{"id":2801,"date":"2020-10-22T17:26:15","date_gmt":"2020-10-22T17:26:15","guid":{"rendered":"https:\/\/procto.ca\/fissures\/"},"modified":"2022-10-07T13:53:20","modified_gmt":"2022-10-07T13:53:20","slug":"anal-fissures","status":"publish","type":"page","link":"https:\/\/procto.ca\/en\/anal-fissures\/","title":{"rendered":"Anal fissures"},"content":{"rendered":"
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Anal fissures<\/h1>
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The pathology of anal fissures<\/h1>
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BETTER UNDERSTANDING, BETTER HEALING!<\/h2>
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Anal fissures should not be confused with anal fistulas.<\/p>\n

While the first is very frequent, the second occurs only seldomly.<\/p>\n

This particular section addresses anal fissures.<\/p>\n

Anal fissures usually develop during childhood or adolescence. At this stage of life, rectums are highly elastic and can therefore accumulate a large amount of fecal matter. We\u2019ve all heard how common it is for a young child to clog the toilet when going to the bathroom.<\/p>\n

In these conditions, the emptying of the fecal bolus can cause internal sphincter hypertonia\u2014this is the etiological hypothesis. In fact, when rectal manometry is performed (measurement of the pressure of the anal canal), it is observed that the internal sphincter contracts excessively and for a prolonged period.<\/p>\n

Subsequently, the evacuation of a large bowel movement, or any other cause of sudden distension of the anal canal (such as explosive diarrhea), can lead to a recurrence of the fissure and cause a new internal sphincter spasm attack.<\/p>\n

This leads to the following symptoms of anal fissure:<\/p>\n

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  • tear in the anal canal, which causes mostly local bleeding (blood on toilet paper) and a burning sensation<\/li>\n
  • internal sphincter spasm, which is extremely painful<\/li>\n
  • a small flap of skin\u2014referred to as a skin tag\u2014can sometimes appear at the lower extremity of the tear<\/li>\n
  • a fibrous cluster\u2014referred to as a fibrous polyp\u2014can sometimes form at the lower end of the tear<\/li>\n<\/ul>\n<\/div><\/section>
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    The anal sphincter system consists of two sphincters: the large external sphincter, which is under voluntary control, and the internal sphincter, which is an autonomous muscle (i.e.: it functions automatically, thus ensuring continence even during sleep). See Anatomy of the Rectum.<\/p>\n

    Anal fissure examinations are quite straightforward:<\/p>\n

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    • On external examination, the anus is contracted, forming skin folds<\/li>\n
    • When a finger is inserted, there is an intense contraction of the internal sphincter (this contraction is graded from Level 1 to 4)<\/li>\n
    • Digital examination causes pain, which is more intense in the quadrant where the fissure is located, and increases internal sphincter pressure<\/li>\n
    • Finally, one can feel the fissure groove: it is most often located posteriorly (when facing the coccyx, it would be located at 6 o’clock). The second most frequent site is the anterior quadrant (at noon).<\/li>\n<\/ul>\n

      A fissure in the lateral quadrants should raise suspicion of another diagnosis: Crohn’s disease, ulcerative colitis, tumour or an infectious lesion.<\/p>\n<\/div><\/section>
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      Treating anal fissures<\/h1>
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      Anal fissures are a recurring issue: a large bowel movement is enough to trigger the problem.<\/p>\n

      There are two types of situations to consider:<\/p>\n

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      • Acute anal fissure, which has occurred recently<\/li>\n
      • Chronic anal fissure, which was left untreated or has been an issue for several months or even years<\/li>\n<\/ul>\n

        In the first case, treatment is fast: a few days of treatment are enough to solve the problem, provided that the treatment is started early.<\/p>\n

        In the second case, treatment can take two to eight weeks, and sometimes more, depending on how chronic the problem is.<\/p>\n<\/div><\/section>
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        Resolving constipation <\/span><\/span><\/span><\/p>

        The first step taken for treatment involves improving the quality of the stool:<\/p>\n

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        • by increasing fibre intake in the patient\u2019s diet (See the Diet section)<\/li>\n
        • by using a stool softener (docusate)<\/li>\n
        • by artificially increasing fibre intake (Metamucil, Benefibre)<\/li>\n
        • by reducing intake of foods that cause constipation, notably bananas<\/li>\n<\/ul>\n

          Laxatives should be avoided and used only in exceptional circumstances.<\/p>\n

          Mineral oil should only be used for very short periods of time since regular use greatly impairs the absorption of several vitamins (A, D, E, K).<\/p>\n

          Regarding hydration, even if we are traditionally taught to push ourselves to drink larger quantities, recent studies have shown that normal hydration (about 1.5 litres per day for adults) is more than enough and that there is no need to overdo it.<\/p>\n <\/div> <\/div> <\/div><\/section>\n

          Basic local treatments <\/span><\/span><\/span><\/p>

          There are many basic local treatments available to treat anal fissures and their painful symptoms:<\/p>\n

          In the acute phase, sitting in a sitz bath (i.e.: plastic bowl placed on the toilet or bidet) filled with moderately warm water quickly relieves pain. Sitting for three to five minutes is generally sufficient. Keep in mind that sitting in a sitz bath for extended periods of time (e.g.: 15 minutes) is not recommended. Also, in this respect, taking a traditional bath is much less effective\u2014and potentially even ineffective.<\/p>\n

          Ointments and creams available at the pharmacy. Certain preparations contain a combination of cortisone and analgesics, while others contain analgesics only (Xylocaine).<\/p>\n

          Glycerine suppositories to help evacuate stool (this is the best choice for young children).<\/p>\n

          Vaseline, which acts as a lubricant and makes stool easier to pass.<\/p>\n <\/div> <\/div> <\/div><\/section>\n

          Local pharmacological treatment <\/span><\/span><\/span><\/p>

          When these basic methods fail, more powerful products must be used:<\/p>\n