Anal fissure.

Anal fissure is a painful but harmless tearing of the skin in the anal area. The pain causes a reflex cramping of the sphincter muscle (sphincter ani), which in turn makes defecation difficult. In addition, blood supply to the anal region grows weaker, which affects wound healing.

Causes

Over-stretching of the anus (childbirth, hard stools, strong pressing, anal intercourse), infections/inflammations in the rectum, poor blood circulation to the anus, increased pressure of the sphincter muscle (sphincter ani).

Types

• by cause

  primary anal fissure with no previous disease, usually occurs due to over-stretching (see Causes)
  secondary anal fissure, result of an underlying disease (e.g. Chron’s disease, syphilis)

• by duration

  acute anal fissures heal after a maximum of 6-8 weeks
  chronic anal fissures heal only after 6-8 weeks

Symptoms

Slight to stabbing pain in the anal area during and after defecation, itching, bright red blood on toilet paper.

Diagnostics

Visible injuries in the anal area (inspection), palpation of any thickening of the anus (palpation), proctoscopy (examination of the anus). Anal fissures should be distinguished from haemorrhoids, which are symptomatically similar to anal fissures. Haemorrhoids are caused by a swelling of the tissue due to the patient contracting his muscles on the toilet, and they usually appear at a slightly different location.

Treatment

• conservative

  Identification and treatment of the causes (e.g. soften hard stools with a high-fibre diet and plenty of fluids), local anaesthetic ointments and suppositories (pain-relieving), sitz baths, drugs to stimulate circulation (nitro ointments such as Rectogesic; calcium antagonists such as nifedipine, Diltiaze; injection of botulinus toxin; calendula ointment) anal dilators (conical plastic rod inserted into the anus for a few minutes several times a day, gradually stretching and relaxing the sphincter muscle).

• surgical

  Fissurectomy (removal of the fissure including the scarred tissue, the sphincter is spared), lateral sphincterotomy (cutting or the cramped muscle fibres of the sphincter).