Anal Fissure
Everything you need to know about Anal Fissure - symptoms, causes, treatment options available in Australia, and when to see a doctor.
Overview
Anal fissures are small tears or cracks in the lining of the anus.
They commonly cause severe pain and bleeding during bowel movements, and can become chronic if not treated.
Key Takeaways
- Anal fissures are common, painful tears in the anus that usually heal with diet and lifestyle changes.
- Most heal within a few weeks, but some become chronic and may need medical or surgical treatment.
- See a doctor immediately if you have:
- Severe or persistent anal pain.
- Heavy bleeding.
- Fever or swelling near the anus.
- Long-term prevention involves hydration, fibre-rich diet, and avoiding straining.
How it works in your body (pathophysiology):
Anal fissures affect your body through several biological processes:
- Increased anal sphincter tone: The internal anal sphincter remains tightly contracted, reducing relaxation and making it harder for the fissure to heal.
- Reduced blood flow to the anoderm: The anoderm (thin, sensitive skin lining the anus) receives less blood supply, slowing tissue repair.
- Disruption of anoderm integrity: Trauma from hard stools, constipation, or straining leads to tears in the anoderm, perpetuating the cycle of pain and spasm.
- Pain–spasm–ischaemia cycle: Pain from the fissure increases sphincter spasm, which reduces blood flow further and delays healing.
Statistics and Prevalence in Australia
- Anal fissures are one of the most common anorectal conditions, second only to haemorrhoids.
- International estimates suggest 10–15% prevalence in the general population at some point in life, though Australian-specific data is limited.
- Both men and women are affected equally.
- They can occur at any age, but are more common in:
- Young adults (due to dietary factors, constipation, and stress)
- Postpartum women (due to childbirth-related trauma)
- Patients with chronic gastrointestinal conditions (e.g., Crohn’s disease).
- As of 2024, the AIHW and ABS have not published detailed demographic breakdowns for fissures in Australia.
Symptoms and Clinical Presentation
The hallmark symptoms of anal fissures include:
- Severe anal pain: Often sharp, tearing, or burning during and after defecation.
- Bright red rectal bleeding: Seen on toilet paper or in the stool.
- Visible fissure: A small linear tear, usually in the posterior midline of the anus.
Other clinical features:
- Spasm of the anal sphincter.
- Sentinel pile (skin tag) in chronic fissures.
- Delayed healing and recurrent tearing with bowel movements.
Red flags requiring urgent review:
- Severe, persistent pain despite treatment.
- Heavy rectal bleeding.
- Signs of systemic infection (fever, spreading redness).
- Suspicion of an underlying condition (e.g., Crohn’s disease, tuberculosis, anal cancer).
Differential diagnoses: haemorrhoids, anal fistulas, perianal abscess, inflammatory bowel disease, and malignancy.
Causes and Risk Factors
Primary causes (common and mechanical):
- Passage of hard stools (constipation).
- Chronic diarrhoea causing repeated trauma.
- Straining during bowel movements.
Risk factors:
- Chronic constipation and poor fibre intake.
- Low fluid consumption and dehydration.
- Stress and anxiety (increasing anal sphincter tone).
- Postpartum trauma (childbirth-related perineal injury).
Secondary causes (less common, systemic or disease-related):
- Crohn’s disease (inflammatory ulceration).
- Infections (e.g., tuberculosis, HIV, syphilis).
- Anal malignancy (rare but must be excluded in atypical cases).
Diagnosis
Diagnosis of anal fissures in Australia follows guidelines set by the Royal Australian College of General Practitioners (RACGP), emphasising clinical history and visual inspection [1][3]. A typical fissure appears as a tear in the posterior or anterior midline of the anus [1]. Digital rectal examination is generally avoided due to pain, and secondary fissures warrant further investigation to rule out underlying diseases [1][3]. In cases where secondary causes are suspected, additional tests such as colonoscopy or imaging studies may be recommended [1].
Treatment Options in Australia
The treatment of anal fissures in Australia is guided by a stepwise approach prioritising non-surgical therapies. First-line treatments include dietary modifications to ensure soft stools, such as increased fibre intake and adequate hydration [1][3]. Pharmacological management may involve topical nitroglycerin or calcium channel blockers to reduce sphincter tone and promote healing [1][3]. Botulinum toxin injections are another option for patients unresponsive to topical treatments [1][3]. Surgical intervention, such as lateral internal sphincterotomy, is considered when conservative measures fail [1][3]. These treatments are supported by the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, ensuring accessibility for patients [1][3].
Living with Anal Fissure
Managing anal fissures involves a combination of medical treatment and lifestyle modifications. Patients are encouraged to maintain a high-fibre diet, stay hydrated, and avoid straining during bowel movements [1]. Regular follow-up with healthcare providers is crucial to monitor healing and adjust treatment as necessary [1]. Patient education focuses on recognising symptoms, adhering to treatment plans, and implementing self-care strategies to prevent recurrence [1]. Psychosocial support may be beneficial for individuals experiencing anxiety or stress related to their condition [1].
Prevention
Preventative strategies for anal fissures focus on maintaining regular bowel habits and avoiding constipation. This includes a diet rich in fibre, adequate fluid intake, and regular physical activity to promote gastrointestinal health [1]. Patients are advised to respond promptly to the urge to defecate and avoid prolonged sitting on the toilet [1]. For those with underlying conditions, managing the primary disease can reduce the risk of fissure development [1].
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