Chronic Anal Fissures: Symptoms, Causes, and Complications

About anal fissures?

Hello, doctor.
Since I had hemorrhoid surgery at the end of February, I have been experiencing rectal bleeding during bowel movements starting a month after the surgery.
The doctors I consulted said it was just skin tears and fissures.
I inquired about the possibility of anal stenosis, but the doctor said it was not the case.
I also underwent a colonoscopy, which showed no issues.
However, this symptom has persisted until now; sometimes it improves for four to five days and then recurs, while other times it occurs for several consecutive days.
The bowel movements are mostly "painless," and I often notice blood when passing soft (but formed) stools.
The diameter of the stool is approximately two fingers wide...
The blood is mostly visible on the toilet paper.
I am using suppositories daily, taking a bath at night, and increasing my water, vegetable, and fruit intake, but the situation has not improved.
This has made me anxious about using the restroom every day, and I am worried about the possibility of developing a fistula.
I would like to ask the doctor if this ongoing situation could lead to any complications.
Have I developed chronic anal fissures? Thank you.

Niming, 30~39 year old female. Ask Date: 2021/12/19

Dr. Ke Fangxu reply Surgery

The typical symptoms of an anal fissure include pain during bowel movements accompanied by slight bleeding.
The common causes are constipation or diarrhea.
If there is no pain, it is likely not an anal fissure and is unrelated to a fistula; it may be due to residual hemorrhoidal tissue bleeding.
If the amount of bleeding is minimal, there are generally no significant complications.

Reply Date: 2021/12/19

More Info

Chronic anal fissures are a common condition that can arise after surgical procedures such as hemorrhoidectomy, as you have experienced. Understanding the symptoms, causes, and potential complications of chronic anal fissures is essential for effective management and prevention of further issues.

Symptoms
Chronic anal fissures typically present with the following symptoms:
- Bleeding: As you mentioned, blood may appear on the toilet paper after a bowel movement. This is often due to the fissure being irritated during the passage of stool.

- Pain: While you noted that you do not experience significant pain during bowel movements, many individuals with anal fissures report sharp pain, especially during and after bowel movements.

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

- Visible fissure: A chronic fissure may appear as a tear or crack in the anal lining, which can be observed during a physical examination.

Causes
Chronic anal fissures can be caused by several factors:
- Trauma: This can include trauma from passing hard stools, which can stretch or tear the anal lining.

- Surgical procedures: As in your case, surgeries such as hemorrhoidectomy can lead to changes in the anal canal that may predispose individuals to fissures.

- Chronic diarrhea or constipation: Both conditions can lead to repeated trauma to the anal area.

- Anal canal narrowing: Although your doctor has ruled this out, anal stenosis can contribute to the development of fissures.

Complications
If left untreated, chronic anal fissures can lead to several complications:
- Fistula formation: Chronic fissures can sometimes develop into anal fistulas, which are abnormal connections between the anal canal and the skin.

- Abscess: An untreated fissure can lead to an infection, resulting in an anal abscess.

- Chronic pain: Persistent fissures can lead to ongoing discomfort and anxiety about bowel movements, which can further complicate the condition.

Management and Treatment
Given your situation, it is crucial to continue with conservative management strategies:
- Dietary changes: Increasing fiber intake through fruits, vegetables, and whole grains can help soften stools and reduce straining during bowel movements.

- Hydration: Drinking plenty of water is essential for maintaining stool consistency.

- Topical treatments: Using over-the-counter topical anesthetics or prescription medications (such as nitroglycerin ointment or calcium channel blockers) can help relieve pain and promote healing.

- Sitz baths: Soaking in warm water can help soothe the area and promote relaxation of the anal sphincter.

If your symptoms persist despite these measures, it may be worth discussing further options with your healthcare provider. This could include:
- Botulinum toxin injections: These can help relax the anal sphincter and promote healing.

- Surgical options: In cases where conservative measures fail, surgical intervention may be necessary to remove the fissure or to perform a lateral internal sphincterotomy, which can relieve tension in the anal sphincter.

Conclusion
Chronic anal fissures can be distressing and may lead to complications if not managed properly. It is essential to maintain open communication with your healthcare provider and report any changes in your symptoms. If you continue to experience bleeding or if your anxiety about bowel movements increases, consider seeking a second opinion or further evaluation to ensure that there are no underlying issues contributing to your condition.

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