National University of Rwanda

Family and Community Medicine

Anal fissure
KABERA Ren,MD
PGY IV Resident
Family and Community Medicine
National University of Rwanda
 Plan
Introduction
Causes, incidence and risk factors
Signs and symptoms
Treatment
Prognosis
Complications
Prevention
 Introduction
An anal fissure is a break or tear in the skin of the anal
canal.
An anal fissure is a small split or tear in the thin moist tissue
(mucosa) lining the lower rectum (anus).
Anal fissures may be noticed by bright red anal bleeding on
the toilet paper, sometimes in the toilet.
 Introduction
Acute fissure cause severe periodic pain after defecation chronic
fissures- pain intensity is often less.
Anal fissures usually extend from the anal opening and are usually
located posteriorly in the midline,
Fissure depth may be superficial or sometimes down to the
underlying sphincter muscle

95% posterior midline

5% anterior midline

Externally = skin tag or sentinel pile

Internally = hypertrophied anal papilla

Chronic fissure may reveal fibers of internal sphincter with sentinel
pile
Introduction
 Causes, incidence, and risk factors

Anal fissures are extremely common in young infants but may

occur at any age.
Studies suggest 80% of infants will have had an anal fissure
by the end of the first year.
The rate of anal fissures decreases rapidly with age.
 Causes, incidence, and risk factors

Fissures are much less common among school-aged children

than infants.
In adults, fissures may be caused by constipation, the passing
of large, hard stools, or by prolonged diarrhea.
In older adults, anal fissures may be caused by decreased
blood flow to the area.
 Causes, incidence and risk factors
Anal fissures are also common in women after childbirth and
persons with Crohn s disease .
Stress or a tight anal sphincter leads to ischemia of posterior
anoderm
Anal intercourse, sexual abuse
Lateral fissures indicate underlying systemic disease: Crohn's ,
Anal cancer, Leukemia, Syphilis, Previous anal surgery
 Symptoms

Anal fissures may cause painful bowel movements and

bleeding.
Blood on the outside of the stool or on the toilet tissue (or
baby wipes) following a bowel movement.
Constipation
 Treatment

Oral pain medication: NSAID, Cox-2 inhibitor

Topical anesthetics: ELA-Max5, Lidocaine jelly
Sitz baths to relieve sphincter spasm: Warm water only
Oral muscle relaxants or Valium to relieve sphincter spasm
High-fiber diet instruction
Encourage 10-12 glasses of water per day
 Medications

Cyclobenzaprine (Flexeril): 10 mg (peds: not indicated) PO

t.i.d.
Diazepam (Valium): 5 mg (peds: 0.12-0.8 mg/kg/day) PO
t.i.d. PRN spasm
Docusate sodium (Colace): 50-200 mg (peds: <3 years =
10-40 mg/day; 3-6 years = 20-60 mg/day; >6-12 years =
40-150 mg/day) PO q12h
 Medications
ELA-Max5 (5% lidocaine anorectal cream): apply t perianal
area q4h PRN pain (peds: not for <12 years of age)
Fiber/bran: 20 g/day
Ibuprofen: 400-600 mg (peds: 40 mg/kg/day) PO q6h
Nitroglycerin ointment 0.2%: apply to fissure b.i.d. (peds: not
indicated)
Psyllium seeds: 1-2 tsp (peds: 0.25-1 tsp/day) PO q24h
 Prognosis
Anal fissures generally heal quickly without further problems.
However, people who develop fissures are more likely to
have them in the future.
 Complications

Occasionally, a fissure becomes chronic and will not heal.

Chronic fissures may require minor surgery to relax the
sphincter.
 Prevention

To prevent anal fissures in infants, be sure to change diapers

frequently.
To prevent fissures at any age:
Keep the anal area dry
Wipe with soft materials or a moistened cloth or cotton pad
Promptly treat any constipation or diarrhea
Avoid irritating the rectum
End

Thank you