An anal fissure is a painful, elongated tear in the anal lining. It is often caused by straining too hard with a hard stool. A typical sign of an anal fissure is stabbing pain during bowel movements. In most cases, it is an acute anal fissure that can be treated with ointments and stool-regulating measures. If the condition is chronic, surgery may be necessary. Find out here what causes an anal fissure, how it can be treated and what effective prevention looks like.
ICD codes for anal fissure disease: K60
• What is an anal fissure? Painful tear in the mucous membrane of the anal canal.
• Symptoms: pain during and after a bowel movement, cramps in the anal sphincter, itching, bleeding, weeping or mucus discharge from the wound, possibly thickening of the skin.
• Causes: Often straining during bowel movements or excessively hard stool, possibly also anal sexual practices, haemorrhoids, diarrhea, chronic inflammatory bowel diseases (Crohn’s disease, ulcerative colitis).
• Diagnosis: Conversation, physical examination, rectal endoscopy if necessary.
• Treatment: conservative with ointments, creams, baths; in the case of a chronic course, surgery.
• Attending physician: proctologist, gastroenterologist.
• Prognosis: An anal fissure is easily treatable, but can recur if there is persistent hard stool or other risk factors.
Anal fissure: symptoms
The anal fissure (Latin fissura, “tear”) is a longitudinal tear in the fine skin or mucous membrane at the mouth of the anal canal (anoderm). There are a lot of sensitive nerve endings there. An injury in this area is correspondingly painful.
An acute anal fissure lasts a maximum of four to six weeks. It becomes noticeable through a stabbing pain in the anus, which occurs when the skin tears. As a result, stool can only be excreted with pain (painful defecation). To avoid this pain, many sufferers hold back their stool (stool retention). A vicious circle, because the retained droppings continue to thicken and become even harder. This ultimately makes going to the toilet even more painful. Typically, the symptoms persist even after going to the toilet in the form of a constant burning pain.
Problematic: The pain can cause the sphincter to cramp so much that the symptoms continue to intensify. The tissue may no longer be well supplied with blood, so that the anal fissure heals more slowly. There is a risk that the acute tear will develop into a chronic anal fissure.
In addition, sphincter spasms may cause further mucosal tears. Because of such muscle cramps you have to push harder when having a bowel movement.
If the tear extends deep into the inner sphincter muscle, the connective tissue around the muscle can multiply and harden over time (fibrosis) due to the strong cramping. Such skin thickening can form with a chronic anal fissure. It ‘s called the picket fold.
Other possible symptoms of an anal fissure include:
• Pain -related chronic constipation (obstipation), when those affected hold back their stool for fear of pain.
• Itching in the anus.
• The wound may weep or secrete mucus (mucus secretion).
• Right red deposits of blood on the stool and traces of blood on the toilet paper.
Blood in the stool should always be checked out by a doctor. In addition to an anal fissure, there can also be a more serious cause (such as cancer) behind it.
Anal fissure: causes and risk factors
It is often not clear why an anal fissure develops. What is certain is that it can occur at any age. However, it does it more frequently between the ages of 30 and 40. An anal fissure usually develops in the direction of the coccyx.
The most common cause of an anal fissure is straining when you have a bowel movement, coupled with hard stool. Both stretch the mucous membrane, which can easily tear it. Excessively hard stool is caused, for example, by chronic constipation. This, in turn, can be caused by a lack of fluid intake, a low-fiber diet, lack of exercise and a “sluggish bowel “.
In some cases, anal sex practices that injure the mucous membrane are the cause of an anal fissure. Haemorrhoids , inflammation in the rectum (cryptitis) and prolonged diarrhea are also possible triggers . Patients with chronic inflammatory bowel diseases such as Crohn’s disease or ulcerative colitis are also prone to anal fissures.
An anal fissure that occurs as a result of another condition (like Crohn’s disease) is called a secondary anal fissure. In contrast, a primary anal fissure is a disease in its own right (e.g., as a result of straining too hard when having a bowel movement).
Anal fissure: investigations and diagnosis
If an anal fissure does not heal on its own within a few days, you should definitely consult a doctor. The right contact person is a specialist in diseases of the rectum (proctologist) or a specialist in diseases of the gastrointestinal tract (gastroenterologist). You can also go to your family doctor first, who will then refer you.
Most of those affected are embarrassed by their problem. They shy away from going to the doctor and prefer to try to get the symptoms under control with home remedies. They often only seek help when the suffering from constant itching, burning, pain and bleeding becomes too great. Please note, however, that home remedies supplement conventional medical treatment at best, but do not replace it.
A wound in the area of the anus (such as an anal fissure) has a very high risk of infection. There are a lot of germs here. If you wait too long to see a doctor, you risk an infection with potentially serious complications.
The doctor first inquires about the medical history (anamnesis). He asks the patient in detail about his symptoms. Possible questions are:
• In what situations does the pain occur? Only when having a bowel movement?
• Do you feel an itchy anus?
• Do you suffer from constipation?
• Have you noticed mucus or fresh blood on the toilet paper?
• Is the wound on the anus weeping?
The doctor then inspects the anal area and carefully feels it. The characteristic, highly painful mucosal injuries are usually found in the expected places. In many cases, a rectal examination is only possible after local anesthesia. In this way, the doctor can assess whether it might be hemorrhoids or other diseases of the anus.
If there is an anal fissure, the doctor may do a rectoscopy (proctoscopy). He can take a closer look at the inside of the rectum and take samples of the mucous membrane. For the proctoscopy, the patient usually receives a local anesthetic (local anesthesia) – in the case of an anal fissure, the examination can be quite painful.
If the doctor discovers signs of a malignant disease (e.g. anal carcinoma = anal cancer), further examinations may be necessary. These can be, for example, blood tests, a colonoscopy, computed tomography (CT) or magnetic resonance imaging (magnetic resonance imaging, MRI).
Anal fissure: treatment
The treatment of an anal fissure depends on whether it is an acute or a chronic anal tear. The two forms differ not only in their duration (acute: max. 4-6 weeks; chronic: longer), but also in the extent of the tissue change:
• In the case of an acute anal fissure, the mucous membrane is injured rather superficially. This can be treated well with conservative (non-surgical) means. These include soothing ointments, creams or hip baths.
• A chronic anal fissure develops when a deep ulcer (ulcer) develops from the acute mucosal injury and the edges of the wound become scarred. Sometimes there is also a rough skin fold (outpost fold). If conservative treatment methods do not work, the chronic anal fissure must be operated on.
An anal fissure is only operated on when absolutely necessary. There is a risk that the anal sphincter will be injured during the procedure. The patient may then no longer be able to control the passage of stool (fecal incontinence).
Anal fissure: conservative treatment
An acute anal fissure can be treated with special creams that relax the sphincter system. They contain calcium antagonists or nitrates as active ingredients. Means that soften the stool and promote defecation, for example solutions with macrogol, are also helpful. However, only use laxatives in consultation with your doctor!
In the case of an anal fissure, you can also apply ointments to numb the skin locally (anesthetic ointments). Painkilling and anti-inflammatory ointments and suppositories are also often used.
Wash your hands before applying an ointment. This prevents wound infections.
Temperature-increasing sitz baths can also relieve anal fissure symptoms. They promote blood circulation in the anus area. This strengthens the local defense and allows the anal tear to heal better. How the sitz bath works : Sit upright in the tub with your feet on a stool outside the tub. Add chamomile extract to the tub and start running lukewarm water at first. Then increase the water temperature to 36 to 40 degrees over ten to 15 minutes. Then take a short cold shower and lie down for an hour if possible (bed rest). If you feel cold during the bath, you can wear socks and a sweater.
Proper anal hygiene is also advisable for an anal fissure : It is best to wash the anal region with lukewarm water after going to the toilet. Do not use soap or shower gel! Both can destroy the skin’s natural protective acid film and dry out the skin. This makes them more susceptible to bacteria. Intimate wash lotions and intimate sprays are also discouraged.
Also, avoid using wet toilet paper. The additives contained in it can lead to allergic reactions of the skin. Use normal toilet paper that is as soft as possible.
If you have an anal fissure, make sure you eat a high-fiber diet : Consume at least 30 grams of fiber per day. These stimulate intestinal movements and bind water in the faeces. This will make the stool softer overall. Lots of dietary fiber can be found, for example, in whole grain products, vegetables and fruit. Wheat bran is also very valuable. But you have to make sure that you drink enough fluids. This is the only way for the dietary fibers to swell well and have an appropriate effect.
Tip: Anyone who suddenly consumes large amounts of fiber can get flatulence. That’s why you should increase the fiber content of your diet slowly. This allows your digestive system to adjust.
In the case of a chronic anal fissure, it can be helpful to carefully widen the anus several times a day with a special anal dilator. This can somewhat reduce sphincter cramping. The blood circulation in the skin/mucous membrane improves and hardening is counteracted.
Anal fissure: surgery
If conservative measures do not help enough in anal fissure therapy, surgery is the last option. In general, the anal fissure surgery is only a small operation that is performed under short-term anesthesia or anesthesia close to the spinal cord. The surgeon will remove the surrounding scar tissue as much as possible. Rarely, part of the anal sphincter must also be removed. The procedure is usually performed on an outpatient basis in younger patients. Elderly patients are briefly admitted to the hospital for the operation.
Like any surgical procedure, anal fissure surgery also has its risks: nerves can be damaged, especially during operations in the area of the anal sphincter, which wraps around the anus in a ring shape. The possible consequence is that the patient will no longer be able to control the passage of feces in the future (fecal incontinence).
The healing process after the operation takes quite a long time (usually four to six weeks). It can be prolonged if a wound infection occurs. This is not uncommon in operations on the anus, because this region of the body is heavily colonized with germs.
Anal fissure: Botox
A new but expensive treatment option for chronic anal fissures are Botox injections into the anal sphincter. Botox (botulinum toxin) is a neurotoxin that paralyzes the sphincter muscle for several weeks. This allows the ulcer to heal in peace.
Anal fissure: course of the disease and prognosis
An acute anal fissure usually heals without any problems after a few weeks if it is treated with conservative measures. If left untreated, however, there is a risk that it will become chronic. Anal fistulas or abscesses (collections of pus) can also develop.
A chronic anal fissure can be successfully treated with surgery in most cases.
Whether acute or chronic – after successful treatment, an anal fissure can recur if the causes and risk factors (such as hard stool, heavy straining) are not eliminated. Therefore, make sure you eat a high-fiber diet, drink enough fluids and get plenty of exercise. This keeps the stool soft and supports the bowel movement and can thus prevent anal fissure.