How can I help heal my anal fissure?

Josh is a 40-year-old male who came to me after 6 months of medical treatment for an anal fissure. He had been working with a colorectal physician who was trying to heal his fissure conservatively. Unfortunately, Josh was no longer able to sit due to pain which started to cause pain in other areas of his body like his back and hips. He began to do his own research after bouncing from doctor to doctor including a trip to a sports medicine physician and neurologist. He came across pelvic floor physical therapy as a treatment avenue to aid in persistent anal fissures, so he made an appointment to be evaluated. 

Anal fissure is the second most common reason for a proctologist evaluation after hemorrhoids.1 I often describe anal fissures like a small cut that you would get on your skin, except it is on the inside of your rectum. Typically, an anal fissure is initially caused by hard or bulky stools or sudden evacuation of liquid stools which results in a tear.1 Increased muscle tension or tone of the internal anal sphincter can be present prior to the anal fissure or can occur after the anal fissure due to pain. This pain can cause an unfortunate cycle where the anal sphincter has difficulty relaxing to have a bowel movement which can further exacerbate the symptoms or the fissure itself. Too much tension in the muscles can also reduce the amount of blood flow to the area which can limit healing due to oxygen limitations.1 

Anal fissures that last less than 6-8 weeks are considered acute and those that persist longer than 8 weeks are considered chronic.2 Most fissures are midline, or in the middle, of the circular tube that is the rectum and can be found either on the front or back side. Fissures that are not in the middle or midline should be further explored to ensure that there is not another medical contributor such as Crohn’s disease.2

It is important to make sure that the underlying contributors to the formation of the anal fissure area are addressed, specifically adequate hydration (we should be consuming half of our body weight in fluid ounces per day), ample nutrition (including adequate fiber), and good bowel movement habits. 

The good news is that 87% of acute fissures heal with a high fiber diet along with stool-bulking agents, such as psyllium, and sitz baths twice daily.2 Continuing a high fiber diet for one year can reduce recurrence rates up to 16% as compared to 68% in those that did not continue to implement a high fiber diet.1 Chronic fissures that last more than 6-8 weeks may require additional treatment options such as smooth muscle relaxants, like diltiazem, and further medical management. Luckily, 65-95% of chronic fissures will also heal.2

Fun fact, topical calcium channel blocks have been found to have fewer adverse effects and similar healing rates as compared to topical nitrates so be sure to ask your physician about your medications if you are noticing unpleasant side effects. Other more invasive options can include Botox (botulinum toxin) injections or surgical management.2 Keep in mind that the recurrence rate is 18-50% with Botox injections, so it is important to make sure that all possible contributing factors are being addressed while the fissure is healing AND after the fissure has healed.3 A surgical intervention often used to address a chronic, non-healing fissure is a lateral internal sphincterotomy; however, a side effect of this surgery is fecal incontinence, which can occur in 3.4-14% of patients.3 

My patient Josh had been doing “everything” including changing his nutrition, taking a stool softener, and even receiving Botox injections prior to his physical therapy appointment. Unfortunately, this did not address his pain. 

Pelvic floor dysfunction can be a contributing factor in those with chronic anal fissures.3 Typically, when we are having a bowel movement, we receive a signal that the rectum is full, and it is time to go to the bathroom. When we sit on the toilet, our external anal sphincter (EAS) and other pelvic floor muscles, especially one called the puborectalis, need to relax to allow the stool to exit our body. For some, the pelvic floor muscles can have a difficult time relaxing or can even contract (called dyssynergia) with defecation, which is not helpful.3 

Luckily, pelvic floor physical therapy (PFPT) can be used to increase awareness, allow for improved coordination of the abdominals and pelvic floor, increase muscle relaxation, improve pelvic floor muscle length, and reduce pain.3

A study was performed that looked at 140 patients (68 men and 72 women) and the outcome of 8 weeks of pelvic floor physical therapy as compared to no pelvic floor physical.3 Pelvic floor physical therapy consisted of internal techniques, such as puborectalis stretching and myofascial release, breathing exercises, pelvic floor exercises, and biofeedback to increase awareness.  The group that received pelvic floor physical therapy demonstrated reduced muscle tone at rest meaning they had reduced muscle tension as compared to those who did not receive physical therapy. Additionally, the group who received PT had an increased rate of anal fissure healing (55.7% in the PT group versus 21.4% in the non-PT group), reduced pain, and improved coordination of the pelvic floor muscles.3

As mentioned in the study above, there are various treatment approaches that should be individualized to each person. Some of these may include internal techniques. While this can seem counterintuitive, there is research to support its use in assisting with fissure healing.

A study looked at 50 patients with anal fissures who were split into two groups: anal self-massage of the anal sphincter (25 patients) or passive anal dilatation using dilators (25 patients).4 Each group performed the treatment for only 7 days. Both groups showed significant anal pain reduction and significant reduction in bleeding after defecation. Six months after treatment, the group that performed anal-self massage showed a significantly greater reduction in anal pain as compared to those who used dilators. After treatment, 60% of patients who used dilators and 80% of patients who used anal self-massage showed disappearance of their anal fissures. Recurrence was only seen in 1 patient who used anal self-massage and 3 patients who used dilators at 6 months after treatment.4

Another technique that can be used is called transcutaneous electrical posterior tibial nerve stimulation or PTN TENS for short.5 Although larger research samples are needed to understand the full benefit of this treatment technique, there has been promising research with smaller group sizes. For example, one study of 10 patients with chronic anal fissures found that all 10 had resolved pain and bleeding after 2 days of treatment. Healing of the fissure was observed in 6 out of 10 patients in 10 days after treatment. Five of those 6 patients had healing at day 5 of treatment. A 7th patient underwent the treatment for a second time and experienced healing of their anal fissure.5 

In Josh’s case, it would have been very helpful for him to attend physical therapy earlier in his treatment to prevent the pain from progressing to the point he was not able to sit “for months”. However, by continuing to address his nutrition, hydration, stool firmness and incorporate appropriate bowel movement habits, pelvic floor muscle relaxation, breathing strategies, and strengthening exercises for his back and hips, Josh is now able to sit more comfortably. He is even able to drive an hour to his parents’ house, which is something “I thought I would never be able to do again”. 

If you are experiencing an anal fissure, especially a chronic one lasting more than 8 weeks, be sure you are doing the following:

• High fiber diet
• Ample hydration (half of your body weight in fluid ounces per day)
• Sitz baths daily (twice if you are able)
• Using a squatty potty when toileting and focusing on slow, relaxed breathing and relaxing your pelvic floor muscles
• Discuss possible topical treatments, such as calcium channel blockers
• Contact your local pelvic floor physical therapist to ensure that the pelvic floor muscles are not contributing to your symptoms!

Written by Jordan Schmidt, PT, DPT

References

• Higuero T. (2015). Update on the management of anal fissure. Journal of visceral surgery, 152(2 Suppl), S37–S43. https://doi.org/10.1016/j.jviscsurg.2014.07.007

1. Dykstra, M., Buie, W., & , (2019). Anal fissures. Canadian Medical Association Journal,

• Van Reijn-Baggen, D. A., Elzevier, H. W., Putter, H., Pelger, R. C. M., & Han-Geurts, I. J. M. (2022). Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial. Techniques in coloproctology, 26(7), 571–582. https://doi.org/10.1007/s10151-022-02618-9

1. Gaj, F., Biviano, I., Candeloro, L., & Andreuccetti, J. (2017). Anal self-massage in the treatment of acute anal fissure: a randomized prospective study. Annals of gastroenterology, 30(4), 438–441. https://doi.org/10.20524/aog.2017.0154
2. Altunrende, B., Sengul, N., Arisoy, O., & Yilmaz, E. (2013). Transcutaneous electrical posterior tibial nerve stimulation for chronic anal fissure: a preliminary study. International Journal of Colorectal Disease, 28(11), 1583-1589.