Anal Fissures

Dr Calvin Ong

MBBS M.MED (SURGERY) MRCS FRCS

What is an Anal Fissure?

An anal fissure is a small tear or cut in the lining of the anus that causes pain and discomfort during bowel movements. It typically occurs when passing hard or large stools, which stretch the anal canal. They are often associated with conditions like constipation or chronic diarrhoea, which increase pressure on the anal canal. The fissure may heal on its own within a few weeks, but in some cases, medical intervention is required for persistent or recurring issues.

Causes of Anal Fissures

Anal fissures typically develop due to various factors that put strain on the anal tissue. The common causes of anal fissures include:

Hard stools

Passing hard or large stools stretches the anal canal beyond its normal capacity, which can tear the delicate tissue lining the anus.

Chronic constipation

Repeated strain due to constipation exerts excessive pressure on the anal muscles, which can lead to small tears in the lining.

Chronic diarrhoea

Frequent bowel movements with diarrhoea irritate the sensitive anal tissue, increasing the likelihood of developing fissures.

Childbirth

During childbirth, the intense strain and pressure applied to the perineal area may cause small tears in the anus.

Inflammatory conditions

Conditions like Crohn’s disease cause inflammation of the digestive tract, weakening the anal lining and making it more prone to tearing.

Trauma

Trauma to the anus can damage the lining, making it more vulnerable to fissures.

Diagnosis of Anal Fissures

Diagnosing an anal fissure involves a physical examination and a thorough review of the patient’s medical history.

Physical examination

An anal fissure is typically diagnosed through a physical examination, where the surgeon visually inspects the anal area for signs of tears and skin tags. This helps determine whether the fissure is acute (recent) or chronic (long-standing), which influences treatment options. The surgeon also assesses the size, location (posterior or anterior), and severity of the fissure, which are important factors in planning treatment.

Medical History Review

A thorough review of the patient’s medical history, including bowel habits, is necessary. The surgeon will ask about pain during bowel movements, the presence of blood in the stool, and any history of chronic constipation or diarrhoea. These factors help confirm if the symptoms are consistent with an anal fissure or if further investigation is needed to rule out other conditions, such as haemorrhoids or Crohn’s disease.

Anoscopy

In some cases, an anoscope (a small, lighted instrument) is used to inspect the anal canal in greater detail. This allows the surgeon to locate internal fissures that may not be visible during the external examination and assess their severity. Anoscopy is especially useful for identifying fissures higher in the anal canal or to rule out other conditions that might be causing similar symptoms.

Treatment Options for Anal Fissures

Non-Surgical Treatment

Non-surgical treatments are the first line of therapy for anal fissures, aiming to relieve symptoms and promote natural healing. They include:

Stool Softeners or Laxatives

These medications keep stools soft and easier to pass, reducing strain and pressure on the anal canal during bowel movements. By preventing constipation, they allow the fissure to heal more effectively without further trauma.

Topical Treatments

Ointments such as nitroglycerin or calcium channel blockers help relax the anal sphincter muscles, reducing spasms and associated pain. These treatments also increase blood flow to the area, promoting faster healing of the fissure.

Botulinum Toxin (Botox) Injections

Botox can be injected into the anal sphincter to temporarily paralyse the muscle, reducing spasms and allowing the fissure to heal by minimising strain during bowel movements. This treatment is often used when topical treatments have not been effective.

Surgical Treatment

Surgical treatments are recommended when non-surgical treatments fail to relieve symptoms. Common surgical options include:

Lateral Internal Sphincterotomy

This procedure involves making a small incision in the internal anal sphincter muscle to reduce muscle tension. By relaxing the sphincter, pressure on the fissure is relieved, allowing it to heal. It provides long-term relief from pain and reduces the chance of recurrence.

Fissurectomy

A fissurectomy involves the removal of damaged or scarred tissue surrounding the fissure. It is typically used when scar tissue is preventing the fissure from healing. By removing the scarred tissue, the body can generate healthy tissue, speeding up the healing process.

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Prevention Tips for Recurring Anal Fissures

Preventing the recurrence of anal fissures involves making dietary and lifestyle changes. A high-fibre diet and adequate hydration help soften stools, reducing strain during bowel movements. Maintaining healthy bathroom habits, such as avoiding excessive straining, is also necessary. Regular physical activity aids in digestion and helps prevent constipation. Those who are prone to chronic constipation may benefit from stool softeners.

Adopting these strategies can lower the risk of future fissures returning and support overall digestive health.

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Dr Calvin Ong Jianming

MBBS (S’pore)|

M.Med (Surgery)|

MRCS (Ireland)|

FRCS (Edin)|

王健名医生

Dr. Calvin Ong is a Senior Consultant with more than 15 years of surgical experience. He specializes in colorectal and general surgery, performing minimally invasive as well as advanced robotic surgeries for benign and malignant colorectal conditions, including inflammatory bowel disease, pelvic floor disorders, colorectal cancer, and hernia repair. He is dedicated to providing high-quality, personalised care for his patients.

Dr. Ong graduated with a Bachelor’s degree in medicine and surgery from the National University of Singapore in 2008 and completed his Masters of Medicine (Surgery) at the same institute. He finished his advanced specialist training in 2016 and became a fellow of the Royal College of Surgeons of Edinburgh.

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    Frequently Asked Questions

    How long does it take for an anal fissure to heal?

    Acute anal fissures often heal within a few weeks with non-surgical treatments, such as dietary changes and topical creams. Chronic fissures may require more time or surgical intervention to heal completely.

    Can children develop anal fissures?

    Yes, children can develop anal fissures, often due to constipation. Maintaining a high-fibre diet and ensuring proper hydration can help reduce the risk in younger individuals.

    Can anal fissures be a sign of a more serious condition?

    Most anal fissures are caused by trauma or constipation. However, in some cases, they may be linked to underlying conditions such as Crohn’s disease or other inflammatory disorders. If a fissure persists or recurs frequently, further medical evaluation may be necessary to rule out other conditions.

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