8. Anal fissure

Definition:

The anal fissure is a tear/crack of the anal skin. It usually is at about 6 o'clock position (posterior) and develops mainly due to overstretching or irritation of the anal skin. It usually occurs from the inside out radialy. The tear begins at the outside anal skin and ends usually at the boundary line between anal channel and final intestine, the Linea Dentata. In chronic cases, there often is an enlarged anal papilla (knot) which prevents the fissure from healing up. Outside often develops a skin fold, which has no disease value except interfering the hygiene

Because of the tear, the internal sphincter (closing) muscle get tensed up. This limits the blood supply to the tissue which prevents the healing. A vicious circle develops; the tear favors the muscle spasm which impairs the healing, whereby the tear continues to maintain the spasm. So, it can exist for many years, in those consequences the fissure becomes chronic. By the increased muscle tension, favorable conditions for the emergence of hemorrhoids are also created.

In contrast to the acute fissure where the tear is fresh, the chronic fissure leads to a scarring of the wound which usually is corrected only by surgical removal of the scar tissue.

Causes:
The main cause is constipation and infections. In addition, periods of diarrhea and irritation of the anal skin may trigger the emergence of anal tears.

Diagnosis:
Due to the high concentration of nerves, the anal skin is highly sensitive. Because of this fact, anal fissures are very painful. Especially at the beginning of the defecation, the pain is intense. Additionally, minor bleeding, itching and burning can be felt.

Treatment:
The main goal is to reduce the muscle spasm and increase the blood supply to the area. Acute or very new fissures can be treated with ointment applications, suppositories as well as a stretch treatment with an anal stretcher are often sufficient. Sometimes, a Botox injection is administered whereby the muscle is relaxed and the wound can heal.

In case of chronic anal fissures, these methods could be insufficient and operation may not be avoided. There are different techniques, which all aim at relaxing the muscle and removing the scar tissue. More or less, a fresh fissure is produced which can heal itself with the increased blood supply.

Eisenhammer method which is used for many decades is being left due to its problems. In this method, the muscle is cut deeply in order to create a fresh wound and the internal sphincter muscle is split up to the boundary line between anal channel and final intestine. This method has often shown that after this operation, a so-called key hole phenomenon occurred - that is that the anus cannot seal any longer correctly (incontinence). Alternatively, predominantly in Anglo-Saxon world, the muscle is operated sideways, a quite extended stretching of the anal canal is then accomplished. This method also can created sealing problems and resultant incontinence.

The wound is cut out generously, taking along of the increased anal papilla and the skin fold so that an outward drainage triangle is created, in which the wound can drain.

In the Proktoklinik, a brand-new operation technique is used with the help of the ELVeS Laser. We apply local anesthesia for the operation. After the minor and simple excavation of the anal papilla, the wound is freshened up carefully so that the muscle is not hurt. Only a small amount of sphincter muscle relaxation is achieved. The existing skin fold is also cleared away with the laser.

By this gentle technique, the complaints are minimized after the operation, and the healing is accelerated.

After this small operation, the area should be kept clean with use of sits baths and douche after each defecation. In addition, an anti-inflammatory medicine and Lactulosesirup in order to keep the stool lubricated can be utilized for a short period.

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Anal diseases - still a topic with taboo   |   Anatomy of the final intestine   |   What are Hemorrhoids actually?   |   How does the illness of the hemorrhoids developed?  
 How does the hemorrhoidal illness express itself?   |   How Hemorrhoids are treated?   |   How is the treatment in the Proktoklinik?   |   Anal fistula / Anal abscess   |   Anal thrombosis   |   Illness of the Linea Dentata   |   Skin folds (Mariscs)   |   Condyloms