Anal fissures are small tears in the lining of the anus that can cause significant discomfort and pain, especially during bowel movements. They can occur for various reasons, including chronic constipation, straining, or passing hard stools. While some fissures heal on their own with conservative treatments, others may persist, requiring medical attention. If left untreated, chronic fissures can lead to long-term pain and complications.
Early treatment of anal fissures is essential to prevent the condition from becoming chronic. In this guide, we will cover the symptoms, causes, and most effective treatment options available at Heritage Surgical Group.
Symptoms: Identifying Anal Fissures
- Sharp pain during bowel movements: Often described as knife-like pain, or like a cut.
- Rectal bleeding: Small amounts of blood, typically seen on toilet paper.
- Visible tear or skin tag: External fissures can be seen as small cuts, often accompanied by a skin tag near the anus. While the tag may be seen as the source of the pain, in fact it is not. The tag pulls on the fissure, and this is what causes the pain.
- Internal Fissures: Located inside the anal canal, these are not visible but can cause significant pain.
- External Fissures: These are located near the anal opening and are often visible.
- Itching and mild discomfort around the anus.
- Tenderness or sharp pain during or after bowel movements.
Causes and Risk Factors
Anal fissures often result from:
- Straining during bowel movements.
- Passing large or hard stools.
- Chronic diarrhea or constipation.
- Spasm of the anal sphincters, which limit blood flow to the inner lining of the anal canal.
In some cases, especially when they are acute (recent), fissures can heal with proper care. These measures include treating constipation, and warm water (sitz) baths. However, chronic fissures, which have persisted for a longer time, may require more aggressive treatment.
While it is possible to manage mild cases of anal fissures at home, medical treatment is recommended to avoid complications such as chronic pain, infection, or the development of skin tags.
Home Remedies for Anal Fissure
For patients with acute anal fissures, which have been present for a short period (usually less than six weeks), non-surgical treatments can be highly effective. These treatments aim to relax the anal sphincter, promote healing, and prevent further irritation.
- Topical ointments: These medications will RELAX the anal sphincter in order to improve blood flow, which helps the fissure to heal. Eighty percent of fissures will heal this way, and therefore this is first line therapy before any surgical intervention.
- Stool softeners: These help prevent further injury by easing bowel movements.
- Warm sitz baths: These can soothe the affected area and improve blood flow.
Surgical Treatments for Chronic Anal Fissures
For patients with chronic anal fissures that do not respond to conservative treatments, surgical intervention may be necessary. At Heritage Surgical Group, we provide several highly effective surgical treatments, tailored to the needs of each patient. These surgical options focus on relieving the underlying cause—muscle tension in the anal sphincter—allowing the fissure to heal and preventing recurrence.
Lateral Internal Sphincterotomy (LIS)
Lateral Internal Sphincterotomy (LIS) is the most commonly performed surgical procedure for chronic anal fissures. It involves cutting a small portion of the internal anal sphincter muscle to relieve tension, reduce pain, and promote healing.
Chronic fissures often result from persistent spasms of the internal anal sphincter, which impede the healing process. By partially cutting this muscle, sphincter pressure is reduced, allowing blood flow to improve and the fissure to heal.
The procedure is typically performed under local anesthesia with sedation or general anesthesia.
- A small incision is made in the internal sphincter muscle, which is responsible for maintaining the anal tone. The cut reduces muscle spasms, easing the pain and allowing the fissure to heal.
- The surgery is minimally invasive and typically takes about 15 to 30 minutes. It is done on an outpatient basis, allowing patients to return home the same day.
Immediate Pain Relief: Many patients experience relief from pain almost immediately after the procedure.
Healing Time: Full healing typically occurs within two to six weeks. During this time, patients may be advised to take stool softeners to avoid straining during bowel movements.
Post-Operative Care: Patients should follow a high-fiber diet and maintain good hygiene to prevent infection. Normal activities can typically be resumed within a few days, although heavy lifting and strenuous activities should be avoided for a few weeks.
- High Success Rate: LIS is considered the most effective treatment for chronic anal fissures, with a success rate of over 90%.
- Long-Term Relief: It offers permanent relief for patients who have not responded to conservative treatments.
- Minimally Invasive: The procedure is quick, with minimal recovery time, allowing patients to return to their normal activities relatively soon after surgery.
While the procedure is generally safe, a small percentage of patients may experience minor incontinence (such as difficulty controlling gas or mild stool leakage). However, these side effects are usually temporary and may improve over time. At Heritage Surgical Group, we understand these risks, and therefore work with you to maximize success, and minimize risk. Surgery is typically left as a last resort.
Botulinum toxin (commonly known as Botox) can be injected into the internal anal sphincter to temporarily relax the muscle, reduce spasms, and promote healing of the fissure.
Botox works by blocking nerve signals that cause muscle contractions. By paralyzing the internal sphincter muscle, the pressure is reduced, allowing the fissure to heal without the need for a permanent surgical incision.
This is a non-surgical procedure typically performed in an outpatient setting with local anesthesia.
Botox is injected directly into the internal sphincter muscle. The effects last for about three to four months, during which time the fissure usually heals.
Patients can resume normal activities the same day, with little to no downtime.
The fissure typically heals within two to three months while the muscle remains relaxed.
- Non-Invasive: Botox injections offer a less invasive alternative to surgery, making them ideal for patients who are not candidates for or wish to avoid surgery.
- Quick Recovery: There is minimal downtime, allowing patients to return to their daily routines almost immediately.
- Temporary Nature: If needed, the procedure can be repeated, or other treatment options can be pursued if the fissure does not fully heal.
The primary risk associated with Botox is that its effects are temporary. Some patients may experience recurrence of the fissure once the Botox wears off, in which case a more permanent solution, such as LIS, may be necessary. While the success rate with botox is not optimal, the benefit is that it does not carry the same long term risk of incontinence as Sphincterotomy.
At Heritage Surgical Group, our expert surgeons work with each patient to determine the most appropriate surgical treatment based on the severity of the fissure and the patient’s overall health. Our goal is to provide effective, minimally invasive treatments that offer long-term relief from the pain and discomfort of chronic anal fissures.