Anal Fissure Treatment in Delhi, India

An anal fissure is a split or tear in the lining of the anal canal. It results in anal pain and rectal bleeding, particularly during bowel movements. An anal fissure is typically caused by trauma to the anal canal, often due to straining during the passage hard stools. 

Anal fissures can be of two types:

• Acute: An anal fissure is classified as acute if it heals within 6 weeks following conservative treatment methods.
• Chronic: Anal fissures lasting longer than 6 weeks or recurring, are classified as chronic. These generally require a more rigorous treatment approach, like surgery.

One of the most common causes of anal fissure is constipation. Hardened stools stretch the anal mucosa beyond its normal capacity, making a tear. The tear causes the fissure. 

The muscle beneath the tear, called the sphincter muscle, spasms in response to the injury. The spasmed muscle causes pain and stretches the tear even further. This is a vicious cycle that leads to the development of chronic fissures if not treated in time. 

Following are some of the risk factors that can increase the chances of anal fissure:

• Prolonged diarrhoea: Diarrhoea can dry out the skin around the anus, causing it to crack. 
• Childbirth: The pressure during childbirth can sometimes cause a tear in the lining of the anus. 
• Crohn’s disease: Anal fissures are a complication of inflammatory bowel diseases like Crohn’s disease.

Symptoms of anal fissure are quite uncomfortable to bear and include:

• Pain: Sharp pain during or after passing stools is a common symptom of anal fissures. The pain can last from a few minutes to several hours.
• Bleeding: The tear in the anal lining can cause slight bleeding, often noticeable on the stool or toilet tissue.
• Tear/Crack: A visible crack or tear can be seen in the area around the anus.
• Skin tag: The presence of a small lump, known as a skin tag, near the anal fissure.

Diagnosing an anal fissure typically begins with a physical examination. A gentle inspection of the anal region helps confirm the presence or absence of a tear. In most cases, a physical examination is sufficient to diagnose a fissure. However, further diagnostic procedures may be required if no tear is detected. In such cases, the following tests might be ordered for confirmation of the fissure:

Digital Rectal Exam

During a gentle digital rectal exam, the doctor inserts a gloved and lubricated finger into the rectum to check for any abnormalities. The procedure typically shows tenderness due to fissure.

Anoscopy

For performing an anoscopy, an anoscope (a rigid, hollow and lighted tube) is used. The anoscope is inserted through the anus after lubricating it with a gel. The anoscope helps identify abnormalities in the gastrointestinal tract by providing detailed images of the anorectal area. It is an outpatient procedure in which the doctor can provide an idea of the results then and there.

Flexible sigmoidoscopy

Flexible sigmoidoscopy is a procedure in which an endoscope (a flexible, narrow tube with light and tiny camera at one end) is used to examine the lower part of the large intestine. Through this procedure, high resolution images of the intestine are projected onto a screen for a detailed look at the anus, rectum, and colon. Tissue samples can also be collection during this procedure for biopsy, aiding in the diagnosis and exclusion of cancer. 

Colonoscopy

A colonoscopy is performed for a comprehensive examination of the colon. The procedure is the same as with flexible sigmoidoscopy, except in colonoscopy the endoscope is inserted to inspect the entire colon. A biopsy is done after colonoscopy to rule out cancer. 

Home Remedies

Most cases of acute anal fissures heal with the help of appropriate home remedies. Following are a few treatments one can try at home to alleviate the symptoms:

• High Fibre Diet: A diet rich in fibre can help soften the stool and ease the bowel movement. Examples of such food include pears, apples, bananas, carrots, broccoli, and oats. Whole grains such as wheat and barley are also good stool softeners.
• Sitz Bath: A sitz bath involves soaking the anal area in warm water for about 10-15 minutes a few times a day. This helps relieve pain and promote healing of the tear.

Non-Surgical Treatment

If the symptoms are mild but persist after home remedies, then the doctor might prescribe medications and ointments. These might include:

• Topical Nitroglycerin: Nitroglycerin, when applied topically, helps increase blood flow to the fissure and promotes healing. It works by relaxing the sphincter muscle that aids in healing of the tear over time. Anal fissures causing moderate to severe pain can often be effectively managed with this ointment.
• Calcium Channel Blockers: If topical nitroglycerin proves ineffective, doctors prescribe calcium channel blockers, which also relax the blood vessels in the anal muscles.
• Botox Injections: If either of the above-mentioned drugs don’t work, then botox injections are the last resort before considering surgical treatments. Botox is a muscle relaxant, with effect lasting approximately 3 months, providing sufficient time for the fissure to heal without the spasms in the sphincter muscle.

Lateral Internal Sphincterotomy (Laser/Open)

If the anal fissure does not resolve with medications or recurs after some time, surgery becomes the only option. This surgery is known as lateral internal sphincterotomy, during which a small lateral incision is made in the internal anal sphincter. An anoscope is used to locate the muscle, which is then cut using laser or scalpel. The procedure is performed under anaesthesia.

Cutting the muscle helps relieve excess tension, thereby stopping spasms and allowing the fissure sufficient time to heal. The procedure is typically performed on an outpatient basis and usually takes around 30 minutes to complete.

Most anal fissures heal on their own within a few weeks (acute anal fissure). If they do not heal, it is often due to continuous muscle spasms, which prevent the wound from healing. Over time, this condition can become increasingly painful. Additionally, complications that can arise from untreated anal fissures include:

• Anal stenosis: A condition characterised by the narrowing of the anal canal.
• Anal fistula: An untreated wound infection may result in anal fistula, which is a tunnel that connects inside the anus to the external skin.
• Faecal Impaction: Chronic constipation can lead to faecal matter becoming lodged in the rectum and backing up into the large intestine, a condition known as faecal impaction.

Anal fissures can be prevented by maintaining a regular exercise routine, consuming a diet rich in high-fibre foods and staying well-hydrated. These practices promote smooth bowel movements and help prevent tears around the anus.

Are anal fissures and haemorrhoids different? If so, how?

Anal fissures are small tears in the lining of the anus, whereas haemorrhoids are swollen veins in and around the rectum and anus. While both conditions can cause pain, their underlying causes and treatments differ.

Can children also develop anal fissures?

Yes, anal fissures are common in infants and toddlers, often caused by constipation or passing hard stools.

What is the recovery time for sphincterotomy?

Recovery from a sphincterotomy typically takes 2-4 weeks. Most patients experience significant relief from anal fissure symptoms shortly after the procedure. 

Are there any dietary limitations after anal fissure surgery?

To promote healing and to prevent complications, patients are advised to consume a high-fibre diet and drink plenty of fluids. Spicy or hard-to-digest food should be avoided for a few days following the surgery. 

When to consult a doctor for anal fissure?

If an anal fissure causes severe pain, bleeding or persists for more than six weeks, it is important to seek medical attention. Consult specialists experienced in treating anal fissures at a hospital equipped for anal fissure surgery to ensure proper treatment.

Reviewed by Dr. Neeraj Goyal, Associate Director - Laser, Robotic Surgery, Department of General Surgery and Robotics, Laparoscopic / Minimal Access Surgery, on 1 Dec 2024.