Q I've been experiencing pain after going to the toilet, and I've also noticed blood on the toilet paper. A friend thinks I could have anal fissures. Can you tell me what these are, and how they might be treated? - MS, Huddersfield
A An anal fissure is an ulcer in the tissue which lines the anal canal, which runs from the rectum to the anal opening. The ulcers are thin, elongated tears. They are fairly common, especially among young - and otherwise healthy - people. In acute cases, the fissure develops quickly, and heals almost as fast. A chronic case lasts for longer than a month or so, and recurs. A chronic fissure often develops when a healed fissure tears every time the sufferer defecates.
Fissures affect both sexes equally, and are common in children, too. Some fissures, usually those that occur in the front wall of the anus, appear in women who have given birth, while children who have strained too hard to defecate can also develop them. It has been estimated that up to one-third of all women suffer either haemorrhoids or anal fissures after giving birth (Dis Colon Rectum, 2002; 45: 650-5).
Sometimes, a fissure can arise after anal surgery, such as for the removal of haemorrhoids, or as a result of ulcerative colitis, irritable bowel syndrome, Crohn's disease or gonorrhoea. An anal fissure may also be caused, or worsened, by anal intercourse. In the main, however, they are caused by the passing of large or hard faeces, which tear off the tissue lining in the anal canal. The problem is often associated with persistent constipation.
The fissure usually begins as a scratch, which fails to heal because of repeated contractions and stretching of the orifice. The tear can cause severe pain during and after bowel movements, and may become infected. Some sufferers may delay going to the toilet because of the pain. This, in turn, can cause further drying and compacting of the faeces, thus worsening the condition.
The main symptom is pain during or after bowel movements, sometimes persisting for several hours. Pain can also occur when any pressure is placed on the anal area, such as when sitting on a chair. Sometimes the pain stops for days or weeks at a time.
Bleeding can occur during or after bowel movements. Often, the sufferer believes they have haemorrhoids - usually because of the bleeding - when, in fact, they have a fissure. The tell-tale sign is pain during or after defecation.
Acute fissures are easier to treat than chronic ones. Sitz baths, suppositories and stool-bulking agents might be tried first, and hydrocortisone may be prescribed to reduce inflammation. However, one study found that sitz baths were of limited benefit. On analysing anal pressures before and after the bath, and comparing the results with those who didn't have a bath, the researchers found no differences between the groups (Dis Colon Rectum, 1993; 36: 273-4).
Topical nitroglycerin ointment can provide pain relief, and so allow the anus to relax. In one trial of 80 patients, 68 per cent of those given glyceryl trinitrate ointment reported fissure healing within eight weeks compared with just 8 per cent who used a placebo (Lancet, 1997; 349: 11-4).
Although such studies have made topical glyceryl trinitrate a first-line therapy for chronic fissures, an Australian study was more circumspect. By questioning 31 treated patients, the study team found that just 15 of them could be said to be cured; symptoms recurred in four of them. Side-effects were reported by 21 patients, and two of these had effects so severe that they stopped the treatment (Dis Colon Rectum, 1999; 42: 1007-10).
Another study found that, while glyceryl trinitrate was successful in 70 patients with either chronic or acute fissures, higher doses did not speed the healing - and many of the patients had recurring fissures afterwards, and complained of headaches during the treatment (Gut, 1999; 44: 727-30).
Fissure recurrence was further highlighted in another study of 43 patients: 22 used nitroglycerin and 21 had surgery. Nearly 80 per cent of those given nitroglycerin reported headaches, and most of the chronic sufferers had a recurrence (Tech Coloproctol, 2001; 5: 143-7).
It also seems not to work on children. One study tested it against placebo and, perhaps surprisingly, pain reduction was similar in both groups, suggesting that time might be as much of a healer as the ointment (Arch Dis Child, 2001; 85: 404-7).
Another ointment, isosorbide dinitrate, was tried on 16 chronic-fissure sufferers. Although all reported mild, transient headaches, pain from the fissures stopped within three weeks in all cases. After three months of treatment, the fissures had healed in all but one case (Ned Tijdschr Geneeskd, 1995; 139: 1447-9).
The latest treatment uses botulinum toxin (botox) injections. This bacterial toxin - usually responsible for food poisoning - causes muscle paralysis. Botox is injected into the anal sphincter muscle. Early data suggest that the therapy improves symptoms in 80 per cent of patients. No long-term data are yet available.
One study found botox to be more effective than topical nitroglycerin as an alternative to surgery. Fifty patients were given either botox or a six-week course of nitroglycerin ointment. After two months, the fissures were healed in 24 of 25 patients given the injection vs 15 of the 25 using the ointment. Five patients in the ointment group stopped because it was causing moderate-to-severe headaches whereas none of the botox group reported any side-effects (N Engl J Med, 1999; 341: 65-9).
Similarly, in a study of 40 patients with chronic fissures, most reported pain relief within a few days of the botox injections, which continued for six months (Gastroenterol Hepatol, 1999; 22: 163-6). The only adverse reaction with botox was reported in a study of 20 patients with chronic fissures, where two people had transient, mild incontinence (Dig Dis Sci, 1999; 44: 1588-9).
A new ointment containing diltiazem has shown success in treating anal fissures. Tested on 71 patients for 2-16 weeks, 75 per cent reported healing after two to three months of treatment (Br J Surg, 2001; 88: 553-6).
Your doctor may prefer a more interventionist treatment. In acute cases, an anal dilator, lubricant and local anaesthetic may be tried twice daily by the patient at home, or the doctor may dilate the anus using his fingers while the patient is under a general anaesthetic. However, this procedure can cause incontinence for 7-10 days.
For fissures that won't heal, surgery is usually required. One involves disruption of the internal anal sphincter muscle, causing a reduced pressure in the anal canal. This is supposed to prevent fissures from forming by improving blood flow to the anus. With surgery, the fissure heals in one to four weeks and remains healed in 95 per cent of cases. Incontinence can result in 15 per cent of patients.
These procedures, which include lateral anal sphincterectomy or dorsal fissurectomy and sphincterectomy, involve cutting away the internal anal sphincter. The latter procedure is generally reserved for very bad cases of chronic fissures.
Although sphincterotomy has been the standard treatment for chronic fissures for over 20 years, one study found that anal dilation, using either a retractor or a balloon, helped to cure fissures in 93 and 94 per cent, respectively, and with fewer complications than surgery (Dis Colon Rectum, 1992; 35: 322-7).
There's little scientific evidence to support the use of alternative and complementary medicine for fissures. Traditional Chinese medicine may offer symptom relief through herbs and acupuncture, while temperature-lowering products such as Anurex - biodyne plus shark liver oil - might give instant relief, even though they cannot cure the ulcer.
Perhaps the best approach is prevention rather than cure. Constipation is one of the main causes of anal fissures, and there's plenty on offer from alternative medicine to treat it.
A number of factors can contribute to constipation, such as prolonged immobility due to bedrest, inadequate exercise, a low fibre and fluid intake, irregular eating habits and stress. Other possibilities include the use of drugs such as aluminium hydroxide antacids and antihypertensives, narcotics such as codeine and morphine, and iron supplements. Constipation can also indicate a more serious condition, such as colon cancer or diabetes, so it's worth having it checked out.
You should drink 8-10 glasses of fluids every day. Tea and coffee can be effective laxatives, though caffeine can contribute to constipation, but should not be included in your daily count of fluids. High-fibre diets can also help - eat plenty of fresh fruits and vegetables, cooked wholegrain cereals with added bran, and foods containing wholegrains such as amaranth, quinoa, oat bran and rye (Ther Umsch, 1997; 54: 190-2).
Take more exercise; walking for half an hour after a meal can be helpful.
Things to avoid or cut down on are milk, refined sugar such as sweets and soda, and calcium-rich products; you should also reduce your iron intake.
Some practitioners find mineral oil beneficial. Helpful herbs include alfalfa, barberry, butternut root bark, cascara sagrada (not to be taken by an IBS sufferer), dandelion, flaxseed oil, ginger root, Irish moss, liquorice, Psyllium, rhubarb root, senna leaves and slippery elm. Supplements such as acidophilus and Miller's bran may also prove helpful.