Anal Fissure or Anal Ulcer

Basic Information

Ano-rectal disorders are common occurrences for at least 50% of the U.S. population. They affect children and adults, males and females, gay and straights alike.

Anal-rectal disorders include anal itch, hemorrhoids (both internal and external), anal fissures (both acute and chronic), anal abscesses, and fistula-in-ano. One of the common first signs of ano-rectal disorder is bleeding, sometimes just a speck on toilet paper of very bright red blood or a drop or two of blood in the bowl following bowel movement which may turn the water red even with just one or two drops. Fortunately in most cases ano-rectal problems can be successfully treated as long as they are not severe or infected. Sometimes symptoms resolve spontaneously but most often some kind of treatment is indicated to help healing anal-rectal disorders. Your health care provider will usually wish to take a gentle examination or external inspection at the very least of your rectum and will want to know a detailed history of your symptoms so that proper diagnosis can be made of the ano-rectal disorders.

Anal fissures or anal ulcers are tears in the lining of the anus. When they occur they can cause extraordinary pain. The primary cause in most cases is thought to be from a traumatic large or hard stool often accompanied by a secondary infection. Because the fissure occurs on the internal sphincter it makes it go into spasms since the sensitive lining is cut. These cuts or fissures are usually quite small and appear at the opening of the anus. Stools, especially when hard, further traumatizes the cut making the muscle spasm tighten the opening of the anus, strengthening the tear and affecting the sphincter muscles. Untreated the fissures may become chronic and what is known as the sentinel pile (or external skin tag) can appear at the opening of the anus because of persistent inflammation.

There seem to be several causes for these fissures. Besides a traumatic bowel movement trauma from anal penetration is often common in gay men. The trauma does not necessarily have to be caused by a penis but by any blunt invasion of the anal cavity opening which can include sex toys. If caused by sexual penetration the fissures may occur almost anywhere unlike the fissures caused by traumatic bowel movement which are most often found in the posterior midline section.

Infants or young children seem also to be at risk for anal fissures, sometimes in an acute form.

Symptoms

Pain, often severe, during bowel movements can continue unabated for hours after the bowel movement because of muscle spasms. Although the pain eventually subsides it will return with the patient's subsequent bowel movement. Bleeding on defecation also occurs usually presenting as a red streak on the stool.

Diagnosis/Treatment

Your health care provider will through examination be able to diagnose an anal fissure. Symptoms often present (with pain and bleeding) as hemorrhoids so your health care provider will make sure that what you have is indeed an anal fissure and not hemorrhoids. Other disorders that mimic anal fissures can include syphilitic lesions, carcinoma and TB. Your health care provider must examine your fissure in its midline location very gently because of the often excruciating pain that may occur just by spreading the anus apart. Because of the great discomfort a certain number of patients will find this type of exam a near impossibility.

The first methods of treatment would be to soften the stool and, as in the case of hemorrhoids, a stool softener such as colace is recommended. Do not use laxatives. Diarrhea is not the answer. The soft stool is what is desired. Creams, often with a steroid element, can be applied by fingertip inside your anal opening. Creams that include a topical anaesthetic will help relax your bouts of muscle spasms. Sitz baths are also recommended. The sitz bath should be warm, not hot, and relief of symptoms should occur at least temporarily once the patient has taken a sitz bath for 15 minutes or so following a bowel movement. For severe spasms your health care provider may prescribe a muscle relaxant. Topical nitrates can be considered for use since the oxygen helps to heal the affected area. Less likely to be used today is cauterization of the fissures. Using electricity to burn the problem area, this process requires a number of treatments and has not proved 100% effective.

Patients with acute anal fissures usually are able to heal using treatments described above, at least half of them within only a few days of instituting the treatment. Patients who have chronic fissures may have more trouble healing and the use of nitrates and cauterization are used primarily for cases of chronic fissure disorders.

Sometimes surgical treatment is indicated for chronic fissures. The goal of the surgery is to cut and weaken some of the sphincter muscle, reducing spasms and enlarging the opening of your anus. Sometime after surgery (which can be performed with a local anesthetic) the patient will be flatulent and have a reduced ability to control bowel movements. This usually resolves with time. The sphincter is stretched and the surgeon determines how much muscle to cut. You and your health care provider must determine the surgeon that you are comfortable with since this can be a delicate procedure.

If you are a gay male and have been anally penetrated by a partner or sex toy you may develop an acute fissure. By refraining from having anal penetration and using some of the treatment methods described above in which the primary goal is to have the stool softened, prognosis is good for healing of the disorder. If a chronic fissure develops and a sphincterotomy is recommended it may be wise to have a second opinion. Usually the sphincter muscles of gay men are already stretched and that is the goal of this surgery, to stretch the muscles of the opening of the anus, allowing the fissure to heal. Patients may also have anal dilation recommended as a treatment method in which the sphincter is stretched until it tears at least partially. This is not particularly recommended because the tearing cannot be controlled in the same way that can occur with surgery where the amount of muscle cut is much more controllable.

It is important to follow-up all treatment methods with your health care provider, especially to watch for development of chronic fissures or any unusual bleeding or any inability to heal. Gay men who have had acute anal fissures may also wish to take the opportunity to be tested for sexually transmitted diseases such as gonorrhea, syphilis, herpes and hepatitis.

A word about HIV positive patients and anal fissures: The HIV positive patient has special concerns because your anal fissure may become much more debilitating and more complicated than a fissure in an HIV negative person and medications may cause diarrhea with further tears along the lining of the anus. The ulcer may need to be removed once biopsy is performed but most often treatments with fiber and diarrhea control will heal the fissure. If you are HIV positive and have anal fissures be sure to go to a health care provider that is experienced, non-judgmental and knowledgeable about anal fissures and the HIV positive patient.

If you have an anal fissure or anal ulcer please contact your health care provider promptly.