Anal fissure: causes, symptoms, treatment

When cracks in the anal canal mucosa cause pain

The anal fissure is a longitudinal crack in the mucous membrane of the anal canal and is therefore also called anal crack or anal crack. Usually such a crack has a length of one to two centimeters.

Anal fissure is almost always a benign disease that can be treated easily. A distinction is made between the acute and the chronic form. Depending on the stage, conservative or surgical treatment methods are used.

Causes anal fissure: stool too hard

The mucous membrane of the anal canal can always be affected and rupture if the area is too heavily stressed. Common causes for anal fissures are therefore:

Stool too hard (constipation)
diarrhoea
Too much pressing during bowel movement
Too much elongation of the area (anal intercourse)

If the anal mucosa (Anoderm) is already pre-damaged as in the case of enlarged haemorrhoids or inflammations of the anal glands (cryptitis), a tear can also occur during normal bowel movements.

Symptoms anal fissure: How to recognize the disease

The acute anal fissure looks like a cut. Typically an anal fissure is accompanied by stinging or burning pain during bowel movement, usually of short duration. The second leading symptom is bright red, sometimes not inconsiderable bleeding. Many patients also have only one bleeding or pain and not both symptoms.

If periods without symptoms alternate with periods when symptoms recur, the disease is likely to be chronic.

Even if the pain is dull, delayed after the bowel movement and longer lasting, this indicates the development of a chronic anal fissure. Patients often report that the pain radiates to the coccyx.

Other complaints that may develop during the course of the disease are itching, anal moisture, traces of blood on toilet paper, constipation with incomplete emptying of the rectum and increased flatulence. Externally visible signs of chronic anal fissure are skin thickening or skin wrinkles called outpost wrinkles. Some patients feel a palpable hardening.

Since these typical symptoms also occur in other proctological diseases such as the coccyx fistula, an exact diagnosis of anal fissure is important.

Treatment anal fissure: conservative and operative

Despite unfavourable conditions in the wound area (intestinal bacteria, confinement, moisture, mechanical stress) the acute anal fissure heals surprisingly mostly by itself. If the symptoms quickly subside, the disease appears to be cured. But sometimes only an apparent healing has occurred: The wound sticks together and heals superficially, but in the depths a chronic inflammation develops due to the intestinal bacteria.

If the scar is not stable and tears open again and again even in normal stools, outpost folds and growths of the mucous membrane (hypertrophic anal papilla) develop. These skin lobules are often thought to be a hemorrhoid or a polyp. They can assume considerable size and emerge from the anus. Over time, the niche can deepen more and more, in which stool particles and bacteria settle, which further irritate the mucous membrane.

Conservative treatment methods

If an acute anal fissure has not existed for a long time, surgery can often be avoided:

Stool regulation: With very hard stools, the anal fissure tears open again and again due to stretching during stool passage. Very soft stool penetrates more into the wound and adheres more strongly to the base of the wound. So the aim is a shaped, not too hard chair. Flea seed shells are ideally suited for chair regulation. They bind liquid and thus make the hard stool softer and soft stool somewhat firmer.
Ointment treatment: Various active ingredients can be used to treat anal fissure. The most common is a combination of local anaesthesia (with lidocaine) and relaxation of the sphincter muscle (with diltiazem). This should give the anal fissure the chance not only to adhere superficially, but also to heal stably from the depth.
Low-Level-Laser-Therapy: The use of laser light is already known for chronic problem wounds that do not want to heal. The same mechanisms of action also apply in the treatment of anal fissure: inflammation inhibition, stimulation of growth factors, improvement of connective tissue stability as well as microcirculation and cellular metabolic activity. Treatment with this form of therapy is therefore also obvious for chronic anal fissure. The treatment takes place once or twice a week for six weeks and is painless. The majority of patients experience a noticeable improvement as a result of this treatment. An assessment with regard to long-term healing is not yet possible with this alternative treatment method.

Surgical treatment methods

The so-called fissurectomy has the purpose to make a deep wound a flat one and to eliminate any kind of pocket or niche formation. Then the wound can heal from the depth and a long-term freedom from symptoms is to be expected. This procedure is always performed under anaesthesia in order not to overlook an anal fistula that sometimes developed at the same time or as a result of the anal fissure.

In our proctological practice we take care of the professional treatment of anal fissures. If you have any questions on this subject, please do not hesitate to call us to arrange an appointment. Dr. Hofer and Mr. Bärtl will be happy to assist you.

Anal fissure: When is surgery necessary?

If there is very severe pain which often occurs shortly after bowel movement and then lasts for hours or even the whole day.
When bleeding occurs in almost every bowel movement for a week or longer
If a complaint has been pending for more than half a year
If there are secondary changes: outpost fold, hypertrophic anal papilla