An anal fissure is a non-healing chronic tear in the lining of the anal canal that usually extends to the edge of the anus. An anal fissure is usually located within the anal canal and as such, is not palpable with the finger.
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The two commonest symptoms are that of severe anal pain and fresh blood when passing motion.
The pain and blood occur when the stools abrade and stretch out the anal fissure during the passage of the motion.
Some patients may feel a small skin tag (an extra bit of skin) at the edge of the anus. This is known as a Sentinel Skin Tag and usually occurs together with an anal fissure. The skin tag itself is not tender. The skin tag can be removed during the surgery for the anal fissure.
Most individuals with an Anal Fissure usually report an episode of passing hard stools that preceded the development of symptoms. It is postulated that the passage of hard stools may have caused an acute tear that subsequently develops into a chronic non-healing anal fissure.
The development of anal fissures usually occurs in a subset of susceptible patients, namely those with high resting anal muscle tone. This is however not a conscious nor voluntary action on the part of the individual. As a result of the high resting anal pressure, the anus will get overly stretched out during the passing of motion and hence leading to an acute tear. Due to a decreased blood supply from the high resting anal pressure, the tear does not heal and ends up as a chronic non-healing tear.
The treatment can be divided into pharmacological (medication) and surgical options.
Patients will usually be treated with medications as a first option. Surgery is usually reserved for patients who have failed medical treatment or who have recurrent anal fissures.
There are two common medications used to treat anal fissures. They both have the same medicinal effect of relaxing the resting tone of the anal muscle and hence allowing the anal fissure to have a chance to heal. The success rate of treatment with medication is more than 60%, though recurrences are also fairly common after a period of time following completion of treatment.
Surgery is reserved as a second-line treatment for patients who have failed or are unable to tolerate the side effects of the medications. In addition, surgery is also considered for recurrent anal fissures after completion of medications. The surgical option is known as Lateral Sphincterotomy, and it involves cutting/dividing part of the anal sphincter muscle so that the muscle ring is disrupted, and the resting anal tone is decreased. The skin tag can also be removed during the same sitting. There is a small chance of some flatus/gas and occasional liquid stool leakage from the anus after this surgery.