Anal Fissures: Causes and Management for Persistent Pain

Anal fissure

Hello Doctor, two years ago I experienced an anal fissure due to constipation.
Since then, every 1-2 months, if my stool is slightly hard, I would experience another fissure.
However, in the past month, even with soft stools, I have been experiencing skin tears.
There is a slight sharp pain only during bowel movements, but it resolves afterward.
I have seen multiple doctors over the past two years, and they have indicated that the severity of the fissures is not serious and that it does not resemble chronic anal fissures.
One doctor mentioned that the wound is similar to perineal tears during childbirth, which may cause the tissue to be more fragile and slow to heal.
I would like to ask, what could be the reason for the skin tearing around the anus even with soft stools? Thank you.

Niming, 30~39 year old female. Ask Date: 2019/02/27

Dr. Ke Fangxu reply Surgery

If a digital rectal examination causes severe pain, it may indicate an anal fissure.
Since I cannot perform a physical examination, I cannot determine the exact nature of the "skin breakdown" you mentioned.
If there is no bleeding and only mild pain, I recommend taking warm sitz baths and using topical medications for treatment.

Reply Date: 2019/02/27

More Info

Anal fissures are small tears in the lining of the anal canal, often resulting from trauma during bowel movements, particularly when passing hard stools. Your experience of recurrent fissures, even with soft stools, suggests that there may be underlying factors contributing to the fragility of the anal tissue.

Causes of Persistent Anal Fissures
1. Chronic Constipation and Straining: While you mentioned that your stools are soft, the history of constipation and straining can lead to a cycle of fissure formation. Even minor straining can cause trauma to already sensitive tissue.

2. Inadequate Healing: The mention of your fissures being near the perineal area, which may have been weakened during childbirth, indicates that the tissue may not be healing properly. This could be due to poor blood supply to the area or the presence of scar tissue from previous injuries.

3. Underlying Conditions: Conditions such as inflammatory bowel disease (IBD), anal infections, or sexually transmitted infections can also contribute to the development of fissures. It’s essential to rule out these conditions if they haven’t been evaluated.

4. Dietary Factors: Even if your stools are soft, dietary habits can play a significant role. Insufficient fiber intake can lead to changes in stool consistency, and dehydration can also affect bowel movements.

5. Muscle Spasms: The anal sphincter may be in a state of hypertonicity (increased tension), which can lead to pain and difficulty in bowel movements, exacerbating fissures.

Management Strategies
1. Dietary Modifications: Ensure you are consuming a high-fiber diet to promote softer stools. Foods rich in fiber include fruits, vegetables, whole grains, and legumes. Additionally, adequate hydration is crucial.

2. Topical Treatments: Over-the-counter topical anesthetics can provide temporary relief during bowel movements. Prescription options include nitroglycerin ointment or calcium channel blockers, which can help relax the anal sphincter and promote healing.

3. Sitz Baths: Regular sitz baths can help soothe the area and promote blood flow, aiding in healing. Soaking in warm water for 10-15 minutes several times a day can be beneficial.

4. Avoid Straining: When using the bathroom, try to relax and avoid straining. If you feel the urge to go, do so without delay, as holding it can lead to harder stools.

5. Pelvic Floor Physical Therapy: If muscle spasms are suspected, working with a physical therapist specializing in pelvic floor dysfunction can help address any underlying muscle tension.

6. Follow-Up with a Specialist: If your symptoms persist despite these measures, it may be worthwhile to consult a gastroenterologist or a colorectal surgeon. They can evaluate for any underlying conditions and discuss potential interventions, such as Botox injections to relax the sphincter or surgical options if conservative measures fail.

Conclusion
Persistent anal fissures can be frustrating and painful, but understanding the underlying causes and implementing appropriate management strategies can significantly improve your quality of life. It’s essential to maintain open communication with your healthcare provider and seek further evaluation if your symptoms do not improve. Regular follow-ups can help monitor the situation and adjust treatment as necessary.

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