Hemorrhoid fissure or Anal fissures are cracks or ulcers in the skin around the rectal area. They often occur together with hemorrhoids and are association with constipation. Fissures are usually less than 5mm in length, but are extremely painful during and after bowel movements, and usually lead to constipation due to fear of moving your bowels.
Causes of Hemorrhoid Fissure
As well as leading to constipation, fissures are also caused by constipation irritating the rectal area, creating a vicious circle. They are more common if you have an inflammatory bowel condition such as Crohn’s disease. They can also affect babies and are the most common cause of blood in the stool in infants. Nitric oxide has been linked to fissures, possibly by decreasing the oxygen supply to the area and also by regulating the internal sphincter. Both haemorrhoids and fissures are common in pregnancy. Occasionally they can occur with drugs for acne such as Roaccutane®.
Symptoms of Hemorrhoid Fissure
You may experience constipation with an anal fissure, as well as severe, tearing pain during bowel motions that has been described as “passing broken glass”. After a bowel movement, you will notice expansion of the internal sphincter around the bowel, and blood on the tissue paper and muscle spasms. Fissures can also get infected because people are afraid to wash the area in case it is painful. These symptoms are likely to affect your daily life and activities.
Diagnosis of Hemorrhoid Fissure
Most fissures can be diagnosed by inspection. They look like a band of cracks around the anus. You may also need a rectal examination and anoscopy (telescope probe) with local anaesthetic to numb the area. If you have a fissure and your doctor is worried it may be due to Crohn’s disease or bowel cancer, you will need a more invasive test such as a colonoscopy or sigmoidoscopy.
Hemorrhoid Fissure Treatment
Stool softening agents will make your bowel movements easier and ease abdominal pain from constipation. Eating a high fiber diet and ensuring an adequate water intake will also help your bowels go smoothly.
Sitz baths (warm or hot water) are helpful to ease the pain and relax the muscles. You can use relaxation exercises on the muscles affected. Stay in the bath for at least 15 minutes a day.
Skin creams are also useful for fissures. Nitroglycerin cream is an effective muscle relaxant and may heal the fissure as well as providing pain relief, although its common side effects (around 14%) include headaches. These can be troublesome but are usually temporary. Diltiazem ointment is also a relaxant that can be used.
Botox injections, or botulinum toxin treatment, can also be used if the other creams are unsuccessful. Studies are currently underway to try to predict which patients will respond to Botox. It is thought that a subgroup of people have a condition known as anal sphincter fibrillation (ASF), which does not respond to Botox therapy. This is similar to atrial fibrillation of the heart, where the muscle contracts rapidly in an uncoordinated manner.
Surgery for Hemorrhoid Fissure
Surgery is generally more effective than medical treatment and has a lower rate of recurrence, although your fissures may heal with medical therapy alone.
Some people require a lateral internal sphincterotomy (LIS), where the internal sphincter is cut to relieve the pressure. This is usually a day procedure performed under local anaesthetic in the outpatient department. However, if you have haemorrhoids, you can have a haemorrhoidectomy at the same time. Another variation is multiple anal sphincterotomy, which makes several cuts in the rectal tissue. The main complication of this procedure is stool incontinence. You should be able to return to work within a few days and the area will usually be healed in a few months.
Another procedure is fissurectomy (removal) with reconstruction of the anus (V-Y anoplasty) from a flap of skin elsewhere in the body to cover the hole. This has been shown to be effective in clinical trials at reducing pain from 7.3/10 to 0.1/10 and constipation scores. It can usually be performed under local anaesthetic. The main side effects are urinary retention and infection (mostly temporary), with a lower rate of stool incontinence than the standard sphincterotomy procedure. However, it is not recommended by all surgeons as it may result in keyhole deformities, which leave a hole similar in shape to an old-fashioned keyhole that may leak mucus. It also has a higher recurrence rate.
A V-Y advancement flap can also be used on its own to treat fissures. In one study of 54 patients, 3 experienced wound rupture and 53 had healed wounds with no further symptoms at 6 months.
For more information about fissures, see this video from the Swedish Colon and Rectal Clinic:
Darren Pollock MD is a colorectal surgeon in the USA
(For those who aren’t squeamish, there is also a real-life video of fissure surgery at https://www.youtube.com/watch?v=AjwzlmTvT8A)
1. Abramowitz L, et al. Sphincter-sparing anal-fissure surgery: a 1-year prospective, observational, multicentre study of fissurectomy with anoplasty. Colorectal Dis. 2013 Mar;15(3):359-367.
2. Anal fissure. USMLE videos. https://www.youtube.com/watch?v=d1KBubEOfUU. Accessed 04/06/13.
3. Anal Fissurectomy. Medscape. http://emedicine.medscape.com/article/1582334-overview. Accessed 04/06/13.
4. Hsu T, et al. Surgical treatment of chronic anal fissure. Diseases of the Colon & Rectum. 1984 Jul;27(7):475-478.
5. Gorfine S, et al. Treatment of benign anal disease with topical nitroglycerin. Diseases of the Colon & Rectum. 1995 May;38(5):453-457.
Image from www.bowelandkeyholeclinic.com