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Condition: Anal Fissure (anal tear, anal skin tags)
Overview (“What is it?”)
- Definition: An anal fissure is a tear or break in the skin at the anus. The anus is the external opening of the rectum, where stool comes out of the body.
- Epidemiology: Fissures occur most commonly in children 6-24 months of age. They are often seen in children who have problems with hard stools and constipation. When hard stools are passed, the lining of the anus can tear, causing pain and bleeding. Anal fissures are the most common cause of rectal bleeding in children.
Signs and Symptoms (“What symptoms will my child have?”)
- Early signs: Streaks of blood on the stool or on toilet paper, pain/crying with bowel movement, constipation.
- Later signs/symptoms: The tear causes pain during stooling, so a child may hold his poop. Unfortunately, this leads to worsening constipation and when the child finally poops after several days, the tear can get bigger. Skin tags next to a chronic fissure as a result of repeated healing and tearing.
Diagnosis (“What tests are done to find out what my child has?”)
- History of pain with stooling and blood streaks on the stool or toilet paper suggests anal fissure. The fissures are usually located on the middle top or bottom part of the anus.
- Blood tests are not usually needed. A doctor may order X-rays of the abdomen to see if there is a back up of constipated stool.
- Conditions that mimic this condition: Anal fistula, anorectal anomalies, inflammatory bowel disease (Crohn's disease) in older children.
Treatment (“What will be done to make my child better?”)
- Local wound care: Sitting in tub or basin (sitz baths) with warm water and mild soap cleanses the wound of stool and urine and soothes the muscle around the anus. Sitz baths decrease the pain associated with the tear. This should be done at least 2-3 times a day and after stooling.
- Medicine: Stool softeners and laxatives make the stool easier and less painful to pass. These medicines are important to make healing of the tear faster. Acetaminophen (Tylenol) and/or ibuprofen (Motrin or Advil) may help with pain.
- Diet: To prevent constipation, a diet high in fiber (fruits and vegetables) and with adequate water is recommended to prevent constipation.
- Surgery: Is rarely needed for anal fissures. Sometimes a rectal biopsy is indicated to evaluate for causes of constipation. In older children, endoscopy (colonoscopy) may be necessary to evaluate for inflammatory disorders of the colon.
- Risks/benefits of surgery: If a biopsy of the rectum is needed, it is usually not done when there is a painful fissure. Risks of biopsy include bleeding.
Home Care (“What do I need to do once my child goes home?”)
- Diet: Your child’s diet should have plenty of fruits and vegetables. Prunes and raisins help soften stools. Apples and bananas can cause constipation, so limit these fruits. Adequate water intake is important.
- Activity: No restrictions in activity.
- Wound care: Sitz baths (soaking in a tub of warm water) 2-3 times a day and after bowel movements. Pat the anal area dry.
- Medicines: Stool softeners, laxatives and fiber additives may be prescribed for your child. Acetaminophen and/or ibuprofen may help with pain.
- What to call the doctor for: Call the doctor or seek medical attention if your child has redness around the anus, drainage of pus, inability to stool, swelling or the belly, vomiting or inability to eat.
- Follow-up care: Your child should be followed regularly by your pediatrician or gastroenterologist (intestine specialist) doctor to make sure the fissure is healing and that the constipation is getting better.
Long-Term Outcomes (“Are there future conditions to worry about?”)
Most infants and children with anal fissures will have no long-term problems. Occasionally, skin tags or growth of tissue will form over the fissure which may cause some discomfort. Usually, once the constipation has resolved, these skin tags will disappear. The most concerning issue in children having anal fissures is chronic constipation that made lead to an endless cycle of pain with bowel movements, repeated trauma to the anus and worsening constipation.
Author: Patricia Lange, MD
Editor: Marjorie J. Arca, MD