occur in the same patient, and in addition to pain, other symptoms include:
- Bleeding, often in the form of staining on toilet paper
- Itching
- Discharge
- Burning sensation
Clinically observed signs include
- Pain and discomfort when attempting to separate the anus with fingers; upon visual inspection, one or more tears may be visible.
- If chronic, a skin projection known as a sentinel tag can be seen on the outer part of the tear (patients often mistake this projection for hemorrhoids). Digital examination can be very painful.
- An anoscope examination can also be painful, requiring local anesthesia. A protrusion resembling a skin tag, called a sentinel polyp, can be observed inside the tear with the anoscope.
- In the early stages, a bleeding point may be visible.
How to Heal Anal Fissure?
Preventing constipation is an absolute requirement; if constipation is not addressed, the chances of recovery decrease, and even if recovery occurs, the condition may recur.
In addition to preventing constipation, healing can occur with creams, botulinum toxin, or surgery, but ultimately, it is a disease that always heals.
The choice of treatment is based on the onset of the disease, the severity of clinical symptoms (complaints), and the patient’s expectations.
Are Anal Fissure Creams Effective?
Yes, if treatment is initiated in the early stages, within 1-2 weeks after the fissure forms, the disease has a 30-40% chance of complete healing and a 60-70% chance of becoming chronic. If medication is started after a delay, i.e., after the disease has become chronic, the likelihood of recovery remains around 3-5%. Therefore, medication is not recommended for chronic fissures, and if the patient wants to try, it can be prescribed.
Ideally, instead of randomly using medication when there is pain in the anus, it is advisable to consult a doctor for an examination and then use medication. This way, there is a 30-40% chance of recovery without chronicization.
How Is Anal Fissure Treated with Botox?
It is a simple procedure involving the injection of botulinum toxin (2). Local anesthesia is applied during the procedure to prevent pain in the crack area and discomfort when inserting a finger into the anus while the patient lies on their left side. Botox injections are administered separately to the right and left sides of the anal muscles. The entire process is completed with three simple injections and takes 1-2 minutes.
Introduced for the first time in Turkey in 2009 at Idea Clinic, the most accurate application has also been developed by Idea Clinic. The application involves a 1-2 minute injection.
Its success is close to surgery, with a success rate of around 98% when the correct dose is applied appropriately. It has many advantages over surgery; it has no side effects, is much more economical compared to surgery, and is easy to administer without the need for wound care.
Is Anal Fissure Surgery Necessary, and How Is It Performed?
Before the invention of botulinum injection therapy, surgery was performed worldwide. The performed surgery is called LIS (lateral internal sphincterotomy). Since one of the muscles that constrict the anus is cut to achieve relaxation, there can be rare instances of permanent gas and fecal incontinence (3). The looseness created in the anus due to muscle cutting is permanent, and the likelihood of experiencing problems increases when the natural weakening of the muscles due to aging is added.
In the past, the widely performed LIS surgery has significantly decreased with the use of botulinum therapy. It has been largely abandoned in most developed countries due to the side effect of permanent gas and fecal incontinence.
In addition to gas and fecal incontinence, there are also non-life-threatening side effects such as bleeding at the surgical site, infection in the wound, and deformation of the anus. Due to such side effects, it is not widely performed in proctology centers specializing in anal diseases. In Turkey, it is more commonly performed in state hospitals.
Laser Treatment for Anal Fissure
Laser treatment is mostly supportive. While the main treatment for the fissure is done with botulinum, the laser is used to burn the base of the crack, turning a chronic wound into a fresh one.
There is no significant superiority to injection treatment, and it is mostly applied to patients with active bleeding. It falls into the category of non-surgical methods and does not pose the risk of gas and fecal incontinence seen in classical surgery because the muscle is not cut.
Anal Fissure Flap Surgery
About 99% of patients complain of pain and discomfort. The main cause of pain is the uncontrolled and excessive contraction of the muscle that tightens the anus. The primary goal in all treatment methods is to relax this contracted muscle. In very rare cases where there is a crack but no muscle contraction, flap displacement can be performed. The inner lining of the lower part of the intestine is shifted to the outer boundary of the anus and stitched to the anus-skin border. It has a side effect of continuous wetness in the anus.
What Happens If Anal Fissure Is Not Treated?
The concern that many patients have about whether it turns into cancer is unfounded; anal fissure never turns into cancer. Not only does it not turn into cancer, but it also does not cause other diseases. If left untreated, the following problems may occur:
- Pain and discomfort gradually increase.
- Due to the inability of the constricting muscles of the anus to relax, defecation and passing gas become difficult.
- Swelling in the abdomen may occur as a result.
- Bleeding may occur, but not to the extent of causing anemia.
- It does not lead to hemorrhoids, a common disease in the region, nor does it transform into hemorrhoids.
How to Use Anal Fissure Creams?
Since the contents and effects of medications vary, the methods of use also differ. Here’s how to use the creams:
How to Use Anuflex:
- When the need for defecation is identified, go to the toilet.
- Before defecation, sit in lukewarm water for 3-4 minutes, a little warmer than bathwater.
- After getting up and drying, apply a small amount of Anuflex Cream to the inside of the anus using the fingertip.
- Anuflex should not be squeezed into the anus but should be applied to the anal canal. After applying the cream, wait another 3-4 minutes for numbing, then defecate.
- After defecation, sit in the same lukewarm water for the same duration again, get up, dry yourself, apply Anuflex Cream to the inside of the anus with your finger, and leave the toilet.
- It is sufficient to use the medication as many times as the number of toilet visits. Some patients complain of pain during gas discharge; in such cases, it can also be used without defecation.
How to Apply Anestol to the Anus: Anestol only has a numbing effect. When applied to the anus before defecation, it reduces the feeling of “pain like scratching glass” felt during defecation, allowing the patient to defecate more comfortably. The pain during defecation leads to uncontrolled muscle contraction, causing subsequent contraction pain.
How to Use Rectoderm Cream: Due to its blood pressure-lowering side effect and to relax the muscle, it is used after defecation. Apply a small amount of Rectoderm Cream, about the size of a chickpea, to the inside of the anus with the help of a finger, without squeezing it into the anus. It can also be used in combination with Anestol Cream before and after defecation. Anracta Cream is used in the same way as Rectoderm Cream since they have the same content.
Diet for Anal Fissure: There is no specific diet or specific food to be consumed. The only food that may be disturbing when consumed is intense spicy food. Spicy food, even burning normal anus skin, can cause unbearable burning on the crack surface. Patients are aware of this, so they avoid consuming spicy foods.
Since constipation is the most important cause of the formation, chronicization, or recurrence of the disease, all foods that prevent constipation are beneficial for the crack. To prevent the disease from becoming chronic and the pain from increasing further, constipation must be prevented; preventing constipation is an essential part of treatment.
Foods containing fiber, especially those with bran and whole grains, should be preferred to improve constipation. The most common source of fiber is vegetables and fruits. Another readily available source of fiber is whole wheat bread.
Additionally, for those who do not find plain bran palatable, it can be mixed with yogurt or incorporated into cereals, salads, or smoothies for a more enjoyable consumption.
Remember, the primary goal is to prevent constipation, and incorporating fiber-rich foods into your diet plays a crucial role in achieving this. Staying hydrated by drinking plenty of water is also essential in maintaining healthy bowel movements.
Moreover, it’s worth noting that maintaining a healthy lifestyle, including regular physical activity and managing stress, contributes to overall digestive well-being and can positively impact the prevention and management of anal fissures.
In conclusion, while there isn’t a specific dietary regimen for anal fissures, a balanced diet with an emphasis on fiber-rich foods, proper hydration, and a healthy lifestyle can aid in preventing and managing constipation, which is a key factor in the treatment of anal fissures.
Diseases Causing Pain in the Anus
One of the most common symptoms of an anal fissure is pain. There are several diseases that can cause pain in the anus, including:
- Hemorrhoids (Piles): This is the most common disease in the region, often appearing as protruding masses resembling small bumps.
- Anal Abscess: An inflammatory condition, the pain increases as the inflammation progresses, reaching unbearable levels. Draining the abscess typically results in an 80% reduction in pain for the patient.
- Anal Hematoma (Collection of Blood Clot in the Anus): Often confused with hemorrhoids, this condition occurs due to straining and causes pain proportional to its size. It is a temporary issue.
- Condyloma (Anal Warts): A contagious disease caused by the HPV virus, it tends to spread rapidly due to HPV’s affinity for moist areas.
- Polyps (Protrusions Resembling Skin Tags): Often mistaken for hemorrhoids, polyps have a different structure and are relatively easy to treat.
- Anal Cancer: This is the most dangerous disease in the region. Due to similarities in symptoms, patients may waste valuable time undergoing various treatments based on recommendations from friends and neighbors. Because it is a serious condition, when symptoms such as pain, discomfort, or bleeding are observed, it is crucial to consult a proctology specialist to confirm the diagnosis.
- Fistula: Pain is not always the primary concern; a persistent discharge is a significant symptom. If the opening where the discharge occurs is blocked, it can accumulate beneath the skin, causing pressure and resulting in pain.
- Traumas: Straining, introducing foreign objects, or forced unnatural sexual acts can strain the muscles and damage the mucosa, leading to pain.
- Dysentery: Inflammation caused by dysentery in the last part of the rectum can result in pain.
- Crohn’s Disease: An autoimmune disease primarily affecting the intestines, Crohn’s disease can also cause various issues in the anal region.
- Solitary Rectal Ulcer: A small ulcer forms in the last part of the colon, occasionally causing symptoms.
It’s essential to seek medical attention and consult a proctology specialist for a definitive diagnosis when experiencing symptoms related to anal pain or discomfort.
References
1- Pramod, K., Ansari, S. H., & Ali, J. (2010). Eugenol: a natural compound with versatile pharmacological actions. Natural product communications, 5(12), 1934578X1000501236.
2- Maria, G., Cassetta, E., Gui, D., Brisinda, G., Bentivoglio, A. R., & Albanese, A. (1998). A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. New England Journal of Medicine, 338(4), 217-220.
3- Kement, M., Karabulut, M., Gezen, F. C., Demirbas, S., Vural, S., & Oncel, M. (2011). Mild and severe anal incontinence after lateral internal sphincterotomy: risk factors, postoperative anatomical findings and quality of life. European Surgical Research, 47(1), 26-31.
4- Jensen, S. L. (1988). Diet and other risk factors for fissure-in-ano: prospective case control study. Diseases of the colon & rectum, 31, 770-773.
