An anal fissure is a tear in the sensitive lining of the anus. It makes it very painful to pass a bowel motion, and tends to bleed. They are often caused by passage of a large hard stool, or trauma to the anus.
Most fissures heal by themselves over time. If you are worried, see your GP who will examine you. Sometimes it is important to be referred for tests to discriminate it from other causes of bleeding from the bowel.
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The best thing you can do is to treat constipation, ensuring easy to pass stools.
Ensure you take good amounts of water and fibre in your diet. Some people find that measuring the water they need to drink throughout the day, and marking it off on a water bottle, can help.
Fibre supplements such as psyllium husk, help to draw water into the bowel during transit. This helps to bind the stool together but also helping it to be soft and slippery. This should pass easily and not cause further anal trauma.
Stop steroid creams. Steroid creams can be taken for anal bleeding, with the understanding that it helps to soothe angry haemorrhoids. If the problem is an anal fissure, steroid creams generally do not help, and can slow skin healing. It is important to discriminate if you are treating haemorrhoids or a fissure, as the treatments are different.
A sitz bath is a warm, shallow bath you sit in to relieve pain, burning or itching around your anus and genitals. Soaking in warm water reduces muscle spasms by relaxing your anal sphincter muscles. Relaxing these muscles improves the blood circulation in your anal tissues, which promotes healing and reduces pain.
The position you take when on the toilet, affects the posture of the bowel when emptying. This makes it easier or harder to empty. Raising both feet on a step stool when sitting on the toilet has been shown to help defecation. By making it easier to pass stool, it eases constipation and prevents trauma to the anus and haemorrhoids.
If your fissure has not healed with 6 weeks of sensible conservative management, or you are worried, then you will need a referral to a colorectal specialist.
They will examine you, confirm your diagnosis, and talk you through your options.
Stop applying steroid creams - they will delay skin healing.
Diltiazem cream 2% is used to promote healing of an anal fissure. It works by relaxing the anal sphincter muscle, increasing the blood flow to the area to allow healing to occur.
Apply in the morning and evening - after a bowel movement is best. Apply a 2cm amount to your fingertip, and then apply in and around the anal edge. Wash your hands before and after use.
Use the cream twice a day (morning and evening), for 8 weeks. You must finish the course to get the full benefit of treatment. If you run out of cream before the end of the course, please ask for more.
Please note: This product is for external use only. DO NOT take it by mouth.
All medicines have side effects, but they don’t occur in all people who take them. The most common unwanted effects of Diltiazem is headache, which should be helped by paracetamol. Some people may experience temporary light-headedness. If you begin to feel dizzy, sit or lie down until the feeling passes.
If lifestyle changes and topical creams have not worked completely, it may be that a specialist will want to examine the area. This can be painful, and can be done under general anaesthetic if needed. The fissure can be cleaned (debrided) and a careful search made for any conditions perpetuating the fissure. This can include a fistula or sentinel tag.
A fistula is an abnormal connection between the inside and outside of the anus, and can occur when the fissure heals in a tunnel configuration, rather than from the base upwards. Lay open of this fistula will often kick start healing.
If the fissure has been there a long time, it may have had several cycles of tearing and healing. This local trauma can create a skin tag to form. This is classically at the front or back of the anus. This can hold the fissure open, and create friction against stool when bowels are opened. Excision of this tag can help the fissure to heal.
A botox injection can help to increase the blood supply to the sphincter muscle and skin, to aid healing. It works in the same way as diltiazem cream, with no need for daily application or headache. It wears off within 3 months, by which time the fissure should have healed.
In people where all other management techniques have failed, there may be a problem with the anal sphincter tension. In those who have a "high pressure" fissure, there is a tendency for very strong sphincter muscles to activate too much, limiting blood supply. A lateral sphincterotomy is a sphincter muscle release, made through an anal incision, that reduces the ability of the muscles to squeeze strongly. There is strong evidence that this is a very good operation for high pressure fissures. Care must be taken, as there is a risk it can cause continence issues later in life, particularly in ladies.
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