Anal Fissures - Causes, Risk Factors, Pathophysiology, Signs & Symptoms, Diagnosis, & Treatment

An anal fissure is a painful, linear tear or crack in the distal anal canal, which is associated with per rectal bleeding. It commonly affects younger and middle-aged people. Fissures develop equally in both males and females.
The exact cause of anal fissures is not known. However, the initiating factor is trauma to the anal epithelium. Predisposing factors for anal fissures include, constipation and straining during defecation. Low fiber diet, and hard stools. Previous anal surgery. Childbirth. Anal intercourse. Anal cancer. Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis. And infections such as HIV and syphilis.
In most individuals, minor tears in the anal epithelium heal rapidly without any residual damage. However, people who have underlying abnormalities in the internal anal sphincter tend to develop acute and chronic anal fissures. Two most common abnormalities include increased tone of the internal sphincter. And sphincter hypertrophy, both of which lead to high resting pressure in the anal canal, predisposing to fissures.
In addition, sphincter hypertrophy also causes increased demand of oxygen to the sphincter muscle, leading to ischemia and impaired healing of the fissures. Moreover, blood flow is further reduced by spasms of the internal sphincter during defecation.
Most prominent symptom of anal fissures is pain during defecation, which may last for hours following defection. Due to the intense pain, patients become reluctant to pass stools, which causes more hardening of stools and worsening of the condition.
Pain is associated with bright red blood in the toilet paper or stools. Sometimes, few drops of blood may fall into the toilet bowl.
Diagnosis of anal fissures is clinical.
The main goals of treatment are to relieve constipation, and to reduce the intense pain associated with fissures.
First line treatment options are, fiber supplementation, stool softeners, and laxatives as needed. In addition, sitz baths after defecation may be indicated. For pain relief, GTN applications are prescribed.
Finally, if the symptoms have not reduced after 3 to 4 weeks of medical therapy, surgery may be indicated.

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