Anal fissure is a painful wound at the skin just inside the bottom of the anal canal (anus). It is usually caused by passage of hard stools. The most common complaint of anal fissure is pain. The referred pain may be excruciating, it usually follows defecation or occurs later. Its duration may last from a couple of minutes till hours after the defecation. People with anal fissure postpone defecation due to the anticipation of pain. Patients often describe pain as razors or fragments of glasses coming out their bottom during defecation. Acute pain causes spasm (contraction) of sphincters (circular muscles around anus) and prevents healing of the fissure wound. Pain equals spasm equals fissure. Constant spasm may cause tightening of the anal canal.
Constant pain which is unrelated to defecation may be due to thrombosed hemorrhoids or inflammation (anal abscess). Superficial skin cracks (fissures) may be caused by excessive cleansing of perianal skin with toilet paper and soap. Superficial fissures can heal easily with proper hygiene. Fissures may be also seen in Crohn’s disease, syphilis, anal cancer as well as in other conditions.
Pain in recent (acute) fissures is not so severe. Acute fissures do not require surgery. They bleed more often than long-lasting (chronic) fissures. Proper skin care, creams and soft stools may heal acute fissures. Soft stools may be achieved by drinking a lot of water, a diet rich in fibers and stool softeners. After every defecation, the anus should be cleaned only with tepid water and no soap should be used. Warm (not hot) water relaxes sphincters and helps fissures to heal. On the contrary, cold water (or ice cubes) causes sphincter contraction and exacerbates pain.
Painful anal fissure requires an intervention in order to heal. This is obvious if finger examination of the anus is impossible. If the treatment with local application of ointments/creams fails within six months or if the fissure reappears, then an intervention might be considered. Any attempt to treat chronic (old) fissure requires relaxation of sphincter (perianal muscle) contraction. There are a lot of muscle relaxant creams or injections that help at the relief of spasm and at healing of fissure. If local treatments fail, laser or surgical intervention needs to be done. Laser is an innovative method that has not been widely used in Europe. Till not, there are already some positive reports but still limited in the literature. Most often a muscle relaxant procedure should be added to laser treatment. The muscle relaxant procedures have excellent results. In Europe and USA, the preferred surgical procedure currently applied for chronic anal fissure is the lateral anal sphincterotomy. During this procedure, the lower third of internal anal sphincter is dissected through a small 5 mm incision. Internal anal sphincter is of lesser significance for the contraction of anus. Sphincterotomy rarely causes a mild incontinence to gas, especially in women.