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Introduction
Chronic anal fissures can be a source of discomfort and embarrassment for those who suffer from them. While they may not be a common topic of conversation, these painful tears in the lining of the anus affect a significant number of people. In this blog, we will explore what chronic anal fissures are, their causes, symptoms, and most importantly, how to manage and treat them effectively.

What is a Chronic Anal Fissure?
An anal fissure is a small tear or crack in the lining of the anus, and when it persists for more than six weeks, it is classified as chronic. These fissures are typically located in the posterior midline of the anal canal and are a common cause of anal pain and discomfort.

Causes of Chronic Anal Fissures

Straining during bowel movements: One of the primary causes of anal fissures is the excessive straining during bowel movements. This can result from constipation, hard stools, or prolonged diarrhea.

Anal trauma: Injury to the anal area, such as from rough wiping, can cause fissures to develop.

Anal sphincter muscle problems: High resting anal tone or spasms of the anal sphincter muscles can lead to reduced blood flow to the anus, making it more susceptible to fissures.

Inflammatory bowel disease: Conditions like Crohn’s disease or ulcerative colitis can increase the risk of developing anal fissures.

Pregnancy and childbirth: The strain on the anus during childbirth can lead to fissures, which can sometimes become chronic.

Symptoms of Chronic Anal Fissures
Chronic anal fissures often present with the following symptoms:
Pain during bowel movements: This is usually the most prominent symptom. The pain can range from mild to severe and can last for hours after defecation.
Bleeding: Bright red blood on toilet paper or in the stool is a common sign of anal fissures.
Itching and burning: Some individuals may experience itching and burning around the anal area.
Spasms: Painful spasms of the anal sphincter muscles can occur, making the pain even more unbearable.

Managing and Treating Chronic Anal Fissures
Fortunately, chronic anal fissures are treatable, and in many cases, they can heal without the need for surgery. Here are some strategies for managing and treating chronic anal fissures:

Dietary changes: Maintaining a high-fiber diet can help soften stools and prevent constipation, reducing the strain during bowel movements. Adequate water intake is also essential.

Topical treatments: Over-the-counter creams or ointments containing ingredients like hydrocortisone or nitroglycerin can help relax the anal sphincter muscles and promote healing.

Sitz baths: Soaking in warm water for 15-20 minutes several times a day can provide relief and promote healing by improving blood flow to the area.

Stool softeners: In some cases, your doctor may recommend stool softeners or laxatives to prevent straining during bowel movements.

Prescription medications: If over-the-counter treatments are ineffective, your healthcare provider may prescribe stronger medications or creams.

Botulinum toxin injection: In cases of severe anal sphincter muscle spasms, botulinum toxin (Botox) injections may be used to relax the muscles temporarily.

Lateral internal sphincterotomy: Surgical intervention, such as a sphincterotomy, may be necessary if conservative treatments fail. This procedure involves cutting a small portion of the anal sphincter muscle to relieve pressure and promote healing.

Conclusion
Chronic anal fissures can be painful and disruptive, but with the right approach to management and treatment, most people can find relief and allow their fissures to heal. It’s important to consult with a healthcare provider for an accurate diagnosis and to discuss the most appropriate treatment plan for your specific case. Remember, early intervention and lifestyle modifications can often prevent chronic anal fissures from recurring, ensuring a better quality of life for those affected by this condition.

The patients in Minnesota often couldn’t tell the differences between anal fissure and hemorrhoids. Although both hemorrhoids and anal fissure are associated with rectal pain and rectal bleeding, they are two very different diseases that are important to distinguish.

Hemorrhoids could be as painful as anal fissure when thrombosis develops. In the most time, the pain caused by hemorrhoids is mild, persistant, dull aching pain, not always related to bowel movement. Anal fissure usually has sharp rectal pain during bowel movements.

Anal Fissure
An anal fissure is a tear in the anal canal in the lower rectum. Anal fissures are typically thought to be caused by trauma from a hard or painful bowel movement, and are often associated with a lack of fiber in the diet. Symptoms include severe rectal pain during bowel movements, which can last from minutes to hours after. The pain is worse with constipation, which may occur if the patient has been avoiding bowel movements due to pain. Many patients report bright red blood on the toilet paper or the stool, though bleeding is usually not significant. If a fissure persists over time it may become a chronic fissure.

Anal fissure require anoscopy as it cannot be directly observed visually. However, anoscopy is quite painful for those with an anal fissure so a doctor may treat it based on symptoms alone. About 80% of fissures resolve themselves without the need for surgery. Initial treatment is generally conservative in nature, with the goal of relieving constipation and breaking the cycle of hard bowel movements. Patients may take stool-bulking agents like fiber supplements and stool softeners, as well as laxatives to encourage regular bowel movements. Mineral oil can serve this purpose as well, but it is not advisable to be used indefinitely. Sitz baths after bowel movements are effective in relieving symptoms.

If these first-line treatments do not work, the patient may be directed to use 0.4% nitroglycerine (NTG) ointment in conjunction the treatments listed above; however, this is generally not preferred as NTG ointment can cause adverse side effects like headache and dizziness. Alternatively, Nifedipine gel is a better option to treat anal fissure.

Botox has also shown to be a promising treatment, its relaxation effect on sphincters lasts for three months that is long enough for anal fissure to heal. If the anal fissure does not resolve following treatments, then a partial anal sphincterotomy may be needed, where a cut will be made on the anal sphincter in a different location in the anus, and both the fissure and new cut will heal together.

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