Anal Fissure (Ring): Brief Overview
An anal fissure is a wound, a tear in the anus that causes pain, sometimes very intense. It is caused by trauma from hard stools. The pain triggers strong tightening (spasm) of the anal sphincters, preventing the fissure from healing.
The pain is very characteristic, often appearing only during bowel movements or up to an hour afterward. It can be so severe that patients fear defecation, leading to constipation. Thus, pain leads to spasm, and spasm prevents healing.
This is what the ancients called a vicious cycle – an unpleasant situation that feeds back on itself and worsens. Pain equals spasm equals fissure – all parts of the same problem.
Anal Fissure: What Are The Causes?
The most common fissure is the one caused by constipation and hard stools, as described above. Anal fissures can also result from excessive washing with soap and wiping with toilet paper. For this reason, using soap and toilet paper on the anus is prohibited. Less common causes include Crohn’s disease, possible intestinal inflammations, syphilis infection, or anal cancer.
A simple trauma or irritation (acute fissure) causes pain and sometimes bleeding.
Anal Fissure: What Are The Symptoms?
The main symptom is pain immediately after defecation, especially in recently formed (acute) fissures. In chronic fissures, pain often starts half to one hour after defecation. The pain of chronic fissures is described as feeling like razor blades cutting through the anus during bowel movements.
Bleeding is less common. Continuous pain usually indicates hemorrhoids or an anal infection (abscess). Chronic fissures, due to persistent sphincter spasm, can also lead to narrowing (stenosis) of the anus, making stool passage painful and difficult.
Anal Fissure: How Is It Diagnosed?
Diagnosis is easily made through detailed medical history and visual examination of the area, revealing the tear. Most patients, however, are reluctant to accept medical examinations or digital rectal exams due to severe pain. In doubtful cases, a thorough examination (digital exam, anoscopy, ultrasound) can be performed under minor local anaesthesia similar to that used by dentists.
Anal Fissure: Treatment
Conservative Management
An acute fissure often heals with proper hygiene (no soap or toilet paper) and healing ointments. Water used for cleaning should be lukewarm to warm – never cold or icy. Cold water and ice are strictly forbidden for fissures.
Warm water relaxes the area, while cold water causes tightening and pain. If ointments fail within six months, or if fissures recur multiple times, surgical treatment may be required (for chronic fissures).
All treatments for chronic fissures must reduce sphincter spasm to be effective. There are medicinal ointments and injections directly into the fissure that reduce spasm and promote healing.
Anal Fissure: Laser Treatment
If conservative therapies fail, laser treatment or surgery is performed.
Very often, laser treatment is combined with sphincter relaxation procedures, especially for true chronic fissures requiring surgery. Sphincter relaxation may rarely cause slight gas incontinence but never fecal incontinence.
Laser treatment alone is not sufficient for definitive healing. It must be performed properly, targeting the internal sphincter, which is relatively unimportant, and never the external sphincter. The external sphincter contributes 90% of sphincter strength and is vital; injury here leads to significant issues. The internal sphincter contributes only about 10% and is less critical.
Reported slight gas incontinence is more common in smaller-framed women whose internal sphincter is shorter.
Treatments Used Abroad
Laser alone cannot significantly help treat a true fissure requiring surgery. To date, the method applied in Europe and the USA for anal fissure treatment is lateral internal sphincterotomy, with no significant reports supporting laser therapy alone. Lateral internal sphincterotomy has excellent results, with an incision only half a centimeter (5 mm) long.
For more information, book an appointment with Proctology Surgeon Dr. Stamatiadis.
Frequently Asked Questions About Anal Fissure
Currently, the main surgical technique in Europe and the USA is lateral internal sphincterotomy. Through a tiny incision, the lower one-third of the relatively unimportant internal sphincter is divided, eliminating spasm and healing the fissure. The incision is only about half a centimeter long.
Anal fissures are caused by excessive spasm of the internal sphincter. Functionally, the internal sphincter is minor (providing only 10% of strength), while the external sphincter is critical. If the procedure is performed correctly, the risk of fecal incontinence is negligible.
