![]() Remember, the internal anal sphincter does not know how to relax and therefore continuously squeezes the cut causing more pain. Because the mouth remains relaxed it allows the cut to heal more quickly. Over a few minutes you relax your lips and remove your hand. This is the typical reflex for any kind of pain. Remember that as soon as the lip splits you purse your lips and put pressure on the cut with your hand. The internal anal sphincter spasm causes increased pressure and tension which is the cause of the persistent pain (see graph 1) and prevents the fissure from healing (see graph 2). It is this hyperactive squeezing that makes the pain relentless and makes it difficult for the cut to heal. Unfortunately, the internal sphincters don’t know how to relax and remain very tight. You will eventually relax the external sphincter as you have control over this muscle complex. The pain reflexively causes the internal and the external sphincters to contract (squeeze) very tight. Usually after a constipated bowel movement or a bout of diarrhea, the skin can split causing pain and bleeding. The internal anal sphincter squeezes tight at all times in order to prevent stool from leaking out of the anus. When you feel the urge to fart while you happen to be on a crowded elevator it is this muscle that you squeeze as hard as you can to prevent the embarrassment that will reign over you if you let the gas out! On the other hand, you have no control of the internal anal sphincter which is in a state of contraction at all times (unless you are trying to have a bowel movement). ![]() It is primarily in a state of relaxation. The external sphincter is the one that you have control over. There are 2 types of anal muscles the external and the internal anal sphincters. Like the mouth, the anus is surrounded by skin and muscle. The pathophysiology of the anus is very complicated but I will try to explain it as best as I can. A proctologist is trained to know the difference. Many patients feel that the swollen tag which is tender is a hemorrhoid. When the examining physician sees the tags and visible internal sphincter muscle, this indicates the fissure is chronic and has less of a chance of healing. Chronic fissures are usually associated with a tag at the outside edge of the anus (sentinel pile) and a tag inside the anus (hypertrophied anal papillae). When a fissure lasts over 6 weeks it is considered chronic and has less than a 60% chance of healing. An acute fissure has an 80% chance of healing. Fissures can be acute (new) or chronic (persistent). Due to the increased vascularity of the anus the bleeding can be impressive but almost always stops after a few minutes. ![]() The blood can be seen on the toilet paper or it can drip into the bowl. The skin around the anus splits causing a sharp or burning pain and bleeding. An anal fissure is exactly the same thing. Over time you stopped pursing your lips and relaxed your mouth. When you looked at your hand you noticed a little blood. At that moment you knew you cut your lip and immediately pursed your lips and put the back of your hand to your mouth to hold pressure. After you opened your mouth as wide as you could, the side of your lip split open. Think about the last time you tried to bite into a sandwich that was too big. A fissure is a tear of the skin at the edge of the anus.
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