Anal Fissure, Abscess, and Fistula

The gastrointestinal tract is a long tube in which the digestive process occurs. It extends up to the rectum, which is continuous with the anus. This is the tract's outer opening through which fecal material is defecated.

The lower part of the rectum is called the anal canal. There are various clinical conditions associated with the lower part of the rectum.

While hemorrhoids are the most common ailment effecting the anal region, other conditions can occur such as anal fissures, abscesses, and fistulas.

Anal fissure:

An anal fissure is a small tear in the mucosal lining of the anal canal. Anal fissures typically arise due to excessive straining from constipation (1).

The difficulty of passing hard and dry stools can cause tearing of the mucosal lining of the anal canal, which is termed anal fissure (2).

Severe bouts of diarrhea or inflammatory conditions of the anal canal can also cause anal fissures.

Anal fissures can be very painful, particularly during passage of stool. The anal canal is rich in sensory nerve fibers, so any tear in this area causes severe pain. Bleeding and/or itching may also occur.

Diagnosis of anal fissure:

Anal fissures are typically diagnosed during anoscopy or colonoscopic exam of the anal region.

An anal fissure can be classified into acute or chronic, depending on the time of onset.
Anal fissures that look like a fresh tear are usually acute, while fissures that last for more than eight weeks are chronic and will have other identifiable characteristics on physical exam.

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Anal fissures commonly occur at the front or back of the anal canal and are usually due to physical trauma (such as straining).

A fissure on the sides of the anal canal can often be due to underlying pathology such as Crohn's disease.

Your GI physician may recommend blood work and stool studies if underlying pathology such as Crohn’s disease is suspected.

TREATMENT FOR ANAL FISSURE:

An anal fissure usually heals on its own. However, stool softeners are often used to reduce pain during bowel movements. Special ointments and creams may also be recommended by your GI doctor to speed up healing (3).

Diluted nitroglycerin is also used to improve blood flow so that the healing process speeds up.

To avoid the risk of infection, it's essential to keep the area between the buttocks clean and dry. After taking a bath, use a soft towel to ensure that the area is dry.

Talcum powder can also be applied to relieve symptoms. A Sitz bath is also helpful in anal fissures. A Sitz bath involves soaking the anal area in plain warm water for about 15-20 minutes several times per day.

Muscle spasms or scarring can interfere with the healing process. If the fissure does not improve with the above treatments, surgery may be recommended (4).

Surgical treatment is typically done on an outpatient basis and involves repair of the fissure and removal of any associated scar tissue.

A small portion of anal muscle can be cut to relieve muscle spasms and improve blood flow to the damaged side of the anal canal as well. This can speed up the healing process.

Complete healing can take a few weeks. However, pain typically decreases in severity after only a few days, with proper post-operative management.

Adequate dietary fiber intake and increased daily water intake can also reduce the risk of developing anal fissures(5).

Anal abscess:

An anal abscess is a pus-filled localized pocket which forms due to bacterial infection. Certain diseases increase the susceptibility for anal abscesses. These can include Crohn's disease, AIDS, and cancer. In addition, when a person's immune system is compromised, susceptibility to infections is greatly increased, and can lead to abscess formation.

Abscesses commonly cause associated pain, swelling, and tenderness. You may also experience chills, fever, fatigue, or weakness. Symptoms are usually relieved when the pus of the abscess is drained.

Diagnosis of the anal abscess:

An anal abscess is diagnosed on anal exam and is associated with redness and swelling.

Treatment for anal abscess:

Abscesses can be surgically drained on an outpatient basis to promote healing and to relieve associated pain and pressure (6).
Antibiotics are usually prescribed after surgical treatment of anal abscesses.

Anal fistula:

Anal Fistula

A fistula is a tiny channel that usually connects two body parts such as two blood vessels or two organs.

An anal fistula connects part of the rectum to the skin around the anus. Certain diseases like Crohn's disease increase the risk of anal fistulas.

In women, an abnormal communication may form between the rectum and vagina or between the rectum and bladder due to birth injuries.

Fistulas often get infected, which can result in drainage of pus. In addition, they may irritate the skin around them.

Diagnosis of anal fistula:

A fistula connecting to the skin surface is typically visible on physical exam. Oftentimes, a fistulogram, colonoscopy, and other radiographic techniques are required for detailed analysis once a fistula is suspected.

Treatment of anal fistula:

Treatment of the anal fistula is greatly dependent on the cause. If Crohn’s disease the underlying reason, then the fistula can usually be managed with medical therapy.

Fistulas that are unresponsive to medical therapy often require surgical treatment (7).

Summary:

Anal fissures, abscesses or fistulas can cause pain and drainage from the anus and the surrounding area.

If you feel discomfort or pain in the anal region, contact Digestive & Liver Health Specialists for treatment.

REFERENCES

1.Constipation in children and young people: diagnosis and management. London: National Institute for Health and Care Excellence (NICE); 2017.

2.Patkova B, Wester T. Anal Fissure in Children. Eur J Pediatr Surg. 2020 Oct;30(5):391–4.

3.Newman M, Collie M. Anal fissure: diagnosis, management, and referral in primary care. Br J Gen Pract. 2019 Aug;69(685):409–10.

4.Fathallah N, Spindler L, Zeitoun J-D, De Parades V. [Anal fissure]. Rev Prat. 2019 Nov;69(9):1005–10.

5.Yang J, Wang H-P, Zhou L, Xu C-F. Effect of dietary fiber on constipation: a meta analysis. World J Gastroenterol. 2012 Dec 28;18(48):7378–83.

6.Ommer A, Herold A, Berg E, Fürst A, Sailer M, Schiedeck T. German S3 guideline: anal abscess. Int J Colorectal Dis. 2012 Jun;27(6):831–7.

7.Pigot F. Treatment of anal fistula and abscess. J Visc Surg. 2015 Apr;152(2 Suppl):S23-29.

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