Home >>Diseases >> Anal fissure
Anal fissure is a spontaneously appeared linear or elliptical tear (ulcer) in the anal mucosa.
Anal fissure is quite common. Among proctology disease this is one of three the most frequent (11%-15% or 20-23 cases
amongst 1000 people). Anal fissures are more prevalent among young and middle- age females.
Etiology and pathogenesis.
There are a lot of explanations of the genesis of anal fissure. The most common are traumatic hypothesis, vascular disorders,
perianal epithelium changes, neurological disorders localized in anal sphincter. The majority of fissures occur in the posterior
midline (more then 80%), 10% are found in the anterior midline (mostly in females). Other location is very rear. Occasionally
there can be combination of two fissures, anterior and posterior. Especially posterior part of anal canal in mails and females and
anterior part of anal canal in females is the less mobile, because of close disposition of coccyx behind and vagina in front in
females. These parts almost don’t move during bowel movement although other parts move down and after defecation came
back in initial position.
Decrease in mucosal blood supply to the posterior and anterior commissures (at 6 and 12 hours), there are high risk of
traumatic damage of mucosal in posterior and anterior commissures area during defecation. Moreover, at the level of dentate
line there are deep anal crypts. If these crypts are full and bowel movement is traumatic, inflammation area forms mostly in
posterior part of anal canal (there crypts are deeper and larger). If these predisposing factors combine with hard bowel
movement appears tear in the anal mucosa (longitudinal defect with neural endings on the bottom). That is the reason of
constant pain, which increase during defecation. This way, there is vicious circle: pain is the reason of sphincter spasm;
sphincter spasm (the reason of ischemia) makes impossible healing of fissure. Some anal fissures appear because of chronic
inflammation in anal crypts. The chronic inflammation in posterior anal crypts (the most deep and large and the biggest amount
of them) makes mucosal of anus fibrous and non-elastic. With these changes, even normal bowel movement can become the
reason of anal fissure. Neurological disorders with long-term sphincter spasm also can be the reason of anal fissure.
There are the reasons of anal fissure:
- Chronic constipation
- Diarrhea and colitis (irritation of anal canal)
- Chronic and acute hemorrhoid
- Hard work
- The habit to sit a lot
- Spicy food, alcohol
Very often anal fissure can be combined with gastritis, ulcer of duodenum and stomach, cholecystitis (all of them can be the
reason of gastrointestinal disorders).
There are acute ant chronic fissures.
Acute fissure is characterized by slit form with acute ends; the bottom of this fissure is muscle tissue. There are three character
symptoms for acute fissure: pain during defecation, spasm of sphincter, anal bleeding. Principal and first symptom is pain, which
begins in the beginning of bowel movement. Pain usually is very strong and can be long-term. Strong pain force patients to
avoid defecation and can be the reason of constipation. Pain is also the reason of another principal symptom – spasm of anal
sphincter. Spasm begins during defecation and can exist several days, up to next defecation. This symptom is the most
important in pathogenesis – completing vicious circle: pain is the reason of sphincter spasm; sphincter spasm (the reason of
ischemia) makes impossible healing of fissure and intensifies pain.
Frequent mucosal trauma and granulation tissue provoke anal bleeding. Mostly bleeding is not intensive (drops in stool or prints
on the paper).
Complications of anal fissure.
The most common complications for anal fissure are extreme pain, which are determined by spasm of sphincter, bleeding from
anal canal, anorectal abscess can occurs if infection come through the anal tear in perianal tissue.
Diagnostic of anal fissure.
First of all, there is necessary to evaluate visually perianal zone and beginning of anal canal Usually this way is possible to fine
fissure. Occasionally we have to accomplish digital examination. This examination gives us the possibility to sight spasm of
Anal fissure treatment.
Treatment of anal fissure depends on degree and duration of its existence. Acute anal fissures are treated by medications with
better result. High effect of treatment we admit in 65-70% of patients. The most important part of conservative treatment of
anal fissure is liquidation of anal pain and spasm of sphincter and only after this, normalization of bowel movement and healing
of anal tear become possible. Mostly this treatment is outpatient.
Patient should follow three the most important conditions:
- exclude alcohol, and spicy, soul, salty, bitter, fried food. Boiled beet (200-300g) with oil or soul cream is very useful. We
recommend also eating a lot of damson, dried apricot and fig. Most of patients who go on this diet have soft bowel
movement. For patient with constipation we recommend diet № 3, with diarrhea - diet № 4b and 4c (Pevzner`s
- limit elevation of heavy things
- normalization of bowel movement (hard excrements break healing of fissure). That’s why it’s better to use laxatives, for
example Forlax. If patient has diarrhea we prescribe adsorbents, ferments, pro- and pre-biotic. Every morning 30min -
1 hour before defecation (it should be in the same time every day) patient should use suppository with anesthetic
(Posterisan-forte, Posterisan). After defecation there is necessary to wash perianal area by breezy water and use again
suppository with anesthetic. Subsequently it’s better to take sedentary bath (water should be warm – 37-39C). Duration of
sedentary bath is 15-20min. After this we recommend to smear anal canal by unguent (Posterisan-forte, Posterisan).
Patient should follow this treatment 2-3 weeks, and if it necessary to repeat it in 1-1,5 month.
If fissure is acute and non very deep but bleeding occurs often sometimes we apply non operative technique
infrared coagulation of anal fissure, the principle is based on photocoagulation of tissue by light stream. The duration of
influence is controlled by timer. We apply infrared coagulation of anal fissure under local anesthesia. From 4-8 points we impact
on ends, bottom of fissure and border hill. The duration of procedure is 1-3sec. There is possible to apply this method even if
patient is pregnant.
The result of treatment of chronic anal fissure is much worse and recurrence occurs much oftener. If conservative therapy of
chronic anal fissure is not effective during 1month proctologist should offer radical treatment - excision of anal fissure
This technique can be performed in or out-patiently, it depends on the level of spasm of sphincter, localization of fissure,
existence of border hill. The reason of excision of anal fissure is liquidation of scar tissue at the ends and bottom of fissure.
Created during operation «fresh» wound is healed easily by medications.
The indications for surgical treatment of anal fissure:
- Consequent pain
- Non effective medication treatment during 15-20 dais
- Complications (anal fistule)
- Anal fissure with hemorrhoids ІІІ and ІV degree
The methods of surgical treatment of anal fissure:
1. Excision of anal fissure (excision of scar tissue of anal canal and perianal skin)
2. Excision of anal fissure with posterior internal sphincterotomy (cut of internal sphincter performs to remove spasm of
sphincter and consequently pain).