Anal fissure

Anal fissure is a tear in the anal mucosa that is extremely painful. A common cause is irritation or injury to the mucosa, but disease can also be behind it. The anal fissure can be treated well and usually heals without consequences.

What is anal fissure?

In anal fissure, the mucosa in the lower anal canal tears longitudinally. The area affected is that where the rectum merges into the anus. Therefore, doctors also speak of anal fissure or anal tear. The disease is extremely painful and can significantly reduce the quality of life.

There are no exact figures on the frequency of anal fissure. The reason is that hardly anyone likes to talk about problems in the intimate area. Many sufferers are uncomfortable with the disease, which is why they hesitate to see a doctor for a long period of time. Medical experts believe that these fissures are not that rare. Anal fissure most often forms in people between the ages of 30 and 50. In principle, however, it can also occur in younger and older adults. Women and men are affected about equally often. In children, however, anal fissure is very rare.

Out of shame, sufferers often endure the pain for months or try to treat themselves with creams or ointments. Thus, a lot of time usually passes until a doctor treats the fissure professionally. In this case, early treatment not only effectively prevents the symptoms, but also improves the chances that the anal fissure will heal completely. So the rule is: seek out our consultation hours in a timely manner.

Acute or chronic anal fissure

Anal fissure can be acute or chronic. In acute cases, it often heals by itself after a few weeks or with treatment accompanied by the doctor. In the second case, the acute anal fissure turns into the chronic form – it then remains longer and may need surgery. Typical of this chronic form is that the acute discomfort and pain first subside, but the fissure persists. However, affected individuals then often develop a deep ulcer, scarring around the edges of the wound, and a characteristic thickening of the skin in the region of the anal fissure. Physicians also speak of the “outpost wrinkle”.

The causes of anal fissure are not always clear

Several causes are probably at work together in anal fissure. Some factors are known to irritate or injure the anal mucosa and cause it to tear. Doctors speak of “primary anal fissure“. Such factors include:

  • Constipation: Bowel movements are hard and sufferers have to push enormously when defecating.
  • Prolonged diarrhea, the stool has a pulpy consistency.
  • Increased muscle tension of the sphincter muscle (sphincter hypertonia): The severe pain during and after defecation in turn causes the sphincter muscle to tense even more.
  • Certain sexual practices: Anal intercourse or objects and sex toys that people insert into the rectum.
  • Inflammation in the area of the anal glands of the rectum (cryptitis) – however, this occurs rather rarely.

However, doctors cannot always find a cause for anal fissure.

Secondary anal fissure – often other diseases are to blame

In addition, some diseases and triggers are known to promote anal fissures. “Secondary anal fissure” is the technical term in this case. Examples include:

  • Chronic inflammatory bowel disease (IBD): This includes Crohn’s disease and ulcerative colitis.
  • Infections with pathogens: Examples are syphilis, tuberculosis (both caused by bacteria) or leishmaniasis (caused by protozoa). But anal fissures can also occur with certain viral diseases, such as HIV/Aids, an infection with herpes simplex virus (HSV) or with the cytomegalovirus.
  • Diseases such as leukemia, cow’s milk allergy or Behçet’s disease (rare rheumatic disease affecting the blood vessels).
  • Medications: some medications are associated with anal fissure, for example, ergotamine, nicorandil, isotretinoin, or cytostatics for cancer (chemotherapeutic agents).
  • Narrowing of the anal canal (anal stenosis)
  • Surgery in the region of the rectum

An anal fissure causes pain

An anal fissure is mainly noticeable by pain, which is often not insignificant and restricts everyday life and quality of life. The following symptoms may occur with anal fissure:

  • Severe pain during bowel movements. Many sufferers describe it as a burning or stinging sensation. Some liken it to sitting on a razor blade. The pain does not go away immediately after a bowel movement, but can last for minutes or even hours. Fearing the pain, many try to hold back bowel movements – this in turn promotes constipation and bowel movements become even more painful.
  • Bright blood deposits on stool and blood on toilet paper – the bright color shows that the blood is fresh.
  • Later: sore that oozes and secretes mucus, itching of the anus.

In primary anal fissure, the pain is often more severe than in secondary anal fissure. The pain can cause the sphincter to tighten so much that the symptoms become more and more severe. Further tearing of the mucosa is also possible due to sphincter spasm. In addition, sometimes the blood flow in the tissue decreases and the anal fissure heals poorly – it can become chronic.

Anal fissure: diagnosis with us

For us, the diagnosis “anal fissure” is usually easy to make and not a problem. Even the discussion of the medical history – the anamnesis – provides the first clues. For example, the following questions are important:

  • What exactly are your symptoms? (e.g. pain during and after defecation).
  • How long have you had the symptoms and how intense are they?
  • Do you have any known diseases, for example chronic inflammatory bowel disease?
  • Are you taking any medications? If yes: Which ones and since when?

This is usually followed by further examinations to diagnose the anal fissure.

  • Physical examination: During the physical examination, we carefully palpate the mucosa of the rectum with our finger to detect any changes.
  • Proctoscopy: A reflection of the rectum with an endoscope (proctoscopy) shows whether the anal canal as well as the rectum are intact or damaged. The proctoscope is a thin metal tube that we push into the rectum. Sometimes we perform proctoscopy under regional anesthesia (local anesthesia) or a short anesthesia. This is because the region around the anus and rectum is very sensitive to pain because numerous nerve fibers run there.
  • Colonoscopy: Possibly a colonoscopy if abnormalities exist or the anal fissure has not healed even weeks later.

Anal fissure: prevention, early detection, prognosis

You cannot prevent anal fissure in every case. Because sometimes doctors do not find a cause for it or anal fissure is the result of another disease. However, there are some factors that increase the risk of anal fissure – and you can address these yourself. Examples are:

  • Prevent constipation: Eat as balanced a diet as possible and consume plenty of fiber (e.g., whole grains, fruits, vegetables, legumes). Also, drink plenty of fluids. Recommended is at least 1.5 to 2 liters per day. Low-calorie drinks such as water, unsweetened tea or fruit juice spritzers are best. A soft stool lowers the risk of anal fissure. Even after anal fissure treatment, these tips are important to prevent a new fissure. Laxatives are then usually unnecessary – otherwise talk to your doctor before taking them.
  • Move a lot in everyday life and do sports. Exercise stimulates bowel activity. For example, take a walk after dinner, climb stairs instead of taking the elevator, or ride your bike to the supermarket instead of getting in your car. If you have a sedentary job, for example, in an office, it is best to try to move as much as possible even during working hours. Take the folder to your colleague yourself instead of putting it in the in-house mail, or stand up when you make phone calls. Exercise not only protects you from anal fissure, but also strengthens your overall well-being.
  • Practice anal sex carefully and it is best to use a lubricant. In this way, you protect the sensitive mucous membrane from injury.

Course and prognosis in anal fissure

If you suspect you have an anal fissure, early detection is very important. This is the only way we can start treatment in time and avoid complications. Consult a doctor promptly and do not treat yourself for a long period of time with home remedies or with ointments recommended to you by medical laypersons.

If we treat anal fissure timely and sufficiently, the course and prognosis are usually good. This means that the anal fissure heals without further health consequences. If not properly treated medically, there is a risk that the anal fissure will return or become chronic. An untreated anal fissure can have these consequences, among others, in the long run:

  • Germs from the intestine can enter the wound – it does not heal.
  • Anal fistulas can develop – fistulas are unnatural channels that don’t normally belong there. Such a fistula may form between the wound and the internal sphincter. This can cause the inflammation to spread to the neighboring tissue.
  • Anal abscess: This is a purulent inflammation that becomes encapsulated in the tissue. Redness, swelling, pain, fever and chills may be the symptoms. Surgical intervention becomes necessary and a surgeon must open the anal abscess.

Anal fissure: treatment with different strategies

Acute anal fissure resolves on its own in rare cases, but usually requires therapy. If we treat the tear in time, anal fissure is well curable. The following options are available for the treatment of anal fissure:

  • Pain relieving drugs
  • Muscle relaxant drugs
  • Warm sitz bath
  • Nutrition
  • Botox
  • Surgery