Anal fissures are small tears in the lining of the anal canal, which can cause significant pain and discomfort during and after bowel movements. They are relatively common in children, particularly those with a history of constipation or hard stool.

History and Examination

  • History of constipation or hard stool
  • Risk factors: Low-fiber diet, dehydration, prolonged sitting, previous anal fissure

Symptoms:

  • Severe pain during and after defecation
  • Rectal bleeding
  • Fear of defecation

Signs:

  • Inspection may reveal a visible tear in the anal canal
  • Sentinel pile
  • Spasm of the anal sphincter

Differential diagnosis (D/D) & Complication:

D/D:

  • Hemorrhoids (painless rectal bleeding, itching, prolapse)
  • Perianal abscess (localized swelling, erythema, fluctuance)
  • Inflammatory bowel disease (chronic diarrhea, abdominal pain, weight loss)

Complications:

  • Chronic anal fissure
  • Anal stenosis
  • Anal fistula

Investigation

No specific investigations are usually required for diagnosing anal fissures, as they are primarily based on clinical presentation and examination

Admission criteria:

  • Severe pain, infection, or failure of conservative management

Management:

Medical

  • High-fiber diet, increased fluid intake, stool softeners, and laxatives to reduce constipation
  • Sitz baths and local hygiene

Rx:

  • Syp Lactulose for 2 weeks
    • It is not absorbed in small bowel and draws water into colon to make faeces soft
    • It is given BD or TDS with the meal
    • Side effects:
      • Can produce diarrhea
      • Tooth decay due to high lactulose so brush teeth after giving it
  • Topical anesthetic (e.g., Lidocaine 2% gel) applied to the anal area before bowel movements for pain relief
  • Topical Nitroglycerin ointment 0.2% applied to the anal area BID for 6-8 weeks (for anal sphincter relaxation)
  • Pain relief with acetaminophen or ibuprofen as needed
  • Sitz bath
    • Warm water bath to relieve discomfort in perineal region
    • It relax anal sphincter and increase the blood flow through anal canal
    • Promotes healing, reduce pain, itching, irritation

Surgical: Lateral internal sphincterotomy is considered in refractory cases or when conservative management fails

Advices:

  • Encourage a high-fiber diet and proper hydration
  • Educate about the importance of regular bowel habits and avoiding straining during bowel movements

Referral:

  • Refer to a pediatric gastroenterologist or pediatric surgeon if conservative management fails or for surgical intervention

Follow up:

  • Schedule a follow-up appointment 2-4 weeks after initiating treatment to assess response and monitor for complications

Additional points:

  • Anal fissure is caused by passage of hard faeces which tears delicate anal lining
  • Anal fissure cycle
    • Passage of hard, dry stoll>>tear of anal lining>> Anal fissure>> pain bleeding >> deliberate hanging on>> hard faces>> eventual defecation>> re-tear of old fissure>> anal fissure

References:

  1. Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;2:CD003431.
  2. Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg. 2008;247(2):224-237.
  3. Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. BMJ. 1986;292(6530):1167-1169.