Anal fissure

What is an anal fissure?

An anal fissure is an elongated tear or crack 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 bowel movements. 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 described as 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 edges of the mucous membrane 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 stressed 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 can injure the sensitive mucous membrane and cause a tear as they pass through the anal canal. People who suffer from chronic constipation are particularly susceptible to anal fissures because they often have to strain hard during bowel movements.

2. strong pressure during bowel movements

Excessive straining during bowel movements, whether due to constipation or inadequate bowel habits, significantly increases the pressure in the anal canal. This pressure can overstretch the mucous membrane and ultimately lead to a tear. This cause occurs frequently, especially in people who have to strain 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 the rapid bowel movements overload the anal canal, which can also lead to a tear.

4. trauma and injuries

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

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 mucous membrane more susceptible to tears.

6. reduced blood flow

Reduced blood flow in the anal area can slow 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 puts pressure on the pelvic floor, which increases the risk of constipation and thus also of anal fissures. In addition, the birthing process can cause anal fissures due to the strain on the anal canal and pelvic floor.

Symptoms

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 bowel movements. This pain can last for minutes or even hours and is often so severe that those affected avoid bowel movements for fear of the pain. This in turn leads to constipation, which worsens 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 alarming. It results from the injury to the sensitive mucous membrane in the anal canal.

3. itching and burning

Irritation of the mucous membrane can lead to severe itching and burning in the anal area. These symptoms often worsen after bowel movements or after sitting for long periods.

4. spasm of the sphincter muscle (sphincter spasm)

An anal fissure often leads to a reflex-like spasm of the internal sphincter muscle (sphincter spasm). This spasm intensifies the pain and reduces blood flow to the mucous membrane, which makes healing more difficult and maintains the vicious cycle of discomfort.

In addition:

• The spasm leads to a narrowing of the anal canal, which makes bowel movements even more painful.
• As the blood flow to the affected area is reduced, the healing process can be slower.
• This cramp often occurs immediately after a bowel movement and can lead to a constant feeling of pain, even without further bowel movements.
• In some cases, this spasm can become chronic and increase the risk of a chronic anal fissure.

5. fear of bowel movements

The severe pain and bleeding cause many sufferers to have 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 constipation and the anal fissure.

6. symptoms of chronic anal fissure

Chronic anal fissures develop from untreated acute anal fissures and are often more difficult to heal. Typical symptoms are

• Persistent pain: Especially during and after bowel movements, often accompanied by a burning sensation.
• Bleeding: Fresh, bright red blood on the toilet paper or in the stool.
• Hardening: Noticeable lumps or scar tissue at the edge of the anus.
• Sphincter spasm: A reflex-like contraction of the sphincter muscle that intensifies the pain.

Diagnosis

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 diagnosing an anal fissure is to take a detailed medical history. The doctor will ask the patient about the symptoms, their duration and intensity, and possible triggers. Particular attention is 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 acute anal fissures, the tear is usually clearly visible, especially if it is located in the posterior area of the anal canal. A chronic anal fissure can be characterized by thickened edges and the formation of skin folds (so-called “sentinel piles”).

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 performed with the utmost 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 identify 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 procedures may be necessary to ensure a permanent cure.

Anal fissure: promote and accelerate healing

In most cases, doctors begin with conservative measures to relieve the symptoms of an acute anal fissure and support the healing process. These approaches aim to facilitate bowel movements, relax the sphincter muscle, and soothe 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 fruits, vegetables, whole grains, and legumes helps to keep the stool soft and avoid constipation. This facilitates bowel movements 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 hydration is crucial to keep the stool soft and pliable. At least 1.5 to 2 liters of water per day is ideal to prevent constipation and support the healing process.

• Stool-regulating medication

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

• Sitz baths

Sitz baths with warm water are an effective measure for pain relief and relaxation of the sphincter muscle. The baths promote blood circulation and help to accelerate healing. It is recommended to take sitz baths several times a day, especially after bowel movements, to relieve symptoms. Additives such as chamomile 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. The most commonly used medications include:

• Nitro-ointments (nitroglycerin): These ointments work by relaxing the sphincter muscles and improving blood flow to the affected region, which supports 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 containing analgesic substances such as lidocaine can be used to relieve pain in the short term, but should not be used for long periods of time.

Minimally invasive treatment methods

If conservative treatments do not bring 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 muscles. In the treatment of anal fissures, Botox is injected directly into the sphincter muscle to release the muscle spasm and reduce pressure on the fissure. This promotes healing, as the reduced muscle tone improves blood flow and reduces the strain on the mucous membrane. The effect of Botox usually lasts for several months, and many patients report a 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 dilation is another minimally invasive method in which the anal canal is carefully stretched under anesthesia. This aims to relax the sphincter muscle and reduce pressure on the anal fissure. This method is used less frequently today because 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 in particularly persistent chronic anal fissures, surgical treatment may be necessary. The 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. Sphincterotomy leads to complete healing of the anal fissure in most cases and has a very low recurrence rate.

The risks of this operation are minimal, but as with any surgical procedure, there are possible 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

In 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 creating space for new, healthy tissue. This procedure can also be performed under general or local anesthesia.

Chronic anal fissure healing time

The healing of a chronic anal fissure can take several weeks to months, depending on the severity of the fissure and the chosen treatment method.

In many cases, it may be necessary to combine conservative treatments with stronger medical interventions such as fissure surgery to speed up healing.

Prevention of anal fissures

Since anal fissures are often caused by mechanical stress and unfavorable lifestyle habits, prevention is crucial to avoid relapses and promote general intestinal 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, both of which are major causes of anal fissures. By consuming whole grains, fruits, vegetables, and legumes, the stool remains soft and pliable, which facilitates bowel movements 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. Lack of fluids can lead to constipation and hard stools, which increases the risk of anal fissures.

3. regular exercise

Physical activity promotes intestinal activity and helps to avoid constipation. Even moderate exercise, such as daily walking or light training, can improve digestion and reduce the risk of anal fissures.

4. avoidance of heavy pressing

Excessive straining during bowel movements should be avoided, as it can lead to increased pressure on the anal mucosa. Take your time for bowel movements and try not to force the stool.

5. gentle anal hygiene

Gentle cleaning of the anal area after bowel movements 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 and alcohol if possible.

Complications of an untreated anal fissure

An untreated anal fissure can lead to a number of complications that can significantly impair 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 chronic cramping of the sphincter muscle, which makes healing more difficult and intensifies the pain. This muscle spasm can also lead to a circulatory disorder, which further hinders the regeneration of the tissue.

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

In chronic anal fissures, so-called sentinel piles can form. These skin folds often form at the edge of the fissure and can further complicate healing.

Summary

An anal fissure is a painful condition that can significantly impair the quality of life of those affected. However, a complete cure can be achieved through timely diagnosis and modern treatment methods. At the 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 relieve the symptoms and restore the health of your anal canal.