Anal Fissure

What Is an Anal Fissure?

An anal fissure is a superficial or deep tear in the first 1-2 cm portion of the anal canal from the anus, at the skin-mucosa junction line. It usually settles in the posterior midline (back portion) of the anal canal.

There are two main types:

• Acute anal fissure: Less than 6-8 weeks duration, superficial tear
• Chronic anal fissure: Lasting more than 6-8 weeks, deep and non-healing tear

In chronic fissures, typically three findings are observed:

• Deep tear and fibrous tissue
• Hypertrophic papilla on the upper part (skin tag)
• Sentinel pile on the lower part

Causes of Anal Fissure

Mechanical Causes

• Hard stool and constipation (most common cause)
• Severe diarrhea
• Trauma during childbirth
• Anal intercourse
• Trauma to the anus area
• Foreign body insertion

Medical Conditions

• Inflammatory bowel diseases (Crohn's disease)
• Sexually transmitted infections (syphilis, herpes)
• Tuberculosis
• HIV infection
• Cancer (rare)

Other Factors

• Excessive tension of the anal sphincter muscle (hypertonia)
• Insufficient blood circulation in the area
• Postpartum period

Symptoms of Anal Fissure

Typical Symptoms

• Severe, cutting pain during defecation
• Pain lasting hours after defecation
• Description of pain like glass shards or a razor blade
• Bright red blood on stool or toilet paper
• Itching around the anus
• A small flesh-like protrusion around the anus (sentinel pile)

Accompanying Complaints

• Constipation (delaying toilet due to pain)
• Tension and discomfort around the anus
• Fear of going to the toilet
• Sleep disturbances (nighttime pain attacks)
• Significant decrease in quality of life

Differences Between Acute and Chronic Fissure

Acute Fissure

• Sudden onset of severe pain
• Fresh, bleeding tear
• Good response to conservative treatment
• Heals within 6-8 weeks

Chronic Fissure

• Ongoing and recurrent pain
• Scarred, deep tear
• Resistant to conservative treatment
• May require surgery

Risk Factors

Factors that facilitate the development of anal fissure:

• Chronic constipation (most important factor)
• Low-fiber diet
• Inadequate fluid intake
• Sedentary lifestyle
• Excessive tension of the anal sphincter muscle
• Women who have given birth
• Mobile and prolonged sitting
• Inflammatory bowel diseases
• Presence of hemorrhoids
• Anal intercourse
• Some medications (opioids, constipation-inducing drugs)

Diagnostic Methods

Physical Examination

The foundation of diagnosis. Careful examination is usually sufficient:

• Visual examination: Observation of the fissure by gently opening the area around the anus
• Presence of a flesh-like protrusion around the anus (sentinel pile)
• Evaluation of warmth and tenderness in the area

Digital Rectal Examination

• Often difficult or impossible due to pain
• May be performed under local anesthesia
• Sphincter muscle tension is evaluated

Anoscopy

• Direct imaging of the anal canal
• May be postponed in acute period due to pain
• Used in follow-up after treatment

Additional Examinations

May be required in atypical or chronic cases:

• Colonoscopy (Crohn's disease suspicion)
• Sexually transmitted disease tests
• Biopsy (cancer suspicion, rare)

Atypical Fissure Locations

Anal fissure normally settles in the posterior midline. The presence of fissures in different locations may indicate an underlying disease:

• Lateral location → Inflammatory bowel disease
• Multiple fissures → Crohn's disease, HIV
• Anterior location → Postpartum, in women

Anal Fissure Treatment

The aim of treatment is to reduce pain, facilitate defecation, and ensure healing of the wound. The vast majority of acute fissures heal with conservative methods.

Conservative Treatment (First Step)

Provides 90% success in acute fissures.

Lifestyle and Nutrition

• Fiber-rich food consumption (vegetables, fruits, whole grains)
• Drinking 2-2.5 liters of water per day
• Regular exercise
• Regulation of toilet habits
• Avoiding prolonged sitting on the toilet

Warm Sitz Baths

• 2-3 times a day, 10-15 minutes
• Warm (not hot) water is used
• Relaxes the sphincter muscle
• Increases blood circulation
• Relieves pain

Stool Softeners

• Fiber supplements such as lactulose, psyllium
• Mineral oils
• Regular defecation is ensured
• Reduces pressure on the wound

Topical Medications (Creams and Ointments)

Glyceryl Trinitrate (GTN) Ointment

• Relaxes the sphincter muscle
• Increases regional blood circulation
• Used for 6-8 weeks
• Side effect: Headache (20-30%)
• Success rate 60-70%

Calcium Channel Blockers (Diltiazem, Nifedipine)

• Relaxes the sphincter muscle
• Similar effectiveness to GTN
• Less headache side effect
• Success rate 65-75%

Local Anesthetic Creams

• Lidocaine ointments
• Provides temporary pain control
• Limited therapeutic effect

Botulinum Toxin (Botox) Injection

Preferred in cases unresponsive to conservative treatment:

• Injection into the sphincter muscle
• The muscle relaxes temporarily (3-4 months)
• Performed under local anesthesia
• Fast and effective method
• Success rate 60-80%
• Low incontinence risk
• Repeatable

Surgical Treatment

Applied in chronic fissures unresponsive to conservative treatment.

Lateral Internal Sphincterotomy (LIS)

The gold standard surgical method:

• Partial cutting of the internal sphincter muscle on the lateral side of the anal canal
• Reduces sphincter tension
• Increases wound circulation
• High success rate (95%)
• Fast recovery
• Can be performed under local or spinal anesthesia
• Risk: Permanent gas incontinence (5-10%)

Anal Dilatation

• Controlled widening of the sphincter muscle
• Was commonly used in the past
• High incontinence risk
• Not preferred today

Fissurectomy

• Removal of the fissure and surrounding scar tissue
• The sphincter muscle is preserved
• Preferred in cases accompanied by inflammatory bowel disease
• Success is increased with combined methods

Advancement (V-Y) Flap Technique

• The wound is closed with a skin flap while preserving the sphincter muscle
• In complex or recurrent cases
• In postpartum fissures
• No incontinence risk

Combined Treatments

In some cases, different methods are applied together:

• Fissurectomy + Botox
• LIS + Local flap
• Conservative + Botox

Post-Treatment Process

First Days

• Continuing warm sitz baths
• Fiber support and plenty of fluids
• Use of topical creams
• Taking painkillers when necessary
• Attention to wound cleanliness

First Week

• Significant relief in conservative treatment
• Return to light activities after surgery
• Natural position when going to the toilet

First Month

• Full recovery after surgery 3-6 weeks
• Sports after 3-4 weeks
• Sexual life after 2-3 weeks
• Continuation of lifestyle changes

Possible Complications

Conservative Treatment

• Failure (10-30%, chronicity)
• Headache due to topical medications
• Skin irritation
• Allergic reactions

Surgical Complications

• Bleeding (rare)
• Wound infection
• Gas or stool incontinence (5-15%)
• Chronic pain
• Recurrence of fissure (5-10%)
• Anal stenosis (rare)

Prevention of Anal Fissure

Nutrition

• Abundant consumption of fiber-rich foods:
  • Whole grains
  • Fruits and vegetables
  • Legumes
  • Wholemeal bread
• Plenty of water consumption (2-2.5 liters per day)
• Reducing spicy and hot foods
• Regular and balanced meals

Toilet Habits

• Not delaying toilet needs
• Not sitting too long on the toilet (less than 5 minutes)
• Avoiding excessive straining
• Not getting distracted with phone, newspaper, etc.

Lifestyle

• Regular exercise (walking, swimming)
• Healthy weight control
• Stress management
• Avoiding prolonged sitting
• Smoking cessation

Hygiene

• Gentle cleaning of the anal area
• Avoiding hard toilet paper
• Preferring soft wet wipes
• Avoiding excessive washing