Anal fissure often occurs between
the edge of the anus and the dentate line manifested by pain. It is usually found
at the posterior and anterior parts of the anus. According to case analysis, the
author finds that solitary anal fissure of the posterior part of the anus is mostly
seen in man and woman, young and adult, seldom see in children ad the aged. In
addition to the type of the posterior fissure there are two types: that of the
antero-posterior medial single fissure and that of the antero-posterior medial
multiple fissure. These three types are believed to be the main ones. The incidence
of an anal fissure is high and the suffering great. Thus the anal fissure is one
of the three chief anal disorders.
Etiology and Pathogenesis
It is caused
by constipation due to excessive heat and dryness in the intestines, and by over-exertion
on bowel movements. As Yi Zong Jin Jian (The Golden Mirror of Medicine) says:"
Constipation, pathogenic fire and dryness are the cause of the anal fissure."
According to modern medicine and clinical experience the etiology of the anal
fissure has a certain relation to the anorectal anatomy, but is chiefly related
to the local inflammation and mechanical injury, and both of them are cause and
result. The etiology will be discussed as follows.
Factors of Anatomy
Small Elastic Force of the Anus and Poor blood Circulation: Due to distribution
of the external sphincters, a triangle area is formed. The superficial part of
the anterior and posterior anus has small elastic force and poor blood circulation.
It is held that the anal posterior internal sphincters do not have enough support
from the external sphincters, but on both sides of the anus the external and internal
sphincters are tightly related to each other.
2. Heavy Pressure on the Posterior
Anus: the natural angle formed by the anal canal (from the antero-lower to the
postero-upper) and the rectum increases the pressure on the posterior anus on
The above two factors illustrate the reason of the occurrence
of the anal fissure frequently at the front-back position, especially at the back
Inflammation decreases the tissue's elasticity and
increases its fragility. When mechanical injury is added, anal fissure easily
Mechanical injury is the direct pathogenic
factor and anal fissure is considered an initial stage lesion. Chronic anal fissure
may develop on continuous inflammation, Constipation is the main cause, but other
causes, for example, injury by foreign body, anal and rectal examination and operation
exist. From the above, we know that the chief cause is injury and inflammation.
Inflammation makes the tissue become brittle and brittle tissues are easily ruptured.
Mechanical injury further make the brittle or healthy tissues be damaged by inflammation,
either of the factors, mechanical injury and inflammation, being both a cause
and effect. The affected part cannot heal or relapse is frequently seen.
It is held that anal fissure is related to conjunctival belt, or the
fibromembranous tissues, short or elasticity, between the dentate line and the
white line under the distortional skin. Because of this condition, the anal canal
is constantly in a strained condition and the sphincters cannot easily relax.
people think that the anal fissure is closely related to the internal sphincters,
and point out it usually takes place at the internal sphincters. At the base of
the edge of the fissure in chronic anal fissure patients, the internal sphincter
fibrosis can be seen, but in the acute anal fissure patients there is no such
condition. On measurement of the pressure and motility of the anus, it has been
found that the anal pressure in anal fissure patients forms caused y dysfunction
of the internal sphincters. It seems that the internal sphincters are chronic
over-exerting. But it is not clear which is the primary or secondary result.
chapping or ulcer due to tuberculosis is rarely seen clinically.
It is necessary to mention the clinical stage classification
for better treatment.
Anal fissure can be divided into the acute and chronic
Stages. The acute or initial stage is manifested by inflammation, Swollen, congestive
edge of the fissure, and severe pain. Inflammation gives rise to hyperplasia of
the connective tissues at the edge of the fissure. The chronic or late stage called
the old stage lesion is marked by relapse, hyperplasia of the affected connective
tissues, causing its edge swollen and forming typical skin vegetation-a skin tag
at the end of the fissure, called formerly Shao Zhi, Shao bing zhi.
the author's observation the acute attack does not necessarily occur at the initial
stage and the early fissure develops to the chronic stage without a process of
inflammation. Therefore anal fissure can be grouped under the initial stage, chronic
stage and a special acute attack. The early anal injury is produced by a mechanical
injury. Some people maintain that it is an injury of the anus due to rubbing,
which is different from the anal fissure. No matter what it is called and how
serious it is, it is exactly the anal fissure, a precondition of inflammation.
The early anal fissure is easily to heal. The chronic stage has been described
as above. An acute attack may deteriorate the condition, which occurs at any time
between the initial stage and chronic stage. The acute attack can be termed as
the inflammatory state of the anal fissure. It indicates only the condition of
the acute inflammation, not the time of attack. Sometimes the anal fissure is
divided into the first second and third stages.
Symptoms and Signs
(1) Specific Pain: Anal Fissure is manifested by severe pain, although
it is a local limited lesion. Therefore the main suffering is a characteristic
pain. Pain is present on bowel movements. A radiation pain is felt, esp. on passing
hard feces. Typical cases are marked b moderate pain on bowel movements and severe
pain after that, with an interval between these pains, forming a specific pain
cycle. the severe pain after an interval is brought about by sphincterismus, while
the moderate pain on bowel movements is the result of the direct injury or irritation.
Sphincterismus due to pain exerts strong pressure on the fissure and makes the
anus in a state of constant tension.
(2) Hematochezia: Anal pain and hematochezia
of different extent occur simultaneously on bowel movements in some patients.
This bleeding is different from that caused by the internal hemorrhoids marked
by the absence of pain. An examination may tell the coexistence of hemorrhoid
(3) Constipation: Passing of dry stools may cause the anal fissure.
Patients are afraid of pain on bowel movements so that they dare not to make bowel
movements, which produces severe constipation, resulting in a vicious circle,
and habitual constipation easily leads to anal fissure.
2. Local Signs
general, the early anal fissure looks red in color with orderly order and has
no skin vegetation. Prolonged anal fissure is dark red in color and there is fibrous
tissue hyperplasia at the edge and base of the fissure. A skin tag produces outside
the fissure. The skin tag at the anterior, posterior and middle positions is the
typical mark of the chronic anal fissure.
Diagnosis and Differential Diagnosis
is easy to make a diagnosis of the anal fissure, determined by the case history
and local physical signs. Patients often suffer from constant constipation, pain,
and it is easy to tell hematochezia due to internal hemorrhoids from that due
to the anal fissure. On examination it is easy to find the fissure occurring at
the anterior or posterior anus only y expanding the anus. Local signs should be
under careful consideration. For individual patients the anal fissure cannot be
discovered naturally, then anesthesia is followed by examination.
The treating principle is to keep one's bowels open and heal the
fissure. The anal fissure is a mild condition with a severe pain. It can be cured
but recurs frequently. It is significant to know this point, because it is helpful
in differentiation of syndromes. At the initial stage treatment is focused on
moistening the intestines and make free bowel movements, kill pain and stop bleeding.
Operation, in general, is unnecessary. In protracted cases when there is a skin
tag or other complications, surgery is applied.
essential to moisten the intestines and make free bowel movements, and then give
other therapies. So the internal treatment is significant in cure and prevention
of the anal fissure. Clinically, it is most important to keep bowels open instead
of dealing only with the fissure itself. Comprehensive measures can be adopted
to keep bowels open. Here is a detail account.
1. Proper Diet: It is a main
link. Intake of less food, lack of water and food with less cellurose may cause
constipation. It is advisable to take more vegetables and fruits, water and beverages
helpful to keeping bowels open. The following is recommended. The stuff suggested
is carrot, radish, celery, chive, spinach, Chinese cabbage, banana, pear, honey,
sesame oil, sweet potato, yam, water chestnut, raw or cooked peanut, walnut, sesame,
pine nut, white and black edible fungus, pear juice, jujube juice, hawthorn juice
and orange juice.
Banana: It helps bowel movements. At any time you can take
it, or take it on an empty stomach in the morning until free bowel movements take
place. For those who suffer from deficiency and cold in the spleen and stomach,
heat bananas with its skin in hot water and then take them hot to avoid abdominal
Pear: It helps bowel movements, moistens the lung and stops coughing.
Have it mixed in hot water and take it. Good effect is seen when it is taken on
an empty stomach in the morning.
Sesame Oil: It functions to eliminate heat
and make free bowel movements. Mix some in boiling water and take it on an empty
Sweet Potato, Yam: Both function to make free bowel movements. Take
cooked sweet patato or yam as much as you like.
Waternut: It functions to eliminate
heat, and makes free bowel movements. Take it raw or cooked as much as you like.
The powder of waternuts can be mixed in water or prepared into porridge and take
it on an empty stomach in the morning or several times a day.
raw or cooked. The roasted or fried peanuts cannot make free bowel movements.
It functions to strengthen the kidney, moisten the lung and makes free bowel movements.
Take it raw.
Sesame, Black Sesame: They function to strengthen the liver and
kidney, and moisten the intestines. Take it raw or roast it and grind it into
powder, then take it with honey.
Pine Nut Kernel: It contains rich Vitamin
E, functioning to moisten the intestine. appropriate amount is taken each time.
Black Edible Fungus: It helps to make bowels open, replenish Yin and moistens
the lung. It can e taken as a single ingredient or cooked.
Fruit Juice Helping
Bowel Movements: Appropriate amount of pear juice jujube juice, hawthorn juice
mixed with water can be taken several times a day. Orange juice is good for regulation
of qi flow, free bowel movements and whetting appetite.
In the treatment of
constipation, in light of individual constitution, it is advised to eat one kind
of vegetable or fruit or several kinds of vegetables and fruits a day. When the
diet therapy fails, take some purgatives, cessation of which follows if bowel
movements turn to normal. But the diet therapy should go on.
is advisable to take drugs keeping bowels open. They include Tab Phenolphthaleinum,
Isaphenin, Tongbian Ling, Liqiid Paraffin, Runchang Wan, Maren Wan, Maren Zipi
Wan, Runchang Pian, fried Semen Cassiae and Folium Cassiae tea. Oleumricini has
a strong action to relax the bowels, so it is only used for constipation. Suppositories
like glycerin suppository, Daobian suppository and Kai Sai Lu can also make free
movements of the bowels. In addition, acupuncture, moxibustion and massage are
helpful to keeping bowels open.
In the morning after getting up it is high
tie for defecation because peristalsis of the stomach and bowels is accelerating,
which may promote defecation. Although time of defecation varies in different
individuals, keeping the regular time is important. For habitual constipation,
give drugs according to differentiation of syndromes. Timely treatment must be
given to severe cases of constipation.
Analgesics are administered for severe
pain of the anal fissure. Take hemostats if there is much bleeding. No treatment
is needed for a little hemorrhage.
Dr. Ming's TCM Medical Center,
Xi Xiao Yuan, Hutian Developing Area,
Huaihua city, Hunan province