No silly questions: the Pain in the bum edition

by | What We're Talking About

They’re often misunderstood and rarely discussed, but did you know anal fissures affect about one in every 10 people? Painful, private but frightfully common, many people suffer in silence with anal fissures unsure of how to help heal the condition. That’s why we’ve put together a shame-free and evidence-based update on how to manage them, and get your backside, back on track. 

What are anal fissures?

Anal fissures are small tears in the highly sensitive lining of the anal canal that cause pain, bleeding and discomfort in the 11 per cent of people who experience them.1-2 The first sign you have an anal fissure could be a sharp pain in the bottom during bowel movements.2-3 You may also notice bright red blood on the toilet paper or in the toilet.1,4-5

What’s the difference between anal fissures and hemorrhoids? 

Anal fissures are small tears in the anal canal’s lining, often caused by trauma or straining during bowel movements, while haemorrhoids are swollen blood vessels in the rectum or anus, usually caused by increased pressure in the area.4 Both can cause pain and bleeding from the back passage however they do require different treatment so if you’re concerned you may be experiencing anal fissures or haemorrhoids or your bowel habits have changed, please see your GP. 4-5

Getting an accurate diagnosis for an anal fissure isn’t just so you can get appropriate management for your condition, it’s also to rule out other conditions with similar symptoms such as colorectal polyps and inflammatory bowel syndrome.4-5 Your GP will perform an examination and may order tests such as a colonoscopy to rule out these conditions.4-5

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Who gets anal fissures?

Anal fissures don’t discriminate with women and men just as likely to experience this challenging condition however some factors may increase the risk.1,4-5 Women who have given birth vaginally may be at a higher risk due to the strain on the perineum and anus during delivery.1 Anyone who experiences constipation – hard stools can cause tears – or diarrhoea – frequent, watery stools can irritate the anal area – has an increased chance of experiencing anal fissures too. And people living with Irritable Bowel Syndrome with the alternating symptoms of constipation and diarrhoea may be even more likely again. Anal intercourse can also be a risk factor so using a suitable lubricant is vital.1

What are the symptoms of anal fissures?

Most people with anal fissure report sharp, burning pain during bowel movements that sometimes lasts up to a couple of hours after.1,4-5 Bright red blood and itchy bottom due to irritation of the skin around the fissure are common too. Some people also notice uncomfortable anal sphincter spasms which are involuntary muscle contractions in the bottom.5

Is it normal for anal fissures to hurt?

Yes, unfortunately discomfort and pain are extremely common for people experiencing anal fissures.1-2, 4 Remembering that anal fissures are a tear in the sensitive mucous membrane of the anal canal, when this lining tears and underlying nerve endings are exposed pain is caused.2 In response to the pain, the muscle that controls the anal sphincter may spasm, making it difficult for the fissure to heal.2 Paracetamol or ibuprofen may be helpful to manage the pain.1

How are anal fissures treated?

Treatment usually requires two approaches – local and systemic. Local treatment addresses the problem where it occurs using a pharmacist-only ointment containing glyceryl trinitrate which acts by relaxing the muscles of the anal sphincter, in turn reducing pain and promoting healing.1,2,4 Talk to your pharmacist or GP about whether this treatment may be suitable for you. 

Systemic treatment includes increasing dietary fibre and staying well-hydrated to soften stools.1,2,4 By reducing straining when using the toilet, trauma to the anal canal is less likely and this gives your bottom a chance to heal.2 If this combination of methods doesn’t resolve the issue, your GP may recommend further treatments such as botox injections or surgery to repair the fissure.4,6

Do warm baths help anal fissures? 

Yes, brief warm baths are thought to help relax the muscle spasm associated with anal fissures but take care not to soak for too long because it can irritate the already sensitised skin in that area.1,2,5 Also avoid fragranced bath products that could worsen irritation. 

Is there anything else I can do to help ease discomfort of anal fissures?

Think back to those systemic approaches – anything that makes going to the toilet more comfortable is going to help. For this, consider the four Fs: “fruit, fluid, fibre and fitness”. The first three are easy, just try to increase your daily intake of fruit, fluid and fibre to prevent constipation and keep your digestion working smoothly.1,4,5 Fitness is a reminder that regular exercise can stimulate regular bowel movements. The final tip to help ease discomfort is to listen to your body: when you need to go, go then, don’t put it off. Delaying bowel movements can make it more uncomfortable when you try go later.4

Do anal fissures ever go away?

Yes, anal fissures typically resolve within six weeks although recurrence is possible.1,4 If you suspect you have an anal fissure or are experiencing symptoms such as bleeding, pain during or after using the toilet or itching of the bottom, talk to your pharmacist or GP. Early intervention can promote faster healing and successful treatment of anal fissures often leads to improved quality of life so it’s worth talking to a healthcare professional about your symptoms today.8

I’m embarrassed about anal fissures, is there somewhere I can speak to a pharmacist privately?

Yes! Most pharmacies have a private consultation room where you can talk to a pharmacist away from other people.7 This room is often used for vaccinations, medication reviews, reproductive health counselling, smoking cessation advice and weight-loss discussions so it’s not unusual for people to be popping in and out of that space in the pharmacy all day.7 All you need to do is approach a pharmacy staff member, say you’d like to speak with a pharmacist privately and you’ll be shown to a consultation room for a private discussion. 

REFERENCES:

  1. Newman M, Collie M. Anal fissure: diagnosis, management, and referral in primary care. Br J Gen Pract. 2019 Aug;69(685):409-410. Accessed August 27, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650108/pdf/bjgpaug-2019-69-685-409.pdf
  2.  Davids JS, Hawkins AT, Bhama AR, Feinberg AE, Grieco MJ, Lightner AL, Feingold DL, Paquette IM. Clinical practice guidelines committee of the American Society of Colon and Rectal Surgeons. Dis Colon Rectum. 2023 Feb 1;66(2):190-199. Accessed August 27, 2023. https://fascrs.org/ascrs/media/files/Education/2023-Anal-Fissures-CPG.pdf
  3. Boland PA, Kelly ME, Donlon NE, et al. Management options for chronic anal fissure: a systematic review of randomised controlled trials. Int J Colorectal Dis 2020;35(10):1807-15. Accessed August 27, 2023. https://www.ncbi.nlm.nih.gov/pubmed/32712929
  4. Daniel WJ. Anorectal pain, bleeding and lumps. Australian Family Physician. 2010;38(6). Accessed August 27, 2023. https://www.racgp.org.au/getattachment/9d1842b4-e59f-43ff-bad7-464f39836048/Anorectal-pain-bleeding-and-lumps.aspx
  5. Schlichtemeier S, Engel A. Anal fissure. Aust Prescr. 2016 Feb;39(1):14-7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4816871/
  6. Soltany S, Hemmati HR, Toussy JA, Salehi D, Toosi PA. Therapeutic properties of botulinum toxin on chronic anal fissure treatment and the patient factors role. J Family Med Prim Care. 2020;9:1562-6. Accessed August 27, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266196/pdf/JFMPC-9-1562.pdf
  7. Hattingh HL, Emmerton L, Ng Cheong Tin P, Green C. Utilization of community pharmacy space to enhance privacy: a qualitative study. Health Expect. 2016;19: 1098-1110. Accessed August 27, 2023.https://onlinelibrary.wiley.com/doi/epdf/10.1111/hex.12401
  8. Navarro-Sánchez A, Luri-Prieto P, Compañ-Rosique A, Navarro-Ortiz R, Berenguer-Soler M, Gil-Guillén VF, et al. Sexuality, quality of life, anxiety, depression, and anger in patients with anal fissure: a case–control study. Journal of Clinical Medicine. 2021;10:4401. Accessed August 27, 2023. https://www.mdpi.com/2077-0383/10/19/4401