Q: I am a middle-aged man and for the past one month, I have been having very painful bowel motions. The pain lasts several hours after going to the toilet and it even keeps me up at night. Life at the workplace has also become difficult because I am unable to sit for long hours due to pain.
Recently, I noticed some blood on the toilet paper after passing stool. This prompted me to go to see a doctor who said that I have an anal tear. He prescribed some ointment for applying and though I have used it for one week, I still have pain. I doubt his diagnosis because I honestly cannot understand how I got a tear in my anus. (I thought only people who insert things up their bottom got tears in that region). If I truly have a tear, shouldn’t it be closed? Please, help me.
Anal tears are medically known as ‘anal fissures’. They occur on the inner lining of the anus and they can affect anyone at any age. In most cases, they are as a result of passing hard large stool and straining in the toilet (often a consequence of constipation).
They can also occur if you have an underlying intestinal condition like inflammatory bowel syndrome (IBD) or long-standing diarrhoea. Infections such as tuberculosis, syphilis and HIV have also been known to be associated with anal fissures. Having anal intercourse and inserting foreign objects can also result in anal tears. Deep anal tears can sometimes occur during childbirth. Rarely, anal tears may be associated with cancer.
Symptoms of anal fissures
Anal pain is the most prominent symptom. The pain can go on for hours after the stool evacuation and it is believed to be due to spasms of the anal sphincter (muscle that keeps the anus closed).
Blood in the stool or on the toilet paper noted after wiping oneself in the toilet. Usually, the blood appears bright red.
Most people also report a small lump or loose skin (known as a ‘skin tag’) at the anal opening.
How does the doctor diagnose anal fissure?
Usually, your symptoms will provide a good guide as to the cause of your problem. To confirm the presence of a fissure, a doctor will gently look inside the buttocks.
Non-surgical treatment for anal fissures
It is important to address the underlying cause of your fissure. Usually, this requires lifestyle changes in addition to medication.
Constipation can be managed by eating a high fibre diet. This diet is rich in fruits, whole grains, nuts and vegetables.
In addition, increasing daily fluid intake to two or three litres a day can improve your stool habits. However, increasing fibre intake can lead to bloating and excessive flatulence so do it progressively.
Medication: In addition to the stool softener, a doctor may prescribe an ointment to apply in the anus. This medication relaxes the anal sphincter and helps in the healing process.
To assist in controlling pain, a doctor will also prescribe an anaesthetic ointment. If the pain is still significant, additional pain tablets may be prescribed.
Some people report pain relief if they sit in warm salty water (sitz baths) for 10 to 20 minutes after passing a bowel motion.
However, avoid narcotic painkillers as these can worsen your constipation (if you are buying the medication over the counter, inform your pharmacist about your constipation to help them select the best drug for you).
Good toilet habits: Avoid holding in stool or straining in the toilet as this can worsen the tear.
Underlying medical conditions: If the anal tear is related to another condition other than constipation (e.g. IBD or infections), get the underlying condition appropriately treated.
Usually, anal fissures related to underlying medical problems do not heal or recur unless the problem is treated.
Sexual habits: Anal sex should ideally be performed with the use of a lubricant (preferably a water-based one). This minimises the chances of getting significant anal tears.
Botox injections (similar to those used in cosmetic surgery to reduce wrinkles) may be injected in the area to help heal a fissure. Often, this is attempted if medical treatment for the fissure is not effective.
Often, surgery is a last resort. The procedure is known as a ‘lateral sphincterotomy’ and it involves cutting the anal sphincter muscles. Usually, this is a day surgery and you can go home afterwards. A concerning possible complication of this procedure is incontinence (loss of control of flatus or stool passage).
How long does it take anal fissures to heal?
With proper treatment (both non-surgical and surgical), most anal fissures take six to 12 weeks to heal completely. In most cases, you will begin to feel relief within two weeks of therapy.
You must continue treatment even when your symptoms subside. In addition, maintain a healthy lifestyle even after your treatment is complete. This is to prevent the fissure from recurring.