eMedicine Specialties > Pediatrics: Surgery > General Surgery
Anal Fissure
Updated: Dec 10, 2008
Introduction
An anal fissure, although ostensibly a minor problem, may lead to years of tremendous discomfort if not promptly diagnosed. Too often, the problem remains underrated or unnoticed by clinicians. However, when considered, the diagnosis is rather simple to make, and the treatment is usually quite effective.
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Anal Abscess, Abdominal Pain in Children, and Rectal Bleeding.
Problem
An anal fissure is a tear of the squamous epithelial mucosa of the anal canal, between the anocutaneous junction and the dentate line. They most commonly occur during passage of a firm stool. Anal fissures are common in infancy, and they represent the most common cause of bright rectal bleeding at any age. If not promptly diagnosed and treated, these small tears and their occasionally associated superficial infection cause severe anorectal pain during bowel movements and set in motion a cycle of stool negativism, constipation, and increasing pain with subsequent defecation.
Frequency
Most fissures affecting the pediatric population manifest in children aged 6-24 months; however, the overall incidence of the problem is not well described.
Etiology
The generally accepted proximal cause of the anal fissure is a mechanical tear resulting from the passage of hard stool. An unhealed fissure may become infected and develop into a chronic ulcer. A healed fissure may develop into a classic sentinel skin tag in the posterior midline.
The differential diagnosis includes pruritus ani, inflammatory bowel disease, tuberculosis, inherited disorders of the immune system, acquired immunodeficiency syndrome (AIDS), chlamydia, gonorrhea, syphilis, or neoplasm. Also, sexual abuse should always be considered in the differential when evaluating patients with anal or genital complaints. Most anal fissures are single in number and occur at the posterior midline. Multiple fissures of the anal canal, lateral fissures, or those that extend proximal to the dentate line should raise the suspicion of a more serious underlying disease process. Lateral fissures should raise the possibility of trauma, infection, neoplasm, AIDS, syphilis, tuberculosis, or inflammatory bowel disease.
Pathophysiology
The underlying pathophysiology of anal fissures is fairly complex. It is likely to be multifactorial and may involve anodermal ischemia, infection, chronic constipation, and hypertonicity of the smooth muscle of the internal anal sphincter and its elevated resting pressure.Fissures have a predilection for the posterior midline (90%) but may also be located in the anterior midline or lateral. The explanation for this phenomenon is both anatomic and functional. The posterior commissure of the anoderm is less well perfused than other anodermal regions. Furthermore, before the branches of the inferior rectal artery reach the anoderm, they course perpendicularly through septa of the internal anal sphincter. Thus, flow through these arterioles is threatened by elevated intramuscular pressure of the internal anal sphincter.
Many studies have demonstrated that adult patients with anal fissures have significantly elevated anal canal pressures that exceed the intraluminal pressure of arterioles. Therefore, increased tone at the internal anal sphincter compromises perfusion of the anoderm, particularly at the posterior midline, by compressing arterioles of the inferior rectal artery. High canal pressures likely result in increased anodermal ischemia that prevents small mechanical tears from healing in a timely fashion; the tears then progress to clinically significant anal fissures. A similar pathophysiology is speculated to be the etiology of anal fissures in infants and children.
Presentation
The diagnosis is usually made through a careful history and physical examination. A history of constipation is often elicited. The child may cry with bowel movements, and streaks of bright red blood on the surface of hard stool, on the diaper, or on the toilet paper after a bowel movement may be identified by the patient or family. Remember that underlying systemic illness frequently manifests with anal lesions. Thus, pertinent negatives, such as fever, rash, oral or skin lesions, weight loss, diarrhea, and abdominal pain, should be excluded. Also, psychological problems and stressors that may provoke stool negativism should be elicited.
The diagnosis is established by inspecting the anal region. For this examination, the parents should hold the child's hips in acute flexion while the examiner separates the buttocks, retracting the perianal skin folds. For older children, the anoderm may be spread apart while the child bears down because this maneuver facilitates visualizing the fissure. If a fissure is identified, a digital examination is best avoided because it is likely to elicit unnecessary pain and sphincter spasm. However, if a fissure is not observed, a digital examination should be performed to rule out other pathology. If the examination is limited by pain and the diagnosis remains unclear, an examination under anesthesia should be pursued.
The fissure appears as a minor laceration, usually in the midline, and is more often posterior than anterior. If the fissure is chronic, a small external skin tag (ie, sentinel tag) may be identified at the base of the laceration; this represents epithelialized granulomatous tissue secondary to chronic inflammation.
If a fissure is suspected, palpation of the abdomen is essential to check for palpable masses (stool) in the left lower quadrant.
Indications
Acute fissures rarely require surgical intervention, and symptoms from an acute fissure often resolve within 10-14 days of conservative medical management. However, if an anal fissure does not heal after 6-8 weeks of medical therapy and the diagnosis is not in question, surgery may be indicated.
Relevant Anatomy
See Pathophysiology.
Contraindications
Relative contraindications to operative treatment of anal fissure include inflammatory bowel disease and profound immunosuppression (ie, absolute neutrophil counts <100/μL).
Workup
Laboratory Studies
- Laboratory and imaging studies are not routinely necessary in the workup of an anal fissure. However, if the clinician suspects the presence of an underlying disease process, additional tests are indicated, such as serology, purified protein derivative of tuberculin (PPD), stool cultures, biopsy, or further GI workup.
Imaging Studies
- An abdominal flat radiograph to check for constipation is often illustrative and serves as a baseline examination before beginning stool softeners.
Treatment
Medical Therapy
Acute fissures rarely require surgical intervention and usually improve with conservative management. This includes dietary modification, stool softeners, and Sitz baths. Increasing the patient's fluid consumption and fiber intake may be sufficient. If a stool softener is used, it should be carefully titrated to avoid the development of diarrhea and dehydration. The stool softener of choice is an osmotic agent that causes water to be retained with the stool (eg, polyethylene glycol [MiraLax]), and the dosage is titrated for the patient's size. It is available as a powder that is mixed with 8 oz of water before administration.
Symptoms from an acute fissure often resolve within 10-14 days of conservative medical management; however, as long as 6-8 weeks may be necessary for the actual tear to heal. After 6-8 weeks, the fissure is considered chronic, and more active measures such as chemical or surgical sphincterotomy may be considered. Although studies validating the use of chemical sphincterotomy in the pediatric population remain limited, the available literature appears promising.1
Glyceryl-trinitrate (GTN) is the most widely used agent for chemical sphincterotomy.2 GTN 0.2% ointment is applied topically to the lower anal canal 2-3 times daily, until the fissure heals. Complications from this treatment modality are discussed below.
Topical diltiazem (available as an extemporaneously prepared 2% gel) may be a potential alternative to GTN with fewer adverse effects; however, sufficient evidence is lacking in the literature upon which to base recommendations for this agent. Topical diltiazem appears to be more effective than oral diltiazem therapy with fewer adverse effects.
Finally, botulinum toxin injections can reduce internal anal sphincter tonicity by inhibiting the release of acetylcholine into the synaptic gap. This therapeutic option is more invasive and significantly more costly than GTN. Also, the dosing and ideal site(s) of administration of botulinum toxin are not yet well established, and experience with this drug is lacking in the pediatric population. Botulinum toxin may be used for multiple, wide-based, and nonhealing fissures.
Surgical Therapy
As mentioned above, surgery is rarely needed for most infants and children with an acute anal fissure. Some fissures may take as long as 8 weeks to resolve with conservative management. Again, be mindful that if the fissure has not healed following medical therapy, the diagnosis may be in question, and an examination under anesthesia is warranted. If the fissure persists despite medical management, the operative procedure in children and infants is an open lateral internal sphincterotomy.
A chronic ulcer may be excised in addition to the sphincterotomy. All excised tissue should be evaluated by a pathologist. Because any associated anal stenosis is relieved successfully with the sphincterotomy, advancement flaps to treat the associated refractory stenosis are not needed. Relative contraindications to operative treatment include profound immunosuppression (ie, absolute neutrophil counts <100/μL) and inflammatory bowel disease.
Intraoperative Details
Treatment of children with anal fissures is slightly different than adults because an outpatient open lateral internal sphincterotomy is the procedure of choice. This relieves the spasm and, ultimately, the vicious cycle that characterizes the constellation of symptoms ascribed to anal fissure. Anal dilatation to treat anal fissure has been abandoned because of the 30-40% rate of recurrence.
In addition, if the history and physical examination reveal a lifelong history of constipation or failure to pass stool in the first 48 hours of life, an ectopically placed anus and Hirschsprung disease must be considered in the differential diagnosis, and a careful rectal evaluation and rectal biopsy should be performed with the same anesthetic.
Open lateral internal sphincterotomy is performed in the lithotomy position under a light anesthetic administered through a laryngeal mask technique. The intersphincteric groove is palpated, and the submucosa is injected with 0.25% bupivacaine with 1:200,000 epinephrine. A 1-cm curvilinear incision is made overlying the intersphincteric groove. The internal sphincter is medial to the external sphincter and lateral to the submucosa of the anus. The sphincter is then identified and elevated, and using electrocautery, a segment is divided as far proximal as the fissure itself. The overlying incision is closed.
Closed lateral sphincterotomy is also advocated in children. The knife blade is positioned in a similar position as with open sphincterotomy, but the difference is that the knife is inserted in the intersphincteric groove, rotated 90°, and advanced toward the anal mucosa. Hemostasis is achieved by direct pressure, and this puncture wound is not closed.
Chronic anal fissures should be treated by excision of the fissure along with its sentinel tag (pile) and internal sphincterotomy at the base of the ulcer. The wound is left open and should heal in 7-14 days without scarring. Compulsive wound care, consisting of washing the area with soap and water after each bowel movement, is essential for a successful outcome.
Postoperative Details
Patients and their families are educated about urinary retention, severe perianal pain, sepsis, bleeding, and transient fecal incontinence.
Follow-up
Dietary modifications, stool softeners, and Sitz baths should be continued for several weeks after operative treatment. A follow-up visit is scheduled for 2-3 weeks after the procedure.
Complications
Headache and diarrhea are the most common complications of administering topical nitrates and stool softeners, respectively. Significant hypotension with topical nitrate administration has not been reported in the literature. However, during the first office visit, children and their families should be questioned about a history of vascular headaches, and blood pressure should be taken before the initial application of topical nitrates. Incontinence has not been associated with these therapeutic regimens.
Short-term complications of operative therapy include urinary retention, hematoma formation, and incontinence. Long-term complications, such as difficulty controlling flatus, daytime soiling of underwear, and nighttime incontinence, are noted with both open and closed internal sphincterotomy. The exact incidence of long-term incontinence is not clear in the pediatric literature. The incidence of this complication is likely to remain unclear because medical management, including chemical sphincterotomy, is increasingly favored over surgery for chronic fissures.
Outcome and Prognosis
In several small studies, chemical sphincterotomy using glyceryl-trinitrate (GTN) with adjunctive stool softeners has been demonstrated to be quite effective at relieving symptoms and promoting healing. However, most pediatric surgeons report equal success with open or closed lateral sphincterotomy for acute and chronic anal fissures. Recurrence rates of open or closed lateral sphincterotomy have been reported to be 0-10%, with most of the recurrences occurring in adults and with chronic fissures. In contrast, anal dilatations have the highest rates of fistula recurrence (10-30%) and, for this reason, are not recommended in children.
Large prospective series describing outcome in patients following surgical intervention for chronic anal fissure also are lacking in the literature. However, most authors report anal dilatation and lateral subcutaneous sphincterotomy both to be effective therapeutic interventions for chronic anal fissures.
Future and Controversies
The treatment of anal fissures has advanced significantly over the last decade. Local reconstruction with advancement flaps is a relatively new and effective adjunct to chronic fissure excision. Reversible chemical sphincterotomy is a promising development in the treatment of acute (and possibly chronic) anal fissures. Large prospective randomized trials comparing the efficacy of the agents within this latter treatment modality remain to be reported.
References
Brown CJ, Dubreuil D, Santoro L, Liu M, O'Connor BI, McLeod RS. Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long-term fecal continence: six-year follow-up of a multicenter, randomized, controlled trial. Dis Colon Rectum. Apr 2007;50(4):442-8. [Medline].
Demirbag S, Tander B, Atabek C, et al. Long-term results of topical glyceryl trinitrate ointment in children with anal fissure. Ann Trop Paediatr. Jun 2005;25(2):135-7. [Medline].
Agnarsson U, Warde C, McCarthy G, Evans N. Perianal appearances associated with constipation. Arch Dis Child. Nov 1990;65(11):1231-4. [Medline].
Burd RS, Price MR. Evaluation and initial management of miscellaneous pediatric surgical problems. Pediatr Ann. 2001;30(12):752-9. [Medline].
Cook RC. Anal fissure and anal fistula. In: Spitz L, Coran AG, eds. Paediatric Surgery. Elsevier Health Sciences; 1995:515-9.
Emami MH, Sayedyahossein S, Aslani A. Safety and efficacy of new glyceryl trinitrate suppository formula: first double blind placebo-controlled clinical trial. Dis Colon Rectum. Jul 2008;51(7):1079-83. [Medline].
Garcia-Granero E, Sanahuja A, Garcia-Armengol J, et al. Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy. Dis Colon Rectum. May 1998;41(5):598-601. [Medline].
Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum. Aug 2001;44(8):1074-8. [Medline].
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. Jan 1989;32(1):43-52. [Medline].
Knight JS, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg. Apr 2001;88(4):553-6. [Medline].
Motson RW, Clifton MA. Pathogenesis and treatment of anal fissure. In: Henry MM, Swash M, eds. Coloproctology and the Pelvic Floor. Butterworth-Heinemann; 1985:340-9.
Parellada C. Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: a two-year follow-up. Dis Colon Rectum. Apr 2004;47(4):437-43. [Medline].
Pena A. Surgical conditions of the anus, rectum, and colon. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. Philadelphia, PA: WB Saunders Co; 2000:1181-83.
Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. XV. Chronic anal fissure: a new theory of pathogenesis. Am J Surg. Aug 1982;144(2):262-8. [Medline].
Sonmez K, Demirogullari B, Ekingen G, et al. Randomized, placebo-controlled treatment of anal fissure by lidocaine,EMLA, and GTN in children. J Pediatr Surg. Sep 2002;37(9):1313-6. [Medline].
Stafford PW. Anal fissure. In: O'Neill JA, Rowe MI, Grosfeld JL, et al, eds. Pediatric Surgery. Elsevier Health Sciences; 1998:1454-55.
Tander B, Guven A, Demirbag S, et al. A prospective, randomized, double-blind, placebo-controlled trial of glyceryl-trinitrate ointment in the treatment of children with anal fissure. J Pediatr Surg. Dec 1999;34(12):1810-2. [Medline].
Keywords
anal fissure, fissure in ano, anal tear, tear of the squamous epithelial mucosa of the anal canal, tear of the anal canal, bright rectal bleeding, posterior midline tear, constipation, anorectal pain, passage of hard stool, blood in the stool, anorectal blood, rectal blood, rectal bleeding, anal skin tag, chronic ulcer, acquired immunodeficiency syndrome, chlamydia, gonorrhea, syphilis, neoplasm, sexual abuse, inflammatory bowel disease
Contributor Information and Disclosures
Author
Brian P Gillett, MD, Assistant Professor, Department of Emergency Medicine, SUNY Downstate Medical Center and King, Department of Emergency Medicine, SUNY Downstate Medical Center and King
Brian P Gillett, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Coauthor(s)
Charles N Paidas, MD, MBA, Professor of Surgery and Pediatrics, University of South Florida; Chief of Pediatric Surgery, Tampa General Hospital
Charles N Paidas, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American College of Surgeons, American Heart Association, American Pediatric Surgical Association, Association for Academic Surgery, Florida Pediatric Society, Johns Hopkins Medical and Surgical Association, Society of Critical Care Medicine, and Society of University Surgeons
Disclosure: Nothing to disclose.
Medical Editor
Aviva L Katz, MD, Assistant Professor of Surgery, University of Pittsburgh School of Medicine; Consulting Staff, Division of General and Thoracic Surgery, Children's Hospital of Pittsburgh
Aviva L Katz, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association of Women Surgeons, Physicians for Social Responsibility, and Wilderness Medical Society
Disclosure: Nothing to disclose.
Pharmacy Editor
Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation
Managing Editor
Gail E Besner, MD, John E Wilson Endowed Professor of Neonatal Research, Nationwide Children's Hospital; Professor of Surgery and Pediatrics, Department of Surgery, Ohio State University College of Medicine; Director, Pediatric Surgical Research, Department of Surgery, Nationwide Children's Hospital
Gail E Besner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Burn Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Medical Women's Association, American Pediatric Surgical Association, Association for Academic Surgery, Federation of American Societies for Experimental Biology, Society of Critical Care Medicine, Society of Surgical Oncology, and Society of University Surgeons
Disclosure: Trillium Therapeutics, Inc. Consulting fee Consulting; Trillium Therapeutics, Inc. Grant/research funds Other
CME Editor
H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.
Chief Editor
Philip Glick, MD, MBA, Professor, Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Research and Development, Department of Surgery, State University of New York at Buffalo
Philip Glick, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, Central Surgical Association, Federation of American Societies for Experimental Biology, Medical Society of the State of New York, Phi Beta Kappa, Physicians for Social Responsibility, Royal College of Surgeons of England, Sigma Xi, Society for Pediatric Research, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, and Society of University Surgeons
Disclosure: Nothing to disclose.
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