• 29Oct

    Anal fissure pain – what to do when defecation is painful?

    An anal fissure is a longitudinal ulcer in the epithelial lining of the anal canal (4 cm long canal just above the opening of the anus). It is one of the most common medical problems encountered in practice. Patients usually complain about pain and bleeding during the passage of stools. Pain subsides after some time and recurs again during next time when stools are passed. The fissure pain can be acute or chronic. The acute variation usually can be healed in 4 to 6 weeks. The chronic fissure continues to produce symptoms beyond this period. Prone patients also have skin tags at the lower end of the fissure. They are associated with constipation but may also occur due to repeated trauma or diarrhea. These patients may also complain about itching around the anus and some watery discharge.

    Toilet sign

    Toilet sign

    Basic facts about anal fissure

    The fissure is usually located in the midline posteriorly (behind) or anteriorly (front). Anterior fissure is more common in females and is related to trauma of vaginal delivery of child. Atypical fissures can be located anywhere and are associated with other diseases like Crohn’s disease, tuberculosis, cancer, human immunodeficiency virus infection and syphilis. Biopsy is done to confirm the diagnosis in chronic cases or when the fissure is located in a lateral position.

    Anal fissure is a common disorder that is effectively treated and prevented with conservative measures in its acute form. Chronic fissures usually require medical therapy. Treatment is required for the relief of pain and bleeding. There are basically two methods of treatment. They are medical and surgical. The medical method consists of local applications and injections.

    Medical treatment of anal fissure pain

    The conservative treatment is usually the first approach. It involves the following methods:

    • Stool softeners or lubricant laxatives like liquid paraffin and lactulose. It is especially effective in patients with acute fissure. They help in easy passage of hard stools through the anus
    • Bulk laxative like isabghol is added in chronic cases. The fibre content helps in relief of chronic constipation
    • Sitz bath – warm water hip bath helps in keeping the area clean. The warmth also improves the blood flow and reduces spasm of anal sphincter to provide pain relief
    • Topical anaesthetic like 2% lignocaine jelly is applied with a nozzle locally, few minutes before the act of defecation. It provides pain relief and is symptomatically soothing
    • Nitroglycerin – topical application of 0.2% glyceryl trinitrate ointment (GTN) results in relaxation of the anal sphincter. It results in 50% to 60% healing rate. The most common side-effect is headache which may result in discontinuation of therapy
    • Calcium channel blockers – Nifedipine 0.2% to 0.5% and Diltiazem 2% used topically or taken orally result in relaxation of the anal sphincter. It reduces pain and heals the fissure
    • Botulinum toxin type A – this is a neuroparalytic protein produced by a group of bacteria called Clostridium botulinum. On local injection, it induces a local paralysis which lasts for 2 to 4 months. This results in healing of the fissure. The popularity of botulinum toxin is increasing

    Surgical treatment of anal fissure pain

    Sphincterotomy is usually done on failure of medical management. The internal sphincter of the anal canal is divided under local/regional anesthesia. It results in relaxation of the sphincter which is followed by pain relief and healing of fissure. Excessive division increases the risk of temporary or permanent incontinence but inadequate division increases the risk of persistence or recurrence.

    Pneumatic balloon dilatation of the anal internal sphincter has also been reported. This is done using a 40-mm balloon which is inflated to 1.4 atmospheric pressure for 5 minutes. The mechanism of healing is the same as above. If overdone these procedures may result in incontinence.

    Anal fissure is a severely painful condition which may result in a long term pain during passage of stools and blood loss. It can be managed both medically and surgically. If you have any of these symptoms, consult it with your doctor before it becomes chronic.

    Anna L.

    It’s all about health!
    I have academic background in drugs related Chemical Technology, as well as extensive professional experience in pharma and medical companies. My main area of interest is everyday life medicine. The goal of my articles is to give people informative answers to the questions that bother them, to dispel doubts and some common misbeliefs and also to inspire everyone to keep healthy lifestyle.

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