Anal Fissure

An anal fissure is a tear or crack in the lining of the anal canal (anus), which causes extreme pain during bowel movements. A fissure tends to occur when passing hard or large stools during a bowel movement.

When the skin lining the interior of the anus tears, the muscle underneath it might go into spasm. This further closes the anus, making it more uncomfortable and difficult to release your bowels, especially if you are constipated. You may also notice that you pass blood and have a painful anus after each bowel movement for a few hours.

Common causes of an anal fissure include passing large stools, constipation and straining during bowel movements, chronic diarrhoea, inflammation of the anorectal area, and childbirth.

Other triggers for an anal fissure, in addition to constipation, include inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn's disease, recurrent diarrhoea, having tight sphincter muscles, pregnancy and delivery and sexually transmitted infections, such as syphilis or herpes.

There are several warning signs that a patient might have an anal fissure. The most common symptom of an anal fissure is severe pain in the anus during passage of a stool.

• Severe pain in the anus during passage of a stool.
• Blood on the stool or toilet paper.
• A visible crack in the skin around the anus.
• A small lump on the skin near the anal fissure.

The symptoms of a fissure are very characteristic of this condition, and a careful history is essential. Examination may reveal the fissure, but this is sometimes so painful that the only way to establish the diagnosis is by examining the area under general anaesthetic (EUA).

Once the diagnosis is made, additional diagnostic tests such as anorectal physiology may also be performed to help decide on the best form of treatment.

Some fissures heal on their own, and this process can be aided by eating plenty of fruits and vegetables and staying hydrated to prevent constipation. If they do not heal on their own, surgery may be required eventually but non-surgical treatment may be tried first.

The aim of treatment is to reduce the pressure generated by the anal sphincter muscles. This can be done by using topical ointments which help relax the anal sphincter, or using a Botox injection, which can paralyse the anal sphincter muscle and aids in relaxing spasms.

Surgical intervention for an anal fissure will be required when the above measures don't work, and the patient's anal fissure doesn't heal and continues to cause pain.

The main surgical options for anal fissures include partial sphincterotomy and fissurectomy (excision of the fissure) plus anal advancement flap.

At the time of your consultation, Mr Lamah will explain in detail what these various techniques mean and how he decides which ones to use.