Women and men are affected by anal fissures about equally often. Most patients are between 40 and 50 years old at the time of diagnosis. However, children can also develop anal fissures.
Most anal fissures heal spontaneously. In the case of non-healing anal fissures, medication or surgery usually help, so that healing is also possible here.
Depending on how long the mucosal tear has existed, it is referred to as an
- acute anal fissure or
- a chronic anal fissure.
If the tear has been present for less than six weeks, the patient suffers from an acute anal fissure. If it lasts for more than six to eight weeks, it is a chronic anal fissure.
Depending on the cause, a distinction is also made between primary and secondary anal fissures. In secondary forms, the fissure is caused by another disease. This is not the case with primary anal fissures.
Rhagades are to be distinguished from anal fissures. These are tears in the skin around the anus, not tears in the mucous membrane of the anal canal.
Most anal fissures are located on the lowest section of the anal opening facing the back. The fissure may be visible from the outside. However, it can also be on the inside and only be found on closer inspection of the anal canal.
Some patients experience pain during bowel movements. It usually lasts a few minutes, but can also last for hours. There is often some bright red blood on the toilet paper, sometimes also on the stool. Without a bowel movement, however, most patients have no symptoms.
Occasionally there is a rash and itching around the anus.
Chronic anal fissures can lead to changes around the tear in the mucous membrane. These include enlarged anal papillae. These are pinhead-sized nodules in the mucous membrane. In the case of an anal fissure, they can grow to the size of a cherry. They are then also called anal polyps or anal fibromas.
Marsicles can also occur. Marisci are folds of skin around the anus and are therefore also known as anal folds or forepost folds.
An anal fissure is a small wound in the mucous membrane of the anal canal © bilderzwerg | AdobeStock
In most cases, no cause for the anal fissure can be identified. Doctors then speak of a primary anal fissure.
How such a primary anal fissure develops has not yet been precisely clarified. However, it is assumed that
play a role in its development.
As a result of the pain caused by the tear, the sphincter muscle contracts spasmodically. The sphincter muscle surrounds the anal canal and regulates the evacuation of stool. This increase in sphincter pressure worsens the blood supply to the mucous membrane. This in turn has a negative effect on wound healing.
As a result, an acute anal fissure can develop into a chronic condition.
Secondary anal fissures are tears that occur due to another illness or injury. Triggers for a secondary anal fissure can be
Risk factors include circumstances that promote constipation and hard stools and therefore increased pressure in the sphincter muscle. These include, for example
Other risk factors include the insertion of foreign bodies into the anal canal and rough anal intercourse.
The doctor first examines the anus and the anal canal. The examiner can often already see the anal fissure by spreading the buttocks. It is also usually possible to tell at this stage whether an anal fissure or a hemorrhoid is present.
As a rule, the proctologist then palpates the anal canal with a finger(digital rectal examination). This examination is usually painful in the case of an acute anal fissure and is not always necessary. Chronic anal fissures are less painful. In this case, the doctor can use a digital rectal examination to detect any scarring.
The doctor uses an anal spreader or a proctoscope (short tube with a light source) to assess the anal canal. This proctoscopy is also known as
- anal endoscopy,
- rectoscopy or
- rectoscopy
known.
This examination provides information about changes in the anal canal that have similar symptoms to anal fissures and therefore need to be ruled out.
Due to the possible pain to be expected during the proctoscopy, the doctor may also first attempt treatment. The prerequisite for this is typical symptoms and a visible mucosal tear.
However, if there is any doubt about the diagnosis, an anal endoscopy must be performed. This is performed under local anesthesia or general anesthesia.
Only in rare cases are further examinations considered, such as
They are used to rule out other diseases or to diagnose underlying diseases.
Proctologists are specialists in anal fissures. They deal with diseases of the rectum, i.e. the rectum and anal canal.
Treatment is aimed at regulating the stool through diet. It also addresses pain, particularly in the case of acute anal fissures, and attempts to reduce sphincter pressure.
Nutrition
An important component of the treatment is a diet rich in fiber. Psyllium husks, for example, can also regulate bowel movements.
However, the stool should not be liquid. You should therefore not take strong laxatives as part of the treatment.
Drug treatment: creams, ointments, tampons and injections
The local application of ointments or creams usually helps very well. As a result, most acute anal fissures heal within six to eight weeks. Studies have shown that calcium channel blockers (e.g. nifedipine and diltiazem) are particularly effective.
Just like nitrates (e.g. glyceryl trinitrate), these medications reduce the pressure in the sphincter muscle or relax it. However, nitrates often cause headaches.
If eczema is present in addition to the anal fissure, the use of creams or ointments containing cortisone is also recommended. Local ointments with local anesthetics (lidocaine) can be used to relieve acute pain.
Some medications are inserted into the anal canal using anal tampons. This releases the active ingredients over a longer period of time.
Anal dilators
Anal dilators inserted into the anal canal can also support healing. They are used alone or in combination with the medications mentioned above.
You can perform anal dilatation independently and carefully several times a day.
Do home remedies, sitz baths and the like help against anal fissures?
Home remedies such as sitz baths and natural remedies can be pleasant, but they do not heal anal fissures. Zinc ointments should not be used on open wounds such as anal fissures.
Bepanthen is supposed to promote wound healing for small tears. However, the current guidelines do not mention it as a treatment option.
Surgery is only a possible option if there is no healing after six to eight weeks of medical treatment. Surgery is often used for chronic anal fissures. The following surgical procedures have become established:
Fissurectomy (= excision of the anal fissure): Therapy of choice according to guidelines. The fissure is cut out flat together with the inflamed and scarred tissue. The wound is not sutured. The sphincter muscle remains uninjured. Sometimes a flap of mucous membrane or skin is placed over the excised area and sutured (anal advancement flap). Fissurectomy has a higher success rate than drug therapy approaches.
Fissurectomy with simultaneous botulinum toxin application: The sphincter muscle is additionally relaxed with the help of "Botox". This could be an advantage over cutting out the fissure alone.
Cutting of the sphincter muscle (sphincterotomy): Severing part of the internal sphincter muscle has a higher success rate than fissurectomy. However, there is a higher risk of fecal incontinence after the procedure.
There are also other procedures that have not yet been established. These include, for example, treatment with a fractionated CO2 laser.
The operation is generally performed on an outpatient basis and under short anesthesia. After the operation, there is usually pain in the anal area for a few days. However, this pain improves quickly.
You will need to keep the open wound caused by the operation clean for a few weeks until it has completely healed. To do this, you should douche the wound several times a day and after every bowel movement. Sitz baths are not necessary. On the contrary: they tend to slow down wound healing.
Many acute anal fissures heal spontaneously, i.e. without treatment. Up to 90 percent of acute anal fissures heal with the help of medication and physical therapy. In the chronic form, the healing rate with this therapy is still around 50 percent.
However, the chances of healing are also very good with the help of surgical treatment options. The cure rates for fissurectomy are around 73 to 80 percent and for sphincterotomy around 80 to 93 percent.
However, it should be noted that there is an increased risk of fecal incontinence. After a fissurectomy, up to around eleven percent of patients suffer from this. After a sphincterotomy, it is even up to 20 percent of patients.
Some patients develop anal fissures again after a few years (so-called recurrence). An adapted diet is necessary to prevent anal fissures and their recurrence.
A diet rich in fiber and fibers, possibly supported by psyllium husks, helps to regulate the consistency of the stool. Anal dilators can also prevent a recurrence.
