Rhagades are sores or lesions that appear on the anus and expand upwards into the canal.
rhagades can be classified depending on the duration of symptoms.

For example:

  • Acute rhagades – when symptoms do not last more than a week.
  • Chronic rhagades – if symptoms persist for more than a month and a half.

The external sphincter muscle (sphincter ani externus muscle) is consciously controlled in every human being. However, the internal sphincter (M. sphincter ani internus) is not controlled by consciousness.
This muscle remains under pressure or tension all the time.
In some people, there may be excessive muscle tension in the two ring muscles controlling the anus (sphincters).
It is a very painful muscular spasm (or spasm) that hinders bowel movements. The result is a strong rubbing against the mucous membrane of the canal, which is injured in the process.

An rhagade can develop if the internal sphincter muscle experiences too much pressure at rest. The result is muscle spasm and reduced blood flow to the anus.
High pressure at rest can also prevent rhagades from healing.


Localization of rhagades

The skin injuries usually occur in the posterior area, but can also appear on the front side of the anus, especially if the patient has ulcerative colitis or Crohn’s disease.
In some cases, the cracks may be caused by Crohn’s disease, an inflammatory bowel disease that causes diarrhea and blood in the stool, abdominal pain, fever, weight loss, and rhagades or fistulas near the anus.

What are the causes of rhagades?

rhagades are caused by lesions (traumas) of the canal. An injury can occur as follows:

A very large ball of feces stretches the canal.
The person suffers from constipation and makes an effort to excrete the firm stool.
With frequent diarrhea.
Also, childbirth can cause trauma to the canal. Some women develop rhagades at birth.
Rhagades can be caused by the insertion of a finger (as in the prostate examination), introduced foreign bodies or anal intercourse.

Since many people suffer from constipation or diarrhea without developing rhagades, many experts believe that there are other causes of rhagades as well.

Less common causes of rhagades include:

  • cancer
  • HIV
  • Tuberculosis
  • Syphilis
  • Herpes

Symptoms of rhagades

Signs and symptoms of rhagades include:

  • pain during bowel movements, which can sometimes be very strong;
  • pain after bowel movements, which can last for several hours;
  • bright red blood on the toilet paper;
  • itching and irritation around the anus;
  • burning;
  • pain when cycling, especially on a road bike with a narrow saddle;
  • a visible tear in the skin.

Complications of rhagades

Complications of rhagades include:

Lack of healing. An rhagade that cannot heal within six weeks is called chronic and may require appropriate treatment.

Recurrence. After one rhagade is present, the likelihood of getting another one increases.

Injury that extends to the surrounding muscles. An rhagade can expand into the sphincter (internal sphincter) and thus make healing difficult.
An unhealed rhagade can start a vicious cycle that requires medication or surgery to repair the injuries.

Diagnosis of rhagades

A rhagade is usually diagnosed by a rectal examination performed manually or visually.
You use a special instrument, a so-called anoscope, or a sigmoidoscope.
One of these two tests can clarify whether there is bleeding or another problem.

In the differential diagnosis it is necessary to exclude from the doctor:

  • perianal abscess,
  • Haemorrhoids
  • perianal fistula.

Initial treatment of rhagades

For most people, the cracks heal spontaneously within a week, as does any other small incision in skin.
The therapy aims to reduce pressure on the canal and relieve pain by keeping the stool soft while the rhagade heals.

pain and discomfort 
Hot baths have a calming effect and help relax the anus. This should also relieve the pain.

A cream or ointment that contains a local anesthetic can help relieve pain.
These remedies should only be used for a short time (5-7 days).
If an anesthetic is used for a long time, it can irritate and sensitize the skin around the anus.
They can only be obtained on prescription. There are also some over-the-counter products in the pharmacy.

A cortisone-containing cream or ointment may be prescribed by a doctor if he detects severe inflammation in the vicinity of the injury.
Corticosteroids decrease inflammation and can reduce swelling around the lesion.
This can help relieve itching and pain. They should not be used for more than a week.
After defecation, carefully wash the anus. Dry carefully. In case of pain, soap should not be used, as this can be additionally irritating.
Painkillers such as acetaminophen and ibuprofen may help relieve pain (avoid codeine).

Gently clean the anorectal zone and avoid sitting on the toilet for too long.
Apply petroleum jelly to keep the anorectal area supple.
With the conservative practices mentioned above, most rhagades (80 to 90 percent) heal in a period of a few weeks to a few months.

Proper nutrition, avoiding constipation and softening the stool
To treat rhagades naturally, abundant fiber should be eaten, found in fruits, vegetables, cereals, whole wheat bread, etc.
Drink a lot. Adults should drink at least two liters (10 to 12 cups) of fluid a day. Most of the fluid is excreted as urine, but some enters the intestines and keeps the stool soft.
Most drinks are suitable for this, but alcohol can lead to dehydration and should therefore be avoided.
Caffeinated products should also be avoided (as they lead to dehydration).

Fiber Supplements
If a high-fiber diet doesn’t help, you can take fiber supplements such as psyllium husks, methyl cellulose, bran, or sterculia gum.
These products can be obtained at the pharmacy or on prescription. Methylcellulose also helps to directly soften the stool to facilitate bowel movements.

to the toilet 
The urge to go to the toilet should not be ignored.
Some people suppress this feeling and wait to go to the toilet later.
This can lead to large feces and thus to difficult bowel movements.
Painkillers such as co-codamol, which contain codeine, should be avoided as they often cause constipation. Paracetamol is preferable for relieving discomfort in rhagades.

rhagades in children

The above measures also apply to children, who may have rhagades just like adults. Children avoid going to the toilet if they suffer from pain.
This can trigger a vicious circle in which even larger feces form, which are even more difficult to excrete during the next bowel movement.
Therefore, in children with rhagades, the doctor should still prescribe a laxative to the above measures.
This is to ensure that the stool is soft so that the rhagade heals on its own.

What happens if the rhagade does not heal despite therapy?
An rhagade usually heals within 1 to 2 weeks, but some people need more time to do so.
Even if it takes six weeks and the rhagade already becomes chronic, there is the possibility of spontaneous healing even without treatment. However, therapy can contribute to faster healing.

The treatment has the following objectives:

  • Relaxation of muscle tone in the anus area. This improves blood circulation and allows the rhagade to heal as quickly as possible.
  • Softening of the stool.

Glycerol trinitrate ointment
When glycerol trinitrate ointment is applied to the anus, the muscles on the anus (sphincter) relax. This can facilitate the healing of lesions. The ointment can also relieve the pain very quickly. The doctor may order to use the glycerol trinitrate ointment for more than a week, especially if the rhagade is chronic.

However, if this therapy is unsuccessful and the rhagade persists, other treatments should be performed, including:

  1. Use suppositories or ointments containing hydrocortisone to reduce inflammation.
  2. Apply other creams and ointments:
  • a medicinal cream to heal the injury,
  • a local muscle relaxant to relax the muscles,
  • a local anesthetic cream for pain relief when it occurs during bowel movements,
  • Nitroglycerin or calcium channel blockers (calcium channel blockers) to relax the muscles and promote blood circulation in this region.
  1. Injections of botulinum toxin type A (Botox) into the sphincter. The injection temporarily paralyzes the sphincter and relieves the pain to promote healing.
  2. Surgery.

What does the operation consist of?

Before recommending surgery, the doctor should re-examine the patient and perform further tests to determine if there are other therapeutic options.
Possible reasons why the rhagades do not heal are: Scars or muscle spasms of the internal sphincter.

Surgical intervention for rhagades

When should surgery be performed?
That depends on the personal load limit. Rhagades can heal spontaneously, but also become chronic, which suggests surgery.
The decision depends mainly on the severity of the symptoms.

There are various surgical techniques for treating rhagades.

Lateral sphincterotomy or splitting of the internal sphincter
This procedure has the greatest healing success and is the most widely used procedure for rhagades. In this operation, the surgeon makes a small incision in the internal sphincter along the length of the fissure.
The procedure is carried out under local anesthesia, the duration is a quarter of an hour, and after a few hours of observation, the patient can return home.
In rare cases, the incision causes fecal incontinence.
The operation is usually performed on an outpatient basis.
The pain passes within a few days and complete healing occurs in a few weeks.
The doctor may prescribe antibiotics to avoid infection of the surgical wound.

In this procedure, the rhagade is completely removed. It leaves an open wound that heals naturally. This operation can be performed on its own, in combination with lateral sphincterotomy, or with the injection of glycerol trinitrate or botulinum toxin A.
Fissurectomy occurs in fistula (a tunnel-like structure that connects the skin around the anus and rectum) and rhagades.

Expansion with dilators
This is a technique that passively widens the canal by means of dilating instruments with increasing diameter, for example with the dilator Dilatan.
There are no scientific studies that demonstrate the effectiveness of this medical procedure, but in some cases it is successful.

Balloon dilatation
balloon dilation is a very effective treatment for rhagades, with lower rates of fecal incontinence than lateral sphincterotomy.
Pneumatic dilation avoids some complications of sphincterotomy: bleeding, abscess, fistula, and chronic pain.
The dilators are also used for gentle stretching during all anorectal operations.
The procedure consists of inserting a balloon into the canal.
Usually this is done under local anesthesia.
Once the balloon is positioned inside, it is inflated with a certain pressure.
The balloon presses on the lifter of the anus (levator ani muscle) for a few minutes and can relax the contracted muscle by using the natural neurological reflex of the human body.
The procedure is performed on an outpatient basis and the patient returns home the same day.
This new method is very effective.

plasty is a technique in which the damaged tissue in the rhagade is replaced by the patient’s healthy mucosa. This form of surgical intervention is more complex and is usually recommended only when other surgical interventions have been fruitless.

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