Anal fissure

What is an anal fissure?

An anal fissure is an elongated tear or tear in the mucous membrane of the anal canal.
The mucous membrane in the anal canal is extremely sensitive and such a tear can cause severe pain, especially during and after a bowel movement.
Anal fissures are divided into two categories:

1. Acute anal fissure: This type of fissure develops suddenly and is usually short-lived.
   An acute fissure can heal on its own within a few weeks if the trigger is removed.
2. Chronic anal fissure: A fissure is considered chronic if it persists for more than eight weeks.
   Chronic anal fissures often do not heal on their own and require more intensive treatment.
   They are often associated with a thickening of the mucosal edges and the formation of skin folds, which makes healing more difficult.

An anal fissure typically occurs at the posterior commissure (rear area) of the anal canal, as this area is particularly strained during bowel movements.
In rarer cases, it can also occur at the anterior commissure.

Causes of anal fissure

The causes of anal fissures are varied and include both mechanical and inflammatory factors.
The most common causes include

1. constipation and hard stools

One of the main causes of anal fissures is chronic constipation.
Hard stools passing through the anal canal can injure the sensitive mucous membrane and cause a tear.
People who suffer from chronic constipation are particularly susceptible to anal fissures as they often have to push hard during bowel movements.

2. strong pressure during bowel movements

Pressing hard during bowel movements, whether due to constipation or an inadequate bowel habit, significantly increases the pressure in the anal canal.
This pressure can overstretch the mucous membrane and ultimately lead to a tear.
This cause is particularly common in people who have to push regularly.

3. diarrhea

Contrary to the common assumption that only hard stools cause anal fissures, frequent diarrhea can also be the cause.
The constant irritation of the mucous membrane and rapid bowel movements overload the anal canal, which can also lead to a fissure.

4. trauma and injuries

Trauma or injuries in the anal area can also lead to the development of anal fissures.
Common causes are excessive cleaning of the anus, aggressive enemas or mechanical irritation through anal intercourse.
These traumatic effects damage the sensitive mucous membrane and lead to fissures.

5. inflammatory bowel diseases

People with inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis have an increased risk of developing anal fissures.
These diseases lead to chronic inflammation of the intestinal mucosa, which makes the mucosa more susceptible to fissures.

6. reduced blood flow

Reduced blood flow in the anal area can slow down the healing of small tears and increase the risk of anal fissures.
This is particularly common in older people or people with circulatory disorders, such as diabetes.

7 Pregnancy and birth

During pregnancy, the growing fetus exerts pressure on the pelvic floor, which increases the risk of constipation and therefore anal fissures.
The birth process can also cause anal fissures due to the strain on the anal canal and pelvic floor.

Symptoms of anal fissure

The symptoms of an anal fissure are often very characteristic and cause considerable discomfort for those affected.
Typical symptoms are

1. severe pain during bowel movements

The most noticeable symptom of an anal fissure is severe, burning or stabbing pain during and after a bowel movement.
This pain can last for minutes or even hours and is often so severe that sufferers avoid having a bowel movement for fear of the pain.
This in turn leads to constipation, which exacerbates the cycle of discomfort.

2. bleeding

Bright red blood on the toilet paper or in the stool is another common symptom of an anal fissure.
The bleeding is usually light but can be distressing.
They result from injury to the sensitive mucous membrane in the anal canal.

3. itching and burning

Irritation of the mucous membrane can cause severe itching and burning in the anal area.
These symptoms often worsen after a bowel movement or after prolonged sitting.

4. cramping of the sphincter muscle

Anal fissures often lead to a reflex spasm of the internal sphincter muscle (sphincter spasm).
This spasm increases the pain and reduces the blood flow to the mucous membrane, which makes healing more difficult and perpetuates the vicious circle of discomfort.

5. fear of bowel movements

For many sufferers, the severe pain and bleeding lead to a real fear of the next bowel movement.
This fear often leads to avoidance of bowel movements, which in turn leads to a worsening of the constipation and anal fissure.

Diagnosis of an anal fissure

The diagnosis of an anal fissure is usually relatively simple and is based on a combination of medical history and physical examination.
The following steps are crucial:

1. anamnesis

The first step in the diagnosis of an anal fissure is to take a detailed medical history.
The doctor will ask the patient about the symptoms, their duration and intensity as well as possible triggers.
Particular attention will be paid to bowel habits, nutritional status and possible pre-existing conditions (e.g. Crohn’s disease).

2. physical examination

As part of the physical examination, the doctor will carefully inspect the anus and anal area.
In the case of acute anal fissures, the tear is usually clearly visible, especially if it is located at the back of the anal canal.
A chronic anal fissure can be characterized by thickened edges and the formation of skin folds (so-called “sentinel haemorrhoids”).

3. rectal examination

In some cases, a careful rectal examination may be necessary to check the condition of the sphincter muscle.
However, this examination can be difficult in acute anal fissures due to the severe pain and should be carried out with great care.

4. endoscopy and other imaging procedures

If an underlying inflammatory bowel disease is suspected, an endoscopy or colonoscopy may be necessary.
These examinations allow the doctor to examine the entire intestinal tract and detect possible inflammation or other changes.

Modern treatment methods for anal fissures

The treatment of anal fissures depends on the severity of the symptoms and the stage of the disease.
A basic distinction is made between conservative, minimally invasive and surgical treatment methods.
Early treatment can quickly alleviate the symptoms and promote healing.
In severe or chronic cases, minimally invasive or surgical interventions may be necessary to ensure a permanent cure.

Conservative treatment methods

In most cases, doctors start with conservative measures to alleviate the symptoms of an acute anal fissure and support the healing process.
These approaches are aimed at facilitating bowel movements, relaxing the sphincter muscle and soothing the mucous membrane.

• Change of diet

A high-fiber diet is one of the cornerstones of conservative treatment for anal fissures.
Eating foods such as fruit, vegetables, wholegrain products and pulses helps to keep the stool soft and prevent constipation.
This makes bowel movements easier and reduces pressure on the anal mucosa.
It is recommended to consume at least 25 to 30 grams of fiber per day.

• Fluid intake

Adequate fluid intake is crucial to keep the stool soft and smooth.
At least 1.5 to 2 liters of water per day is ideal to prevent constipation and support the healing process.

• Stool-regulating medication

If constipation persists, stool-regulating medication such as stool softeners (e.g. Docusat) or osmotic laxatives (e.g. lactulose or polyethylene glycol) may be prescribed.
These medications help to soften the stool and reduce the pressure during bowel movements, thereby protecting the mucous membrane.

• Sitz baths

Sitz baths with warm water are an effective way of relieving pain and relaxing the sphincter muscle.
The baths promote blood circulation and help to speed up healing.
It is recommended to take sitz baths several times a day, especially after a bowel movement, to relieve the symptoms.
Additives such as camomile or oak bark have anti-inflammatory and soothing properties and can enhance the effect of the sitz baths.

• Topical medications

There are a variety of ointments and suppositories that can be used to relieve anal fissures.
These usually contain anti-inflammatory or antispasmodic substances that relax the sphincter muscle and promote healing.
Commonly used medications include

• Nitro ointments (nitroglycerin): These ointments work by relaxing the sphincter muscles and improving blood flow to the affected area, which aids healing.
  However, they can cause headaches as a side effect.
• Calcium channel blockers (e.g. diltiazem): These drugs also work by relaxing the sphincter muscle and have fewer side effects than nitroglycerin ointments.
• Local anesthetics: Ointments with pain-relieving substances such as lidocaine can be used for short-term pain relief, but should not be used for long periods of time.

Minimally invasive treatment methods

If conservative treatments do not bring any improvement after 6 to 8 weeks, minimally invasive procedures can be considered.
These methods are particularly effective for chronic anal fissures and help to relax the sphincter muscle and promote the healing process.

• Botox injections

Botulinum toxin (Botox) is a neurotoxin that can relax the muscles.
In the treatment of anal fissures, Botox is injected directly into the sphincter muscle to release the muscle spasm and reduce the pressure on the fissure.
This promotes healing, as the reduced muscle tone improves blood circulation and reduces the strain on the mucous membrane.
The effect of Botox usually lasts for several months and many patients report significant relief of symptoms.
This method is used in particular for chronic anal fissures that do not respond to conservative treatments.

• Dilation of the anal canal (manual dilatation)

Manual dilatation is another minimally invasive method in which the anal canal is carefully stretched under anesthesia.
This aims to relax the sphincter muscle and reduce the pressure on the anal fissure.
This method is used less frequently today as it is associated with a higher risk of complications such as incontinence.

Surgical treatment methods

In cases where conservative and minimally invasive treatments fail, or for particularly stubborn chronic anal fissures, surgical treatment may be necessary.
Surgical procedures are usually very effective and offer a permanent solution for patients suffering from chronic pain and discomfort.

• Lateral sphincterotomy

Lateral sphincterotomy is the gold standard in the surgical treatment of chronic anal fissures.
In this procedure, part of the internal sphincter muscle is cut to reduce muscle tone and allow healing.
This procedure is usually performed under general or local anesthesia and is very effective.
In most cases, sphincterotomy leads to complete healing of the anal fissure and has a very low recurrence rate.

The risks of this operation are minimal, but as with any surgical procedure, there are potential complications, including temporary or, in rare cases, permanent incontinence.
Nevertheless, lateral sphincterotomy is considered a safe and effective treatment method with a high success rate.

• Fissurectomy

During a fissurectomy, the damaged tissue of the chronic anal fissure is surgically removed.
This procedure is usually performed for chronic fissures that do not respond to other treatments.
Fissurectomy promotes healing by removing the damaged tissue and making room for new, healthy tissue.
This procedure can also be performed under general or local anesthesia.

Prevention of anal fissures

Since anal fissures are often caused by mechanical stress and unfavorable lifestyle habits, prevention is crucial to avoid recurrences and promote overall bowel health.
Here are some important measures to reduce the risk of anal fissures:

1. high-fiber diet

A high-fiber diet is key to avoiding constipation and hard stools, which are both major causes of anal fissures.
Eating whole grains, fruits, vegetables and legumes keeps stools soft and pliable, which makes bowel movements easier and reduces pressure on the anal canal.

2. sufficient fluid intake

Drinking enough water (at least 1.5 to 2 liters per day) is crucial to keep the stool soft.
A lack of fluids can lead to constipation and hard stools, which increases the risk of anal fissures.

3. regular exercise

Physical activity promotes bowel function and helps to prevent constipation.
Even moderate exercise, such as a daily walk or light training, can improve digestion and reduce the risk of anal fissures.

4. avoidance of heavy pressing

Forceful pushing during bowel movements should be avoided as it can lead to increased pressure on the anal mucosa.
Take your time to have a bowel movement and try not to force the stool.

5. gentle anal hygiene

Gentle cleansing of the anal area after a bowel movement is important to avoid irritation and injury to the sensitive mucous membrane.
Avoid excessive rubbing and use soft toilet paper or moist wipes without perfume or alcohol if possible.

Complications of an untreated anal fissure

An untreated anal fissure can lead to a number of complications that can significantly affect the quality of life of those affected.
These include

1. chronification

If an anal fissure is not treated in time, it can become chronic.
Chronic fissures are more difficult to treat and often require more intensive or surgical measures to achieve complete healing.

2. painful sphincter spasm

A persistent anal fissure often leads to a chronic spasm of the sphincter muscle, which makes healing more difficult and increases the pain.
This muscle spasm can also lead to a circulatory disorder, which further impedes tissue regeneration.

3. infections

The mucous membrane in the anal canal serves as a protective barrier against bacteria.
If this is damaged by an anal fissure, there is a risk of bacterial infection.
Such an infection can spread to the surrounding tissue and lead to an anal abscess or fistula.

4. sentinel hemorrhoids

Chronic anal fissures can lead to the formation of so-called sentinel haemorrhoids.
These skin folds often form at the edge of the fissure and can make healing even more difficult.

Summary

An anal fissure is a painful condition that can significantly impair the quality of life of those affected.
However, timely diagnosis and modern treatment methods can lead to a complete cure.
At VenaZiel Venenzentrum Berlin, we offer specialized diagnostic and therapeutic approaches for anal fissures that are tailored to the individual needs of our patients.
From conservative measures to minimally invasive and surgical treatments – we help you to alleviate the symptoms and restore the health of your anal canal.