Anal fissure (anal tear) – briefly summarized

With an anal fissure, the sensitive skin in the anal canal tears and an ulcer forms. The reasons behind this have not yet been clarified. Factors such as constipation with heavy straining during bowel movements, but also hemorrhoids or diarrhea seem to increase the risk of anal canal ulcer. An anal fissure can also occur in the context of certain underlying diseases such as Crohn’s disease. Women in menopause can also be affected due to increased dryness in this area (Lichen Sclerosus).

The tear usually causes severe, sometimes burning pain when defecating. In addition, there is often bright red blood in the stool or on the toilet paper. Symptoms such as itching or burning can also indicate an anal fissure.

The therapy of the actual anal fissure is to keep the stool soft. Ointments and suppositories are used as support. The acute anal fissure usually heals with time. If you suffer from a chronic anal fissure, the only remaining option is surgical treatment.

What is an anal fissure (anal tear)?

Doctors speak of an anal fissure when the very sensitive skin in or near the anal canal (anoderm) tears and an elongated ulcer forms.

Anal fissures can affect people of all ages, men as well as women. Anal cracks occur particularly frequently between the ages of 30 and 40. Doctors differentiate between acute and chronic anal fissures. Some authors recommend dividing the anal fissure into a spastic (= acute) and an inflammatory (= chronic) form according to its mechanism of origin.

While the acute anal fissure usually heals, a chronic anal fissure can show further changes in the anus. So an outpost fold (= mariske) can form. Although this thickening of the skin is largely harmless, it interferes with hygiene. An anal fibroma (a benign connective tissue nodule) as well as scarred, bulging marginal walls around the ulcer or fistulas (duct formation) can also develop.

What are the causes and risk factors of an anal fissure?

Researchers do not yet know what exactly leads to an anus tear. However, the texture of the stool seems to play a major role in whether an anal fissure occurs. For example, those who suffer from constipation, i.e. have a hard bowel movement, are more likely to get painful anal cracks. Strong pressure when defecating also increases the risk of injuring the sensitive inner skin in the anal canal (anoderm). Conversely, diarrhea or mushy stool can also promote anal cracks.

Another risk factor: hemorrhoids. Because the anoderm is already damaged and can tear more easily. Infections – for example, cryptitis (inflammation in the area of ​​the rectum) – reduced blood flow to the anal skin or cramped sphincter muscles in the anus can lead to an anal fissure. Sometimes an anal fissure occurs as a result of an underlying disease (secondary anal fissure), for example in Crohn’s disease.

Symptoms: What are the symptoms of an anal fissure?

An anus tear typically causes stabbing or burning pain when defecating. The pain can go away immediately after a bowel movement, but can also reappear after a short, pain-free interval and last for hours.
The tears in the special skin in the anal canal (anoderm) are often noticeable through bright red blood stains on the toilet paper or the chair. In addition, the anus can itch, burn or ooze.

A vicious circle begins, as an anal rupture can cause severe pain, often resulting in restrained bowel movements (constipation). However, the hardened stool irritates the wound and the anal fissure can deepen. This in turn increases the pain. As a result, the sphincter muscles also tighten, which increases the problems with bowel movements. In addition, the anoderm is poorly supplied with blood due to the cramped muscles, and the healing process slows down. It is therefore important to break this mechanism.

If you have complaints in the anal area, you should contact your doctor. They can then refer you to a specialist in rectal diseases (proctologist), as there may be a possible anal fissure as well as many different causes of problems in the rectum area (for example hemorrhoids, tumors or ulcers). We therefore urgently recommend clarifying any complaints in the anal area!

Diagnosis: how does the doctor determine an anal fissure?

In addition to the anamnesis, an examination of the external anal area is carried out, whereby the painful tear is partially discovered. Most anal fissures are longitudinal and occur towards the tailbone.

If the external inspection is not sufficient, the anal canal is examined further under local anesthesia, as the examination can otherwise be quite painful.

Therapy: How can an anal fissure be treated?

Anal fissures can be challenging to treat naturally. Keeping the stool soft is most important. Using something like Oxy-Powder works best.
Also using emu cream or calendula cream 3x per day and after every bowel motion, usually give good results if the fissure is not spastic or chronic.
If the area seems to be infected, Lugols iodine can be dapped onto the fissure.

The therapy of the acute (spastic) fissure aims at lowering the pressure of the sphincter muscle. Furthermore, ointments with nitroglycerin or calcium antagonists are used for topical therapy. Both ointments are to be used three to four times a day for about six to eight weeks. A stretching treatment can also help.

Another measure to lower the pressure of the sphincter muscle is the therapy with botulinum toxin A (botox). This is injected into the sphincter muscle and causes its paralysis, whereby the increased pressure is reduced. Note that this treatment can lead to temporary incontinence.

With the above-mentioned conservative therapy options, the anal fissure heals in over 90 percent of cases.
If therapy fails, surgical therapy may be necessary but should be seen as a last resort.

A chronic (inflammatory) fissure must be treated surgically. Various surgical techniques are available for this, which are determined depending on the location, cause and other findings. If there is scarred tissue or an outpost fold, the attending physician removes the skin or anoderm changes as flatly as possible (fissurectomy). A transection of the sphincter muscle (sphincterotomy), which was often used in the past, is no longer recommended by experts due to the risk of incontinence.

How can you prevent an anal fissure?

Cracks in the anus are often caused by hard stool and constipation, or when patients strain too hard when defecating. However, you should only use laxatives in exceptional cases. When used frequently, they disrupt the natural regulation of digestion and remove important minerals from the body.

Better: eat enough fiber. Dietary fiber increases the volume of the intestinal contents and thus stimulates digestion. This prevents people from becoming constipated. In addition, fiber makes you full longer and therefore helps to maintain weight. Healthy ingredients can be found in fruits, vegetables and whole-grain products.

Drinking enough fluids (water, unsweetened tea) and exercise are also important. A fluid intake of 1.5 litres should be achieved – provided there are no underlying diseases such as impaired kidney function to prevent it. More exercise can often be built into everyday life: take a regular walk, cycle to the bakery or go for a walk.

References:

– Classen, Diehl, Kochsiek: Internal Medicine, Elsevier, Urban & Fischer, 6th edition
– R. Winkler with a contribution by WH Jost, pp. 143-158 “Anal fissure” from J. Lange et al.: “Chirurgische Proktologie”, Springer Verlag, 2012
– Raulf F., Kolbert GW: Practical Handbook Coloproctology Dr. Kade (2006)
– G. Kolbert, M. Stoll: Guideline-compliant therapy of anal fissures, coloproctology 5/2016
– H. Mlitz, V. Wienert, F. Raulf, Analfissur, self-published, 2012

Anal Fissures are contraindicative for Colonics, but there are other ways to clean your colon even with Anal fissures.