Symptoms
Anal fissure is a tear or cut in the skin of the anal canal. This results in severe pain that occurs during and up to several hours after defecation. It may radiate locally and be accompanied by an uncomfortable itching sensation. Fresh blood can often be seen on toilet paper or stool.
Causes
Possible primary causes include hard stools due to constipation, persistent diarrhea, childbirth, anal sex, Crohn’s disease, and injury. The injury causes pain and spasm of the internal anal sphincter. This reduces blood flow, which decreases oxygenation (ischemia) and delays wound healing. Therefore, without therapy, an acute anal fissure can become chronic (> 6 weeks). Those who have already had an anal fissure are prone to recurrence.
Diagnosis
Diagnosis is made by medical treatment based on patient history, anorectal examination, and imaging techniques. Various other anorectal conditions, such as hemorrhoids, anal fistulas, abscesses, or cancers, must be ruled out.
Nonpharmacologic treatment
For non-drug treatment and prevention, intake of adequate fluids and a healthy diet with fiber are recommended. A surgical procedure called lateral internal sphincterotomy (LIS) is performed as a second-line treatment when conservative therapy fails. In this procedure, a small portion of the internal anal sphincter is removed.
Drug treatment
Dietary fiber:
- Such as psyllium, Indian psyllium husk, and stool-regulating agents such as macrogols are taken with adequate fluids to increase stool volume and make stool softer and more slippery.
Nitrates and calcium channel blockers:
- Such as nitroglycerin, nifedipine, and diltiazem are applied locally as a cream or ointment. Pain relief occurs relatively quickly, but wound healing takes about 4 to 8 weeks. The active ingredients relax the internal anal sphincter, dilate blood vessels, increase blood flow and have analgesic and wound healing properties.
- Apart from nitroglycerin ointment (Rectogesic), there are no ready-made medicines on the market. The remaining preparations must be prepared in a pharmacy as a magistral prescription. Despite local application, systemic side effects may occur, especially headache. In the literature, L-arginine is additionally mentioned.
Overview:
- Nitroglycerin ointment (Rectogesic, some countries: Rectiv).
- Nifedipine cream (Magistral formulation).
- Diltiazem ointment (magistral formulation)
Botulinum toxin:
- Botulinum toxin injections into the internal anal sphincter show good efficacy, but can cause flatus and fecal incontinence. Therefore, it is usually administered as a second-line agent. Botulinum toxin paralyzes the internal anal sphincter and relaxes the smooth muscle.
Local anesthetics:
- Such as lidocaine can be used to relieve pain before defecation.
Other ointments:
- Other topical preparations such as witch hazel ointments or zinc oxide ointments may possibly help to improve the symptoms.