Anal Fissures: Causes, Symptoms, and Treatment Options

Anal fissure distress

Hello, Doctor: I apologize for having so many questions, and I appreciate your help in answering them one by one.
Thank you.
I’ve read online that "constipation" leads to anal fissures, but I don’t have constipation! Just a few days ago, my bowel movements were smooth, and I even went twice in one day.
Although I eat out, I try to consume plenty of vegetables every day and drink over 1500 ml of water daily.
Just yesterday, I even had a large piece of pumpkin! However, this morning, I felt pain during a bowel movement, which was concerning.
When I wiped with toilet paper, there was blood...
In the afternoon, I had another bowel movement, and there was still bleeding...
With two bowel movements a day, it should be smooth, so why do I still have an anal fissure? Since the first significant bleeding from an anal fissure in February of this year (the blood was enough to turn the toilet water red), I had another fissure in March and June (but these two were milder, with only blood on the toilet paper, no dripping into the toilet).
I thought I was in the clear recently, but now it has happened again, and I’m really frustrated...
I would like to ask the doctor...
(1) Why did I still get an anal fissure even though I haven’t been constipated and have had two bowel movements a day? (2) Even though I eat vegetables and drink plenty of water, why are my stools still hard? (3) Once I’ve had an anal fissure, will it keep recurring for the rest of my life? (4) I read online that I shouldn’t strain during bowel movements, but when the stool is hard, it’s impossible not to strain...
Should I just let the stool sit in the rectum and not let it come out? But if it has already formed into hard stool, won’t taking a stool softener be too late...? How can I avoid straining? (5) At what severity of an anal fissure should I consider surgery? (6) Hemorrhoid ointments can only be applied around the anal area, making it difficult to reach inside the anus.
Can this still treat an anal fissure? (7) Do I need to take sitz baths every day? Or only when I have an anal fissure? Is one sitz bath in the evening after a shower enough when I have a fissure? (But I can’t take sitz baths at work...) (8) Since I don’t have constipation, do I still need to go to the pharmacy to get stool softeners?

Pi Er, 30~39 year old female. Ask Date: 2021/08/06

Dr. Ke Fangxu reply Surgery

1.
In addition to constipation, frequent loose stools can also be a cause of anal fissures.
Furthermore, excessive contraction of the anal sphincter is another contributing factor.

2.
It is important to have an adequate intake of dietary fiber; simply eating vegetables is not enough.
If dietary adjustments are not possible, fiber supplements can be taken.

3.
There is a possibility that the key issue lies in bowel habits and patterns.

4.
If hard stools have already formed, it is necessary to exert some effort; however, the focus should be on preventing the formation of hard stools in the first place.

5.
Recurrent episodes, severe pain, and impact on daily activities are concerning.

6.
You can use a soft tube for irrigation or switch to using suppositories.

7.
Whether dealing with anal fissures or hemorrhoids, sitz baths can be beneficial.
It is generally recommended for office workers to take sitz baths in the morning, after work, and before bed.

8.
You mentioned that there is no constipation, yet also noted that the stools are very hard, which seems contradictory.
Regardless of whether the stools are loose or hard, increasing the intake of plant fiber can help soften the stools.
It may be necessary to consider taking stool softeners, or you should consult a physician for evaluation.

Reply Date: 2021/08/06

More Info

Anal fissures are small tears in the lining of the anal canal, often causing significant pain and bleeding during bowel movements. Understanding the causes, symptoms, and treatment options for anal fissures is crucial for effective management and prevention of recurrence.

Causes of Anal Fissures
While constipation is a common cause of anal fissures, it is not the only one. Even with regular bowel movements, factors such as:
- Hard or large stools: Even if you are not constipated, if your stools are hard or larger than usual, they can still cause tearing during passage.

- Diarrhea: Frequent loose stools can irritate the anal area and lead to fissures.

- Straining: Even with soft stools, excessive straining during bowel movements can contribute to fissure formation.

- Anal trauma: Activities such as anal intercourse or the insertion of foreign objects can also lead to fissures.

- Underlying conditions: Conditions like Crohn's disease, which affects the gastrointestinal tract, can predispose individuals to fissures.

Symptoms of Anal Fissures
The primary symptoms include:
- Pain during bowel movements: This can be sharp and severe, often described as "tearing" pain.

- Bleeding: Bright red blood may be seen on toilet paper or in the toilet bowl.

- Itching or irritation: The area around the fissure may feel itchy or irritated.

- A visible crack or tear: In some cases, a fissure may be visible during a physical examination.

Treatment Options
1. Dietary Modifications: Increasing fiber intake through fruits, vegetables, and whole grains can help soften stools. Drinking plenty of water (aim for at least 2 liters daily) is also essential.

2. Stool Softeners: If stools remain hard, over-the-counter stool softeners can help. Even if you do not feel constipated, these can assist in making bowel movements easier.

3. Topical Treatments: Over-the-counter creams containing hydrocortisone or other soothing agents can help reduce inflammation and promote healing.

4. Sitz Baths: Regular sitz baths (soaking the anal area in warm water) can relieve pain and promote healing. It is recommended to do this several times a day, especially after bowel movements.

5. Avoid Straining: It is crucial to avoid straining during bowel movements. If you feel the urge to go, try to respond promptly rather than holding it in.

6. Medications: In some cases, doctors may prescribe topical nitroglycerin or calcium channel blockers to help relax the anal sphincter and promote healing.

7. Surgery: If conservative treatments fail and fissures recur, surgical options such as lateral internal sphincterotomy may be considered. This procedure involves cutting a small portion of the anal sphincter muscle to reduce tension and promote healing.

Addressing Your Concerns
1. Why did I get a fissure even without constipation?: As mentioned, hard stools or straining can occur even if you are not constipated. It's essential to monitor stool consistency and avoid excessive straining.

2. Why are my stools hard despite a high-fiber diet?: Factors such as dehydration or rapid transit through the intestines can affect stool consistency. Ensure you are drinking enough fluids.

3. Will I always have fissures once I have had one?: While some individuals may be predisposed to recurrent fissures, proper management and lifestyle changes can significantly reduce the risk.

4. How to avoid straining?: If you feel the urge to go, try to relax and allow your body to do its work. If stools are hard, consider using a stool softener or increasing fiber intake.

5. When to consider surgery?: If you experience chronic pain, recurrent fissures, or if conservative treatments fail, consult a specialist about surgical options.

6. Can topical treatments help?: Yes, while they may not reach deep fissures, they can help soothe the area and promote healing.

7. Do I need daily sitz baths?: Daily sitz baths, especially after bowel movements, can be beneficial. If you cannot do them during the day, try to incorporate them into your evening routine.

8. Should I get stool softeners?: If you are experiencing hard stools or pain during bowel movements, it may be beneficial to use stool softeners even if you do not feel constipated.

In summary, managing anal fissures involves a combination of dietary changes, proper hydration, topical treatments, and possibly medical intervention. If symptoms persist or worsen, it is essential to consult a healthcare provider for further evaluation and treatment options.

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