It’s a problem little discussed in social circles but one that affects an estimated 250,000 to 340,000 people a year in the United States: anal fissures. The average lifetime risk of developing one is close to 8 percent, cited a paper in BMC Gastroenterology in 2014.
An anal fissure is a tear in the skin that lines the anal canal. Many heal spontaneously or with the simple measures described below. But medication or surgery is needed if the problem becomes persistent.
You may have one if . . .
A hallmark of anal fissures is pain, sometimes severe, during or after a bowel movement. The pain may be brief or continue for hours afterward. There may also be spasms in the anal sphincter along with anal itching. Bleeding frequently accompanies the bowel movement, with the blood typically appearing on the outside of the stool or on toilet paper. Anal fissures are frequently confused with hemorrhoids, but hemorrhoids usually don’t cause pain when you pass stool. Still, you can have both hemorrhoids and an anal fissure.
What’s behind anal fissures
Constipation and straining are common causes of anal fissures, but other reasons include diarrhea, childbirth, and anal intercourse. A high resting anal pressure (tight anus) appears to be a factor. Tightness or spasm of the anal sphincter also interferes with blood supply to the anal canal, which may prevent healing of a tear. Less frequently, an anal fissure can be a sign of certain sexually transmitted infections, inflammatory bowel disease, a tumor, or other conditions.
Checking for fissures
If you suspect you have an anal fissure—or have any bleeding of unknown cause when you go to the bathroom—you should see your doctor, who will examine you, possibly using an instrument called an anoscope to view the inside of the anal canal. The fissure appears as a tear, like a paper cut, most often in the middle of the anus toward the back of the body. If the fissure is located in any other area, further evaluation is necessary to determine if there is some underlying condition, such as Crohn’s disease, associated with or causing the problem.
Further evaluation should also be considered if there are repeated recurrences or if you have another medical problem such as anemia.
How to treat
The good news is that some 70 to 90 percent of acute anal fissures (those present less than six weeks) heal on their own with simple remedies, such as eating a high-fiber diet, increasing intake of water and other fluids, using stool-softening laxatives, and taking sitz baths for 10 to 20 minutes, ideally following each bowel movement, to help relax the anal sphincter. You can take a sitz bath by soaking in warm, shallow water in a bathtub or in a plastic basin that fits over your toilet. Anesthetic creams such as lidocaine may temporarily help with pain. Topical cortisone is not effective and can delay healing.
If an anal fissure doesn’t heal after six to eight weeks despite these simple measures, it is considered chronic and further treatment is usually needed. Your doctor may prescribe nitroglycerin ointment (0.4 percent), which was approved by the FDA in 2011 for moderate to severe pain associated with chronic anal fissures. Some doctors recommend this at the onset of symptoms, especially if there is significant pain.
Calcium channel blockers, commonly used to treat high blood pressure, are sometimes used off-label for anal fissures, either topically or orally. Another treatment option is the injection of low doses of botulinum toxin A (Botox), a paralyzing agent, into the anal sphincter to relax it. If a chronic anal fissure doesn’t heal with medications, surgery may be recommended.
This article first appeared in the UC Berkeley Wellness Letter.