Anal fissure can be a pain in the butt!

The Goddess in Catalonia Square, Barcelona, Spain. (Dr. Noorali Bharwani)
The Goddess in Catalonia Square, Barcelona, Spain. (Dr. Noorali Bharwani)

Anal fissure is a painful and annoying problem. I have written about this twice in the last few years (2004 and 2014). These columns are posted on my website. I thought it is about time to review the subject again.

An anal fissure is a tear in the lining of the anus (anal mucosa). Most often it is caused by injury sustained during passage of a large hard bowel movement. Pain in the butt may be mild to severe. It may be acute or chronic (recurrent). Sometimes pain is associated with bleeding.

Other causes of anal fissure are: chronic diarrhea, anal intercourse and childbirth. There are other less common causes of anal fissures. These are: Crohn’s disease or another inflammatory bowel disease, anal cancer, HIV, tuberculosis and syphilis.

Fissures of less than six to eight weeks’ duration are acute, and those persisting longer are chronic. Chronic fissures are associated with skin tags at the edge of anal margin.

Anal fissures are very common in young infants but can affect people of any age. Most anal fissures get better with simple treatments, such as increased fiber intake or sitz baths. Some people with anal fissures may need medication or, occasionally, surgery.

Ninety per cent of fissures are located in the upper or lower anal midline. Fissures that are not in the midline (atypical locations) may be associated with cancer, Crohn’s disease, HIV, syphilis or tuberculosis.

Good news is most fissures will resolve with medical management.

Studies have shown up to 87 per cent of acute fissures treated with a high-fibre diet or stool-bulking agents (psyllium) and sitz baths twice daily will resolve the problem. Patients with chronic fissures require the addition of topical smooth muscle relaxants (two per cent diltiazem). Medical management will heal chronic fissures in 65 to 95 per cent of patients.

There is strong evidence that topical calcium channel blockers (diltiazem) have fewer adverse effects and similar fissure healing rates when compared with topical nitrates (0.2 per cent nitroglycerin ointment). More patients complain about headache with nitrates than diltiazem.

Diltiazem works by relaxing the muscle around the anus (the anal sphincter). This reduces pressure and increases blood flow to the area to allow healing to occur. About 30 per cent of patients will have recurrence of fissure after medical therapy.

Certain fissures may heal quite quickly, whereas others can take several months to heal. Patients whose fissures do not resolve after six to eight weeks of medical management should be considered for botulinum toxin injection or surgical management.

Even with classic symptoms and a midline fissure, patients with new rectal bleeding who are older than 50-years or have any suspicious symptoms (weight loss, change in bowel habits, unexplained anemia or family history of colon cancer) require colonoscopy to rule out a more proximal cause of bleeding.

Some individuals will need surgery. Most effective surgical procedure is called partial lateral internal sphincterotomy (division of anal sphincter). Most people will notice that the pain from an anal fissure goes away within a few days after the surgery. In my experience most people find immediate relief after surgery. Rarely a small number of people have problems controlling stools when they pass gas. This usually gets better with time.

Surgical treatment is offered to those who do not respond to medical treatment or who have frequent recurrences. Rate of recurrence of fissure after surgery is small, about three per cent in one study.

How can I prevent getting a fissure in the future?

The quality and quantity of stool passing through the anal sphincter is important. It should be soft, bulky and dry. Chew your food well. Eat lots of fruits and vegetables. Use psyllium daily. And relax when you have a bowel movement.

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Do Not Confuse Anal Fissure (Pain in the Butt) with Anal Cancer

A clinical picture showing a case of anal fissure. (Dr. Noorali Bharwani)
A clinical picture showing a case of anal fissure. (Dr. Noorali Bharwani)

There are various kinds of anal and rectal problems. Some are painful and some are not. Some are serious and others are a mere nuisance – if that is the right word. But all of them are a real pain in the butt – so to speak.

Anal fissure can be really painful. On the other hand, cancer of the rectum may be painless. The only way to find the real diagnosis is to see a doctor to get a good rectal examination consisting of inspection, finger examination and some sort of a scope test depending on your age and history. The important thing is to make sure we are not dealing with cancer or Crohn’s disease.

I have written about this subject before. You can check it out on my website. Today, I want to focus on the management of anal fissure. I want to emphasize that management of painful anal fissure requires a more aggressive approach than managing a “hemorrhoid itch.”

Five steps to manage acute or chronic anal fissure:

1. Make your stool well formed and bulky with a diet high in fiber. Take psyllium (Metamucil) two to four capsules per day with lots of water. This relaxes the anal muscles, helping the healing process.

2. Sit in a hot bath for 20 minutes twice a day for several days until the pain goes away. This really helps the healing process by relaxing the anal sphincter.

3. Minimize the intake of constipating painkillers.

4. Use two per cent diltiazam or nifedipine ointment inside and outside of anal canal twice a day. You need a prescription for this. This medication is associated with healing of chronic anal fissures in 65 to 95 per cent of patients.

5. What can be done if the fissure does not heal after three to six weeks? Rule out other illness of the colon and rectum. Your colon and rectal specialist will advise you on that. Surgical options for treating anal fissure include Botulinum toxin (Botox) injection into the anal sphincter and surgical division of a portion of the internal anal sphincter (partial lateral internal sphincterotomy).  Both of these are performed typically as outpatient procedures with good results and minimal of complications.

During my surgical training, I was taught if a doctor does not put a finger in the patient’s rectum then he may end up putting his foot in it. If you have rectal and anal symptoms then get that area examined well. You do not want anybody’s foot in it!

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Anal Itch Can Drive you Embarrassingly Crazy

Anal itch or some people may call it rectal itch is also known as pruritus ani (proo-rí-tus a-ní). It is a fairly common condition. Most people think that the reason they cannot stop scratching their butt is because of hemorrhoids. But hold your breath or your gas (so to speak), there is more to itchy butt than you think.

There are several benign conditions which can cause anal itch. Conditions to keep in mind are hemorrhoids, fecal incontinence of varying magnitude and severity, anal fistulae and condyloma (anal warts). Anal fissures are very painful but may be a cause of anal itch in chronic cases.

Other benign conditions which can cause anal itch are contact dermatitis, fungal infections, diabetes, pinworm infections, psoriasis and seborrhea (dermatitis of the oil glands).

A common cause of anal itch is excessive moisture in the area. Moisture may be due to perspiration or a small amount of residual stool around the anus. Itching can be made worse by scratching, vigorous cleansing of the area or overuse of topical treatments. Use of dry rough toilet paper can be another source of itch. You might as well use sand paper (just kidding!).

In some individuals, itching can be caused by eating certain foods, smoking and drinking alcoholic beverages, especially beer and wine. Examples of food items associated with anal itch are coffee, tea, carbonated beverages, milk products, tomatoes and tomato products such as Ketchup, cheese, chocolate and nuts. That is hell of a list. If you are over indulging in any of these items then you may know where the problem lies.

Cleanliness is next to godliness, so once a person develops the itch there is a tendency to wash the area vigorously and frequently with soap and a washcloth. This almost always makes the problem worse by damaging the skin and washing away protective natural oils. God will not be happy with that.

What about cancer? Yes, we have to keep that condition in mind. You may recall, Farrah Fawcett, one of the Charlie’s Angels, was diagnosed with anal cancer in 2006. She died in June of this year.

Be aware of the condition but do not panic. Anal cancer is fairly uncommon. It accounts for about one to two per cent of gastrointestinal cancers. About 4,000 new cases of anal cancer are diagnosed each year in the U.S.A., about half in women.  Approximately 600 people will die of the disease each year.

Anal cancer is commonly associated with the human papilloma virus (HPV). This virus causes warts in and around the anus and on the cervix in women.  It is associated with an increased risk of cervical cancer in women.

If you have anal itch, then talk to your doctor and get the area thoroughly checked. This includes a good history and a physical. Visual inspection of the anal area, a digital rectal examination and a scope test should be part of the examination. A biopsy of the area and stool test may be necessary. Once this is complete then the doctor (or a specialist) should be able to give you a diagnosis of the problem.

Treatment depends on the cause of the problem. Besides that there are things you can do. Try dietary modifications. Avoid moisture in the anal area by using cotton balls, gauze or corn starch powder. Avoid further injury to the area by avoiding soap of any kind and do not scrub the area. For hygiene, it is best to rinse with warm water and pat the area dry. Use wet toilet paper, baby wipes or a wet washcloth to blot the area clean. Never rub.

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Anal Fistula Can Be Difficult To Treat

This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)
This model illustrates various pathology of the rectum. (iStockphoto/Thinkstock)

Last week, I was in San Francisco, California to attend the Clinical Congress (convention) organized by the American College of Surgeons. It is one of the largest surgical conventions in the world. The convention lasts five days (Sunday to Thursday). By Wednesday afternoon, total registration for the convention was 14,397: 8916 were physicians and the rest were exhibitors, guests, spouses and convention personnel.

Not everybody is in one auditorium or room at the same time. Each room has its own list of speakers and topics for discussion. So you head yourself to a room which offers discussion on a topic which interests you the most. The conference was held at the Moscone Convention Center. It is the largest convention and exhibition complex in

San Francisco. It comprises three main halls with total of 84,000 square meters of space (900,000 square feet).

One of the symposiums I attended was on surgical problems of anus and rectum: cancer, fistula, fissure and hemorrhoids. Today, I will review the subject of anal fistula (fistula-in-ano).

What is a fistula? A fistula is an abnormal tunnel connecting two body cavities (such as the rectum and the vagina) or a body cavity to the skin (like the rectum to the outside of the body). Fistulas are usually the result of infection, injury or surgery. With an anal fistula there is a tunnel between the anus (and/or rectum) to the skin. A peri-anal abscess has a 50 per cent risk of turning into a fistula.

Anal fistulas do not generally harm the body. They are mainly a nuisance with some pain or discomfort and irritating intermittent discharge of blood, pus or stool. They can form recurrent abscesses which may require drainage under local anaesthetic.

Most of the time the diagnosis of fistula is made on the basis of classical clinical history and physical findings. Examination of the rectum may show an opening of the fistula onto the skin, the area may be painful on examination, there may be redness, a discharge may be seen or it may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula.

Treatment of the fistula depends on the presentation of the problem. If there is active infection or abscess then it needs to be treated with drainage of the pus and antibiotics. Once the infection is cleared the fistula can be treated surgically. If it is difficult to get rid of the infection then long term drainage can be established by inserting a seton – a length of suture material or thin rubber tubing is looped through the fistula which keeps it open and allows pus to drain out.

The treatment aim should be to prevent recurrence of fistula. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.

There are several options. Doing nothing – a drainage seton can be left in place long-term to prevent problems. But this does not cure the fistula. Fistula can be layed open under anaesthetic. Once the fistula has been layed open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. Depending on the depth of the fistula, this option may affect continence if the fistula involves sphincter muscles. Most fistulas are superficial and can be layed open under local anaesthetic without much problem with continence.

Other methods of treating fistula are: using fibrin glue injection, using fistula plug, creating a flap to cover the internal fistula opening and using a seton to cut through the deep fistulous tract. Each method has advantages and disadvantages.

Some fistulas are very difficult to treat if they are caused by inflammatory bowel disease like Crohn’s disease. Any patient with recurrent fistula should be investigated for inflammatory bowel disease. Otherwise, most fistulas can be cured with patience and perseverance.

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