Anal fissure or anal tear is a tear in the skin or mucous membrane of the anus that can be very painful. Anal fissures heal poorly due to the location and physical stress on the affected area of the body and can take a chronic course.
What is an anal fissure?
Anal fissure or anal tear is a tear in the skin or mucous membrane of the anus that can be very painful. The term “fissure” comes from Latin and means “gap”. Accordingly, anal fissure is a slit-shaped tear in the skin of the anal canal. This skin at the lower end of the anal canal is very sensitive. When a tear occurs, an elongated, cleft-shaped ulcer forms. An anal tear is usually also closely associated with other diseases or conditions in the rectal area. These include hemorrhoids, anal cancer, coccygeal fistulas and anal abscesses. Because most people are uncomfortable or embarrassed by diseases of the anus, they are late in seeing a doctor, which may lead to further complications. Therefore, a doctor should always be consulted quickly in case of anal discomfort.
Causes
An anal fissure can have different causes. First of all, an anal fissure can be caused by hard bowel movements. Chronic constipation promotes hard bowel movements and thus the possibility of an anal fissure. But persistent diarrhea can also be a cause of tearing of the anal skin or mucosa. The inflammation causes persistent irritation of the sensitive anal canal skin. Furthermore, hemorrhoids are among the favoring factors. Anal fissures can also occur as a result of an underlying disease, for example Crohn’s disease. Long-term abuse of laxatives can also be a cause. Various sexual practices, such as anal intercourse, are also among the possible causes of anal fissure.
Symptoms, complaints, and signs
An anal fissure often causes stabbing or burning pain during bowel movements. Usually, the discomfort persists for several hours after defecation. Externally, an anal fissure can be recognized by the typical tears at the anus. These usually bleed and cause bright red stains on the toilet paper or stool. This can be accompanied by unpleasant itching, burning and oozing in the area of the anus. Many patients also suffer from constipation. If the anal fissure is caused by hemorrhoids, further symptoms may occur, such as pain when sitting and infections at the anus. Furthermore, an anal fissure can lead to cramps. This makes it necessary to press harder when going to the toilet. In the long run, the connective tissue around the muscle can increase and eventually harden. Such a severe course is manifested by increasing pain, bleeding and cramps during defecation. An anal tear sometimes also results in psychological discomfort. For example, some sufferers develop a fear of going to the toilet, resulting in retention of stool and subsequent constipation. Characteristic of a chronic or recurrent anal fissure is mucosal secretion, which can be detected by transparent discharge and increasing bleeding.
Diagnosis and course
The physician makes the diagnosis based on interviewing the patient and inspecting the anus. Most often, the anal fissure is found in a six o’clock position … toward the coccyx. Less commonly, the fissure is located toward the perineum. On palpation, the physician may feel an ulcer causing pain to the patient. An anal fissure manifests itself in the following symptoms: fresh bright blood, pain during defecation (sharp pain and persistent burning after defecation), spasm of the sphincter muscle, itching. Due to the reflex spasm of the sphincter, the stool is often passed only as a thin stream. Fear of the next bowel movement often leads to constipation. A vicious circle develops: the constipations lead to tearing of the anal skin and pain during defecation. For fear of the pain, the bowel movement is held back, a spasm of the sphincter muscle occurs, which in the end increases the pain again. However, all these signs can also indicate other diseases of the intestine and must therefore also be clarified in terms of differential diagnosis. An acute anal fissure can heal spontaneously or with appropriate treatment. However, it can also recur and even become chronic.It is not uncommon for a connective tissue benign tumor called an anal papilla to form.
Complications
An anal fissure can be very painful. Therefore, it should not only be treated immediately with ointments, but also requires special care. As a complication, the fissure can become inflamed. The reason lies in the germs that can enter the anal fissure during the passage of stool. The deep fissure in the anus is predestined to be subject to germ contamination. This is especially true in the case of chronic anal fissures. These are to be regarded as open wounds. Since stool is passed one to several times a day, the anal fissure comes into contact with intestinal germs several times a day. One possible complication is fistula formation. The resulting inflammation can spread and affect the surrounding tissue. Another complication of an anal fissure is the development of an anal abscess. This is an encapsulated purulent focus of inflammation in the surrounding tissue. This complication leads to considerable pain. The area around the anal fissure is indurated and turgid. Fever with chills may occur. An anal abscess cannot be repaired without surgical intervention. To prevent such complications, anal fissures should be avoided whenever possible. Causes such as a low-fiber diet and chronic lack of exercise can be eliminated. Certain sexual practices should be avoided if there is a tendency to fissure. Bowel examinations and medical supervision can help prevent complications.
When should you see a doctor?
In general, treatment of an anal fissure should not be delayed under any circumstances. Although the affected person can try to get relief for a few days by means of sitz baths, ointments and a diet that leads to soft stools. However, if the pain, bleeding and other symptoms worsen or are constant, a specialist must be consulted. Proctologists and gastroenterologists may be considered. Otherwise, due to poor wound healing in the anal area, affected individuals risk transitioning to chronic anal fissure, which is associated with many complications. In the event that the affected person develops further symptoms, such as fever, nausea and pain in the limbs, this is an indication of a secondary infection. Such an infection can easily occur, especially in the case of a torn mucosa. In addition, pus formation and signs of inflammation can occur, causing further pain and itching, which should also be clarified by a doctor. A doctor should also be consulted in the case of recurring anal fissures. After all, there may be causes for this in the sphincter muscle and the surrounding tissue itself. This should be done regardless of whether or not the affected person can identify possible causes for their anal fissure. Surgery must be considered if conservative therapies to relieve and heal an anal fissure are not effective.
Treatment and therapy
For acute anal fissure, regulation of bowel movements is the key measure. This includes a high-fiber diet and a high fluid intake. Through a healthy diet, the anal canal naturally stretches and the bowel movement is permanently soft and formed. For the pain and burning during or after defecation, the doctor prescribes an ointment with a local anesthetic, that is, an ointment that locally numbs the skin. Of course, careful anal hygiene with ph-neutral soaps is also important. Warm chamomile baths can also help. An acute anal fissure heals with these measures within six to eight weeks. In the case of a chronic anal fissure, the symptoms last longer than two months. In addition to all measures in the treatment of an acute anal fissure, the doctor now prescribes medication with the active ingredient nitroglycerin. Calcium antagonists (nifedipine and diltiazem) are also used. These agents relax the sphincter muscle. The patient must apply the ointments three to four times a day for the next 6-12 weeks. In most cases, chronic anal fissure will then heal. If, however, healing does not occur despite the patient’s consistent adherence to the appropriate diet and exact application of the prescribed ointments, the physician must consider surgery. In this case, the fissure is removed together with the scarred tissue. However, wound healing takes quite a long time, as the doctor does not usually use sutures.
Outlook and prognosis
Minor anal fissures, especially those that are injury-related, often heal on their own within a few days or weeks if the area in question is kept clean and excessive stress on the anal region is prevented (pressing during bowel movements, stools that are too hard, sexual practices in the anal region). Smaller fissures heal without consequential damage. The decisive factor for the healing process is the extent to which the injured area is protected. Irritation and muscle tension in the corresponding area have a counterproductive effect, while gentle behavior, warm sitz baths, etc. have a positive effect. Bacteria also play a role. If a fissure becomes inflamed, spontaneous healing is no longer to be expected. Ointments, sitz baths and other measures become necessary at this point at the latest. If an inflamed anal fissure is not treated medically, the prognosis is poor. Subsequent complications are then frequent and worsen the clinical picture. Irreversible damage can occur for the person affected, as the sensitive tissue of the anal region is pathologically altered by inflammation. In addition, a chronic – i.e. recurring and not permanently healing – anal fissure can develop if the affected person carries over inflammation and structural damage in the corresponding area. In retrospect, surgery (for example, a fissurectomy) may therefore become necessary. However, the prognosis for anal fissures is good overall.
Prevention
The best way to prevent anal fissure is to eat a healthy, high-fiber, balanced diet, get enough exercise, and stay hydrated.
Aftercare
Anal fissure (anal tear) can be treated both conservatively and surgically. This depends on the severity of the condition and the needs of the patient. Depending on which option of therapy is chosen, the aftercare also varies somewhat. Those who opt for conservative treatment can in many cases dispense with aftercare. Because the anal fissure is clearly noticeable through stabbing pain and bleeding, those affected also notice if the treatment with creams, anal dilators or stool softening agents was successful. Only if the symptoms do not disappear completely is it advisable to see a doctor again for follow-up care. The proctologist or the family doctor with experience in this area are the people to contact. If the patient does not experience any symptoms, aftercare often includes the application of ointments and a consistent diet rich in fiber, including a large amount of fluids, as aftercare and at the same time prevention of a new rupture. After surgical interventions, follow-up care by the proctologist is important. He checks the wound healing, for example with regard to an infection. In addition, he can make sure that bowel movements after surgery have not caused a recurrence. He checks the tone of the muscles of the sphincter and can give tips to avoid heavy pressing, which is counterproductive for fissure healing.
Here’s what you can do yourself
If an anal fissure is suspected, it is always advisable to go to the doctor first. Accompanying the complaints can be alleviated, among other things, by good anal hygiene and gentle care products. It is also important to get enough exercise, for example in the form of pelvic floor muscle training or yoga. In addition, attention should be paid to a healthy and balanced diet. High-fiber foods and plenty of fluids guarantee pleasant and regular bowel movements and thus contribute to the healing of an anal fissure. If constipation is already present, laxatives are also recommended as a transitional measure. If the pain is severe, anesthesia can also be administered. Mild painkillers can also be taken in consultation with the doctor to relieve acute discomfort. If, despite all measures, the symptoms worsen, special preparations from the pharmacy can be used. Such ointments and lotions contain active ingredients such as lidocaine and bufexamac, which have an analgesic and anti-inflammatory effect on hemorrhoids. Alternatively, special suppositories, anal dilators or sitz baths are recommended. Early application is crucial to avoid further intensification of the anal fissure. If the symptoms are particularly severe or recurrent, an anal fissure should always be taken to a doctor.