An anal fissure is typically defined as a small tear in the thin, moist tissue (also called mucosa), in the lining of the anus. Sometimes this can happen in young infants but can affect people of any age. This typically happens when people pass hard or large stools during a bowel movement which results in pain and bleeding. It can also happen from chronic diarrhea, anal intercourse or even childbirth. In anal fissures, there is a reduction in mucosal blood flow which delays the healing of the fissure. Spasms may also occur in the muscle area of the anus (anal sphincter).
What are the signs/symptoms and complications of anal fissures?
The signs and symptoms of anal fissures that usually will present are:
- Pain during and after bowel movements (can last for several hours)
- Bright red blood on the stool or toilet paper after bowel movements
- Visible crack in the skin around the anus
- Small lump or skin tag on the skin near the anal fissure
If left untreated, anal fissures can lead to severe complications which include, failure to heal, recurrence and a tear that may extend to other surrounding muscles. This can be avoided by preventing constipation or diarrhea which can typically be accomplished by eating foods high in fiber, drinking plenty of fluids such as water, and exercising regularly to help reduce the need to strain during bowel movements.
What is the difference between Anal Fissures and Hemmorroids?
Many times fissures get confused with hemorrhoids therefore it is important to be able to differentiate between the two. When it comes to anal fissures and hemmorhoids there are differences on how they present and what causes them to occur. For hemorrhoids, it is a result of pressure in the veins of the anus causing them to bulge and expand. Whereas, anal fissures are a result of trauma to the lining.
The symptoms are both similar and different. For one there is anal pain that occurs for both especially when experiencing a bowel movement and there will also be an appearance of bright red blood when patients wipe with toilet paper. However the main difference is that anal fissures can also cause bright red blood to appear in the stool as well and hemorrhoids can cause anal itching, some anal pain and a hard tender lump can occur near the anus.
There is also a difference in treatment. Mainly for hemorrhoids over the counter creams and suppositories are used that basically soothe the pain and provide temporary relief. Usually what’s used for hemorrhoids are astringents (witch hazel), protectants (zinc oxide), decongestant (phenylephrine), corticosteroids and topical anesthetics to treat pain. Phenylephrine’s role in hemorrhoid treatment, the main ingredient found in the popular Preparation H cream, is to shrink the blood vessels in the rectum resulting in relief from itching, burning and swelling. Anal fissure treatment is a bit different than what is used for hemorrhoids.
What are the treatments used for Anal Fissures?
First thing is to rule out any type of internal bleed. This is usually done by verifying if patients are taking any blood thinners (i.e., warfarin, aspirin) or if they have any history of gastrointestinal issues that have led to blood in the stool in the past. Checking for internal bleeding is crucial because this will help lead the healthcare provider into deciding an appropriate treatment plan or deciding if a patient needs to either seek a specialist or go to the emergency room immediately depending on the causes and severity of the fissures.
Anal fissures heal in a few weeks and sometimes can be simply treated by just soaking in warm water for about 10 to 20 minutes several times a day. This will help relax the sphincter and promote healing of the anus. Other treatments include:
- Applying nitroglycerin (Rectiv) will help increase blood flow to the fissure and will promote healing by relaxing the anal sphincter.
- Adding fiber rich foods and fluids in order to keep stool soft.
- Anesthetic creams such as lidocaine may be helpful as well to ease the pain of the fissure.
- Botulinum toxin type A or Botox, can paralyze the anal sphincter and relax the spasms.
- Taking blood pressure medications either orally or topically (diltiazem or nifedipine) can also help to relax the anal sphincter.
- Surgery is another last line option if the anal fissure is resistant to other treatments or is severe in nature.
What is diltiazem and how can it be used for anal fissures?
Diltiazem is a medication that is generally used for high blood pressure and other heart conditions, such as, atrial fibrillation, arrhythmias and even angina. Typically this medication is taken orally but there is evidence that it can be used topically to relieve anal fissures. The mechanism behind using diltiazem rectal ointment is to increase blood supply to the fissure area where it is ischemic (area of reduced blood flow) which will result in better healing and can also reduce anal pressure and pain. This ointment usually comes in a 2% strength and has also been associated with fewer side effects. This is because it is used just topically in the rectum and therefore does not enter the blood system therefore showing less side effects than if taken orally. Usually patients will have to apply this ointment for about 2-3 months before seeing results.
The downside to this option is that it does have to be made by a compounding pharmacy since it is not typically manufactured by a drug company. Because of this, many insurances might not cover this and therefore patients will have to pay the price the pharmacy sets for this medication.
The pain and discomfort that comes with anal fissures are not a laughing matter. This can lead to serious complications that might warrant surgery if severe enough. Treating these fissures are important but having patience and knowing that it is not an overnight fix will bring promising results. Diltiazem 2% rectal ointment might be the next best treatment which will provide significant healing without causing significant side-effects.
References:
- Knight JS, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg. 2001 Apr;88(4):553-6. doi: 10.1046/j.1365-2168.2001.01736.x. PMID: 11298624.
- Mott, T., Latimer, K., & Edwards, C. (2018, February 1). Hemorrhoids: Diagnosis and treatment options. American Family Physician. Retrieved January 20, 2022, from https://www.aafp.org/afp/2018/0201/p172.html
- (2021, May 7). Recognizing the differences between anal fissures and hemorrhoids. Colorectal Clinic of Tampa Bay. Retrieved January 20, 2022, from https://www.tampacolorectal.com/blog/recognizing-the-differences-between-anal-fissures-and-hemorrhoids
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