Anal fissures are sores or lesions that occur in the anus and extend up the anal canal.
Anal fissures can be classified according to the duration of symptoms.
For example:

  • Acute anal fissure – if the symptoms do not last more than six weeks
  • Chronic anal fissure – if symptoms persist for more than a month and a half.

The external anal sphincter is under the conscious control of each individual. But the internal anal sphincter is not controlled by the mind.  This muscle remains under pressure or tension all the time.
Some people may have excessive tension in the two muscular rings (sphincters) that control the anus. It is a very painful muscular contracture (or spasm) that obstructs the passage of feces, the consequence is a strong friction against the mucosa of the anal canal that develops an injury.  An anal fissure can develop if the internal sphincter undergoes too strong a resting pressure. The consequence is a muscle spasm and a reduction of blood flow to the anus.  The high pressure at rest can also prevent the healing of the fissure.


Location

The skin lesions usually occur later but may appear in front of the anus, particularly if the patient suffers from ulcerative colitis, Crohn’s disease or syphilis.
In some cases, anal fissures can be caused by Crohn’s disease , an inflammatory bowel disease that causes bloody diarrhea in the stool, abdominal pain, fever, weight loss, and fissures or fistulas near the anus.

What are the causes of anal fissures?

Anal fissures are caused by lesions (traumas) of the anal canal. The lesion may occur if:

  • If there is a very large stool mass that extends the anal canal.
  • If the subject suffers from constipation and tries to pass the hard stool.
  • Who suffers many times from diarrhea.
  • Even childbirth can cause traumas to the anal canal. During labor, some women develop anal fissures.
  • Fissures can also be caused by insertion of fingers (for example, during examination of the prostate), insertion of foreign objects or anal intercourse.

Since many people suffer from constipation or diarrhea without having anal fissures, many experts believe there are other causes of anal fissures.

Less common causes of anal fissures are:

  • Anal Cancer
  • HIV
  • Tuberculosis
  • Syphilis


Symptoms of anal fissures

Signs and symptoms of anal fissures include:

  • Pain, sometimes severe, during evacuation,
  • Pain after bowel movements that can last for several hours,
  • Live red blood on toilet paper,
  • Itching or irritation around the anus,
  • Anal burning ,
  • Pain when riding a bicycle, especially with that of running with the narrow seat,
  • A visible crack in the skin around the anus.


Complications of anal fissures

The complications of anal fissures are:

Lack of healing. An anal fissure that does not heal within six weeks is considered chronic and may require more treatments.

Relapse. After having an anal fissure, you are more likely to have one. An injury that extends to the surrounding muscles. An anal fissure can extend to the muscular ring that keeps the anus closed (internal anal sphincter), making it harder to heal.

The unhealed cleft can activate a vicious circle that needs medication or surgery to reduce pain and repair the injury.

 

Diagnosis of anal fissures

A fissure is usually diagnosed with a rectal examination that can be done manually or visually. A special instrument called an anoscope or a sigmoidoscope is used.  One of these two tests can determine if there is an hemorrhage of the anus, or if there is a different problem.

In the differential diagnosis, the physician should exclude:


The initial treatment for anal fissures

In most people, cracks heal spontaneously within a week, just like any other small cut or tear on the skin.
The therapy aims to reduce pressure on the anal canal and relieve pain by keeping the stool soft during healing of the cleft..

Relieve Pain and Discomfort

  • Hot baths have a calming effect and can help relax the anus, and can relieve pain.
  • A cream or ointment that contains anesthetic can help relieve pain.
    This medicine should only be used for short periods (5-7 days). If used over time, anesthesia may irritate or sensitize the skin around the anus. Can only be purchased with a prescription. It is possible to buy some products in pharmacy without a prescription.
  • A cream or ointment that contains cortisone may be prescribed by a doctor if he sees too much inflammation around the lesion. Corticosteroids reduce inflammation and may reduce swelling around the lesion. This can help relieve itching and pain. It should not be used for more than a week at a time.
  • Wash your anus with care after going to the bathroom. Gently dry. Do not use soap when it hurts because it can irritate.
  • Analgesics like paracetamol or ibuprofen can help relieve pain (avoid codeine).
  • Thoroughly clean the anorectal area by avoiding sitting in the toilet for a long time. Use petroleum jelly to help lubricate the anorectal area.

The aforementioned conservative practices cure most fissures (80-90 percent) over a period of a few weeks to a few months.


Proper nutrition, avoid constipation and keep soft stools

To heal the cracks in a natural way, eat a lot of fiber that is found in fruits, vegetables, cereals, brown bread, etc.

Drink plenty. Adults should drink at least two liters (10-12 glasses) of fluids per day. Most of the fluid is expelled in the form of urine, but a part enters the intestine and softens the stool.
Most beverages are useful, but alcoholic beverages can cause dehydration, so avoid drinking them.
Avoid products that contain caffeine (which causes dehydration).

Fiber supplements. If the high fiber diet does not help, it is possible to take fiber supplements like ispaghula, methylcellulose, bran or Sterculia foetida. You can buy these products in pharmacies or by prescription. Methylcellulose also helps to soften the stool directly to facilitate evacuation.

Bathroom. Do not ignore the urge to go to the bathroom to evacuate. Some people suppress this feeling and wait to go to the toilet later. This can cause the formation of larger feces and therefore, evacuation is more difficult .

Avoid analgesics containing codeine as codamol because they are a frequent cause of constipation. Paracetamol is preferred to relieve the discomfort of a fissure.


Anal fissures in children

The above measures apply to children who may have cracks as adults. Children avoid evacuating if they have anal pain. This can cause a vicious cycle because even larger feces are formed which are more difficult to eject below. Therefore, in addition to the measures mentioned above, your doctor may prescribe laxatives for children with an anal fissure.
The goal is to make sure the stool is soft as the fissure heals spontaneously.

What happens if the anal fissure does not heal despite treatment?
An anal fissure heals within 1-2 weeks in most cases, but some people need more time for healing. Even if it lasts six weeks, when it becomes technically a chronic anal fissure there is still some chance of spontaneous recovery even without treatment. However, the treatment can help heal faster.

The treatment has the following objectives:

  • Relax the tone of the muscles around the anus. This improves blood circulation and allows the fissure to heal as quickly as possible.
  • Keep stool

Glycerin trinitrate unguent
If you apply the glycerin trinitrate ointment to the anus, the muscles around the anus relax (anal sphincter). This may facilitate healing of the lesion. The ointment can also relieve the pain quickly. The doctor may recommend the use of glycerin trinitrate in case of anal fissure for more than a week, and especially if it is a chronic anal fissure.
However, when the treatments do not work and the anal fissures persist, you have to do other treatments, including:

  1. Use creams or suppositories that contain hydrocortisone to reduce inflammation
  1. Apply other creams and ointments:
  • medicinal cream to help heal the injury,
  • A topical muscle relaxant to relax the anal muscles,
  • An anesthetic ointment to reduce pain, if it interferes with evacuation,
  • Nitroglycerin or calcium channel blockers (calcium antagonists) to relax the anal muscles and increase blood flow in the region.
  1. Injections of botulinum toxin type A (Botox) into the anal sphincter. The injection temporarily paralyzes the anal sphincter muscle, relieving pain to encourage healing
  2. Surgical operation


What is the surgical procedure?

Before considering the surgical approach, the physician should examine the patient and perform other tests to determine if there are other treatment options.
The reasons why the fissures do not heal can be: scars or muscle spasms of the internal anal sphincter.

 

Surgical intervention

When is the operation required?
It depends on the personal resistance, the fissures can heal spontaneously, but when they become chronic, one can consider the surgery. The decision depends mainly on the severity of the symptoms.
There are several surgical techniques for the treatment of anal fissures.

1.Lateral internal sphincterotomy
This procedure has the best cure rate and is the most commonly used procedure for anal fissures. In this operation, the surgeon makes a small cut in the internal anal sphincter muscle for the length of the slit. The surgery is performed under local anesthesia, the duration is 15 minutes and after a few hours of observation, the patient can go home. Cutting the muscle rarely causes fecal incontinence.

Usually, the surgery is done under an in-patient regime in Day Hospital). The pain subsides within a few days and complete healing occurs within a few weeks. Your doctor may prescribe antibiotics to prevent infection of the surgical wound.

2.Fissurectomy
In this procedure, the anal fissure is completely removed, leaving an open wound that cures naturally. This operation can be performed alone, along with lateral internal sphincterotomy, or by associating the injection of drugs, such as glycerin trinitrate or botulinum toxin A.
Fissurectomy is done in the case of anal fistulas (a tunnel-like structure connecting skin around the anus and rectum) and anal fissures.

3.Dilatation with dilators
It is a technique that passively dilates the anal canal through the insertion of dilating anal dilators, for example dilatation.
There are no scientific studies that prove the effectiveness of this medical procedure, but in some cases it is effective.

4.Balloon dilatation

  • Anal dilatation with balloons is a very effective treatment for anal fissures, with lower rates of fecal incontinence with regard to lateral internal sphincterotomy.
  • Pneumatic anal dilation prevents other complications of sphincterotomy: hemorrhage, abscess, fistula and chronic pain.
  • Dilators are also useful for delicate dilatation during all anorectal surgeries. The procedure involves inserting a balloon into the anal canal. It is usually done under  local anesthesia .
    When it is inside, it fills with a specific pressure. The balloon presses on the anus lift for a few minutes and can relax the contract muscle using a neurological-natural reflex of the human body.
  • The surgery is done on an inpatient basis at Day Hospital and the patient returns home the same day.
    This new method is very effective.

Anplasty
Anplasty is a technique that involves replacing torn tissue in the cleft with the patient’s healthy mucosa. This type of surgery is more complex and is usually recommended only when other surgical options have been unsuccessful.

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