An anal fissure is a tear in the sensitive lining of the anal canal. Patients with anal fissures typically present with painful rectal bleeding and / or pain during bowel opening and for several hours after the bowel motion. Unlike internal haemorrhoids where the bleeding is often painless, anal fissure disease is clearly a painful condition. Some patients will also describe the pain as a burning or spasm.
The usual cause of anal fissures is the passage of a hard stool after a period of constipation. The hard stool generates the tear and the anal canal muscles go into painful and prolonged spasm which not only causes the troublesome symptoms but prevents healing.
The management of anal fissures is to ensure, through history and examination, that there are no other conditions present like complicated haemorrhoids, anal infections or more serious conditions like colorectal cancer and inflammatory bowel disease. These conditions may require colonoscopy to diagnose or exclude their presence. Initial treatment is then to apply Rectogesic cream to the anus on a gloved finger. This treatment is combined with laxatives and stool bulkers to ensure that constipation is avoided.
Rectogesic can cause headache and if it not tolerated then Diltiazem cream, from a compounding chemist, maybe helpful. For those who continue to have severe symptoms, treatment may be escalated to Botulinum toxin injection or Botox. This medical therapy is injected directly into the anal muscle, usually under anaesthetic. It provides relief of anal canal spasm in 2/3 of patients with most of the patients healing the anal fissure in the 3 months that the Botox is in effect.
Occasionally, the Botox is not effective and a muscle incision or lateral internal anal sphincterotomy is required. While this is a very effective treatment, it does weaken the anal muscle and possibly lead to faecal incontinence and so non-operative medical management with Rectogesic and Botox is the mainstay of successful treatment.