The anus is so much more than the very last stop of your digestive system. It’s a marvelous organ, packed with blood vessels and sensitive nerves, surrounded by the pleasure-responsive muscles of the pelvis. As such, the anus can be a source of great pleasure but also, sadly, pain and discomfort from such conditions as anal fissures.
What are Anal Fissures?
To understand anal fissures, it helps to know a little about anal and rectal anatomy.
Picture the anus as a short tube inside your body, only 1 1/2 inches or 4 centimeters long, attached to the rectum which is about 5 inches long and attached to the sigmoid colon. The anus has two sets of sphincter muscles: internal near the rectum and external ones at its opening, which gives its puckered appearance. These sphincter muscles control the exit of waste but can also relax to allow sexually stimulating penetration.
Whether acute or chronic, anal fissures present as a linear or oval-shaped tear or crack in the lining around the anus or the skin around the external anus. This condition is painful but ultimately treatable, with medical and pharmacological methods generally preferred over surgical procedures.
The earlier the treatment, the better, and accurate medical advice is always crucial.
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Symptoms
How do you know if you have an anal fissure?
- The first sign is often a sharp pain during bowel movements.
- This might be followed by a sensation of deeper burning, sometimes for hours.
- You might also notice bright red blood on either your bowel movement or on the toilet paper.
- Feelings of irritation or itching around the anus are also common.
- You might see a tear or lesion around the anus or feel a “small lump or skin tag.”
- You may also feel spasms in your anal sphincter muscles.
Be sure to let your medical providers know all your symptoms, so that you receive a definitive diagnosis and the advice that's right for you.
What Causes Anal Fissures?
Physical trauma is the culprit here.
Anything which damages the delicate anal mucosa can create a fissure. Tight, tense anal sphincters can even pull on the mucosa and cause it to tear!
An extensive update on anal fissures published in 2021 by Sajad Ahmad Salati in the Polish Journal of Surgery differentiates between primary and secondary anal fissures. Primary anal fissures can be caused by localized trauma, such as constipation and passing hard or large stools; frequent and long-lasting diarrhea; repetitive injuries; and even vaginal childbirth.
Rough or forceful anal penetration is another possible cause of primary anal fissures. Jack Morin, author of Anal Pleasure & Health (2010), reminds us that the anus and rectum are not self-lubricating. To prevent trauma during anal sex, Morin recommends using lots of lube and slow, patient movement.
Quoting from Salati's article, secondary fissures may be related to "a history of previous anal surgical procedures, inflammatory bowel disease (e.g., Crohn’s disease), granulomatous disorders (e.g., tuberculosis, sarcoidosis), infections (e.g., human immunodeficiency virus, syphilis, Haemophilus ducreyi, herpes, cytomegalovirus), chemotherapy or malignancy (leukaemia)."
Opioids have also been associated with anal fissures.
Risk Factors
The above causes are also risk factors and it might be advisable to take care of such conditions as constipation and diarrhea before they lead to anal fissures. Anal cancer and chemotherapy have also been linked to anal fissures.
There may also be a psychological component. Morin wrote: “Many people prone to fissures find that their internal sphincters are ‘tension zones.’ As a result, they have a much higher tension level even at rest, and also a tendency for the anal muscles to go into spasm during defecation (Ehrenpreis, 2003).”
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Complications of Anal Fissures
If an acute case does not resolve within six to eight weeks, the anal fissures are classified as chronic. The good news is that medical science has advanced in both understanding and treatment of chronic anal fissures.
According to this 2007 study, “Chronic anal fissure (CAF) is usually associated with internal anal sphincter spasm, the relief of which is central to provide fissure healing.” Medical treatments often promote smooth muscle relaxation.
CAF has also been associated with some types of food sensitivity. In some cases doctors might diagnosis this and recommend a diet change as part of the treatment plan.
Other complications include anal abscesses or fistulas (abnormal connections between organs). A 2022 Korean study of 143,884 people found that anal fissures and fistulas increase the risk of a later diagnosis of anorectal cancer.
And, of course, a recurrence anal fissures, which is far more common after the first case, is never welcome.
When to See a Doctor
See a doctor if you experience persistent anal pain and/or bleeding and/or notice a visible tear or crack around your anus.
You'll also want to seek medical treatment if home remedies haven't improved your symptoms, particularly if you have been dealing with an anal fissure for more than a few weeks.
Treatments
As one study states, conservative "treatment of anal fissure focuses on breaking the cycle of pain, spasm, and ischemia" (inadequate blood supply).
However it's important to act promptly "to relieve symptoms by reducing anal muscle contractility and spasm. This decreases the risk of repeated trauma upon defecation."
Start with home remedies and follow up with a medical provider.
Home Remedies
Home comfort measures can do a lot to diminish pain and promote healing.
This includes taking frequent sitz baths. Soak your bottom in a small basin of plain, warm water for 10-20 minutes several times a day, especially after defecation. Do not add soap or any other substance to the water.
It's also important to refrain from straining while having a bowel movement, which can cause repetitive trauma. If constipation and large, hard stools are a problem, stool softeners and laxatives can help. It can also be a good idea to switch to a high-fiber diet and increase your fluid intake. Some people also find that putting their feet on "potty stools" can prevent or ease strain while sitting on the toilet.
Over-the-counter pain relievers can also help make you more comfortable but if you have questions about medication, it is imperative to get a doctor's advice.
Medical Treatments
Topical medications, prescribed by a doctor, include nitroglycerin ointment (NTG) and injection of botulinum toxin (botox). Calcium channel blockers (CCBs) can be topical or given orally, via tablets.
Some newer treatments are cannabis-based. A 2020 study reported five patients who were successfully treated with topical CBD to diminish anal pain and assist vasodilation. A 2023 study published in Medical Cannabis and Cannabinoids used an herbal and hemp-based ointment and reported a significant reduction in pain and symptoms with eighty out of ninety-two patients after just a week's use.
The most common surgery is lateral internal sphincterotomy, but post-surgical incontinence is a possible complication. Discuss this with your medical team if you are advised to have surgery.
How to Heal an Anal Fissure
Your medical provider will give you a definitive diagnosis as well as advice tailored to your case. Following this advice will give you the best chance of a quick resolution of the fissure.
In addition to medical recommendations, regular use of home remedies like sitz baths will create soothing warmth and increase the blood flow necessary for healing. You can minimize additional anal trauma by quickly treating constipation and/or diarrhea, making changes to your diet and hydration, and avoiding anal play until the anal fissures are healed.
Prevention of Anal Fissures
Lifestyle changes can be important whether you want to heal an existing fissure, prevent a reaccurance, or make sure you never ever experience a fissure! This can include creating and maintaining a healthy diet with plenty of fiber, drinking enough water, learning to pass a bowel movement without straining, and yes, ensuring your anal sex is relaxed, safe, and lubed.
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The Bottom Line
Anal fissures can happen to almost anyone of any age, but there are ways to minimize your risk. Fissures are treatable and most people heal with conservative measures, including through home care remedies. You also have several options for both medical and surgical treatments.
It may take time, but healing is not only possible but probable assuming you get and take the best medical advice available to you.
