Anal fissure

An anal fissure (anal fissure) is a linear tear in the wall of the rectum, which continues onto the wall of the anal canal, involving its skin part.

 What does a crack look like?

As a rule, there is only one fissure in the rectum. More often it is located on the back, coccygeal wall of the anus. Less commonly, the crack can be in the anterior commissure (mainly in women after a rupture of the perineum during childbirth). It is very rare to see two cracks located opposite each other, on the back and front walls.

The length of the crack is about 1-1.5 cm, the width ranges from 0.2 to 0.5 cm, and the depth is 0.1-0.2 cm.

Causes of anal fissures

The exact cause of anal fissures is unknown. However, factors have been identified that increase the risk of its formation:

• injury to the anus with hard feces,
• secondary infection,
• severe straining (with prolonged constipation, heavy lifting),
• childbirth in women,
• hemorrhoids (due to blood stagnation, thrombosis),
• inflammatory processes in the rectum (including Crohn's disease localized in the anus).

In women, anatomically, the anterior part of the anal canal is designed in such a way that the vagina and the fibrous center of the perineum seem to connect here. Therefore, this structural feature of the external sphincter leads to the formation of a crack in women on the anterior wall of the anal canal. This occurs not only with excessive stretching, but also with inflammatory processes that lead to a decrease in the elasticity of the wall.

A true fissure is a traumatic tear in the wall of the anus, accompanied by severe spasm of the sphincter and pronounced pain.

Such a fissure is always located only along the midline of the anus. With the patient lying on his back, it is localized at 6 o’clock on the dial (coccygeal side), less often at 12 o’clock (front wall).

The reason that the fissure is located in strictly defined places is the anatomical structure of the anal sphincter.

 Why does a crack form?

The fact is that the anus is the most sensitive part of the rectum. Spinal nerves and numerous branches of the autonomic nervous system intertwine here.

When a tear occurs, irritation of the nerve endings causes a strong reflex spasm of the sphincter, which causes a crack to form. It reaches the internal sphincter and leads to its convulsive contraction. Constant contractions do not allow the wound to heal. Thus the process becomes chronic.

Sharp crack

Sharp cracks can form even in infants.

The most striking symptom of an anal fissure is a sharp pain that occurs during or immediately after defecation. The pain does not go away for 2-3 hours, sometimes more. The pain is so strong that it unsettles the person; he literally finds no place for himself.

Another characteristic sign of an acute anal fissure is sphincter spasm. Because of it, the pain intensifies and becomes throbbing. A person develops a fear of defecation. You have to either artificially delay bowel function or take a laxative.

However, when taking a laxative, many pieces of unprocessed food remain in the stool, which fall into the crack, causing even greater suffering.

Bleeding from an anal fissure is usually minor. The crack may appear as droplets of blood and streaks on the surface of the stool.

If an acute crack is not treated, then after 3-4 weeks it usually becomes chronic.

 Chronic anal fissure

A chronic fissure takes the form of a trophic ulcer. The pain during defecation is not so sharp and lasts several minutes. When straining, the pain intensifies. The sphincter spasm is not so pronounced. Blood is found in the stool in the form of droplets.

A chronic trophic fissure is formed as a result of the replacement of fibers of the subcutaneous part of the external anal sphincter with connective tissue. If the disease continues for a long time, then this process leads to weakening of the sphincter.

A complication may be the formation of rectal fistulas. Symptoms of fistulas are

• purulent discharge,
• itching,
• irritation in the anal area.

For a chronic fissure, as for all trophic ulcers, periods of exacerbation alternate with periods of rest, when it seems that the problem has disappeared. However, if the diet is violated, heavy lifting, or straining during bowel movements, the wound opens.

Such cracks usually require surgical treatment.

 Acutely recurrent anal fissure

This is another type of anal fissure. In this case, a trophic ulcer does not form. The crack heals as a result of conservative treatment. However, with constipation, physical exertion and poor diet, it occurs again.

Fistula formation

When a crack becomes infected, an abscess develops.
When it breaks into the anal canal, an incomplete internal rectal fistula is formed. Signs of such a scenario are

• pain relief,
• the appearance of weeping,
• itching in the anus.

Read more in the article “ Paraproctitis ”

 Diagnostics

The doctor can make an assumption about the presence of an anal fissure based on a survey of the patient. Three characteristic signs (severe pain during defecation, drops of blood on the stool and anal itching) allow us to conclude that there is a fissure.

A physical examination is carried out in the knee-elbow position or on a gynecological chair. When spreading the buttocks, a fresh tear is immediately visible, which begins to bleed.

In case of an acute fissure, digital examination and sigmoidoscopy can be done only with anesthesia.

Anesthesia is performed by injecting a small needle into the outer edge of the anus.

The cause of the formation of a crack can be other diseases, such as polyp, cancer and others. Therefore, you must immediately consult a doctor and get examined.

Examination of a chronic fissure does not require pain relief, especially during remission. Upon external examination, a defect 1.5-2 cm long, 0.5-1 cm wide, with scarred edges, is visible on the back wall. The bottom of the ulcer is often covered with a gray coating.

A tubercle is often identified at the upper pole of the fissure, which is often incorrectly regarded as an anal polyp.

In addition to examination by a proctologist, it is necessary to conduct an endoscopic and x-ray examination of the colon, since a fissure may be the first sign of cancer, syphilis, and tuberculosis.

It is important not to confuse a crack with various superficial damage to the skin. This may include skin irritation, abrasions, and weeping due to inflammatory processes.

 Treatment of anal fissures

An acute crack can be treated with conservative methods, it heals well.

During treatment, strict adherence to the diet is necessary. All sour, spicy, salty foods and alcoholic drinks are excluded from the diet. Fiber intake should be kept to a minimum as it can cause looseness and extra stool.

A light, predominantly protein diet is prescribed:

• cottage cheese,
• eggs,
• boiled chickens,
• boiled meat,
• broths,
• white crackers,
• apples.

For 2 weeks, bowel movements should be done only with an enema. You should not take laxatives.

Cleansing enemas are the main remedy in the treatment of acute anal fissure.

 How to give an enema correctly?

It is very important to follow a number of rules when administering an enema.

1. The tip of the enema and the anus area must be lubricated with a large amount of Vaseline ointment.
2. The tip should be inserted into the anus along the edge opposite to where the crack is located.
3. For an enema, use 1 liter of boiled water at room temperature.
4. It is best to administer an enema while lying on your left side.
5. 7-10 minutes after the enema you can go to the toilet.
6. An enema is given once a day or more often if there is a urge to defecate.

Under no circumstances should there be spontaneous bowel movements during the treatment period.
The course of treatment is 14 days. After this, you can proceed to independent defecation.

Immediately after cleansing, you need to take a bath:

• a weak solution of potassium permanganate at a temperature of 35-36 ºС is poured into a basin;
• you need to sit in the basin, spread your buttocks so that the solution washes the anus.

The procedure lasts 10-15 minutes.

After this, you need to insert a candle into the anus.

 Candles and ointment

For treatment, it is recommended to use the following ointment:

• novocaine 0.5 g,
• streptocide 5 g,
• zinc ointment 50 g.

For acute cracks, candles made according to the following recipe are recommended:

• Extr. Belladonnae 0.015
• Novocaini 0.14
• Xeroformii 0.1
• Butyri Cacao 1.7
• Mf Suppos.

You can use patented ready-made suppositories, which can be purchased at the pharmacy (ultraproct, procto-glivenol, hepatrombin G, preparation N). In this case, the candle that best suits the patient is selected individually.

The second suppository is administered at night.

The anus area and the outer part of the fissure must be lubricated several times a day with this ointment.

 What to do after this course?

After a 14-day course of treatment, the crack usually heals. Therefore, it is necessary to take measures to prevent injury.

First of all, you need to change your diet. Now it should be aimed at eliminating constipation in order to eliminate straining during bowel movements.

Food containing plant fiber should be included in the diet. To soften the stool, you can eat three boiled red beets, grated on a coarse grater, with vegetable oil or sour cream at night. As a last resort, drink one tablespoon of liquid Vaseline oil at night.

If a person suffers from chronic constipation, then these remedies may not be enough.

You can read more about the treatment of constipation in the article on constipation .

You should not achieve significant loosening of stools, especially by using saline laxatives. This can lead to injury to the crack area and its re-formation.

If conservative treatment does not help, then surgical intervention is resorted to.

Treatment of chronic fissure

As practice shows, conservative treatment of anal fissure does not give a positive result. With this treatment, symptoms seem to improve. However, fistulas and leaks under the intestine may continue to form under the scar, which ultimately leads to weakening of the sphincter function.

Therefore, surgical treatment of chronic anal fissures is recommended.

Surgical treatment

Currently, there are several types of surgical treatment:

• excision of anal fissure with dosed sphincterotomy (partial dissection of anal sphincter fibers).
• excision of anal fissure using radio wave method (Surgitron),
• laser vaporization of anal fissures.

 Laser treatment

A surgical technique that allows you to remove a chronic anal fissure without sutures. This reduces pain after surgery, shortens the rehabilitation period and speeds up the process of restoring the patient’s ability to work. The operation lasts from 10 to 20 minutes and does not require a 24-hour hospital stay.

Excision of anal fissure with dosed sphincterotomy

The operation consists of excision of the crack itself within the healthy mucous membrane. A rectal speculum is inserted into the rectum, the crack is outlined along the entire oval with a scalpel, and then it is excised from the outside to the inside with scissors along its entire length. The wound is left open in the lumen of the rectum. The wound usually heals easily and quickly, within an average of 10-15 days, with a thin scar.

The main thing in this operation is to decide whether it is necessary to perform an additional sphincterotomy (partial dissection of the fibers of the anal sphincter). Without this additional manipulation, in most cases the operation is not successful; the crack recurs due to renewed tonic contractions of the sphincter.

If the patient’s sphincter spasm is not detected before surgery or is only slightly expressed, then sphincter dissection (sphincterotomy) may not be performed.

The postoperative period usually takes place on an outpatient basis. In this case, it is necessary to strictly follow all hygiene recommendations.

For one week, you need to take daily sitz baths and apply ointment to the wound of the anal canal.

It is necessary to adhere to a diet that will provide daily soft stools not only in the immediate postoperative period, but also in the future period of life.

In rare cases, complications are possible:

• wound suppuration,
• bleeding,
• slight insufficiency of the anal sphincter.

As a rule, they are associated with insufficient wound care.

The advantage of the surgical treatment method is that it allows you to radically solve the problem.

Many patients cite the painful and long postoperative period as a disadvantage.

Prevention

Since most often the disease develops against the background of prolonged constipation, the main measure is to follow a diet and take other measures to eliminate this disease.

Maintain personal hygiene measures to prevent inflammation of the tissues around the anus.