Anal tear – anal fissure
What is an Anariss?
An anal fissure - anal tear - is a tear in the mucous membrane of the anal canal, which is often caused by excessive pressing during constipation or diarrhea. Typical symptoms include severe pain during and after bowel movements, itching, bleeding, oozing or mucus secretion. There are two forms of anal fissures: acute and chronic.
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An acute anal fissure is superficial and usually heals within 4-6 weeks. However, it can occur again and again, especially if there is an underlying disease - most often hemorrhoids and thin, swollen mucous membranes. A chronic anal fissure is deeper and can develop from an acute anal fissure. Treatment depends on the type of anal fissure. In acute cases, connervative measures, stretches and ointments are used to combat the anal fissure. In the chronic form, the most effective is laser irradiation of the fissure, best in combination with muscle relaxing treatment. There are still the classic surgical procedures, but in the HeumarktClinic practice these can be avoided in most cases.
Laser therapy is a gentle method for treating anal fissures. The tear is treated with a laser beam, which specifically and precisely removes the damaged tissue without affecting the surrounding healthy tissue. The affected areas can be made germ-free with the laser. This special effect comes about through the targeted generation of heat. The laser method creates an elastic scab that covers the crack. Under the scab, the fissure heals naturally and painlessly. In comparison to conventional surgery, in which the damaged tissue is excised along with the peripheral wall, laser treatment scabs over the mucous membrane including the peripheral wall. Since the laser light does not penetrate as deeply into the tissue, it is less damaged. It is important to have laser anal fissure treatment performed by an experienced proctologist or specialist doctor to achieve the best results and minimize possible risks. The doctor will evaluate your individual situation and advise you of the best treatment options that best meet your needs.
You can see a simulation of the treatment in the video Laser removal of anal fissure, laser sealing of anal fissure
Laser removal of anal tear
Advantages of laser surgery and microsurgery
Laser fissure surgery with the diode laser (1479 nm) has a number of advantages over standard surgery, as follows:
- Tissue protection: An important advantage is the protection of tissue. There is no current flow through the tissue and we observe significantly less thermal collateral damage, i.e. the impairment of the neighboring tissue due to heat, than with an electric scalpel. Wound healing begins earlier and the scars become smooth and elastic. By using magnifying glasses that make the smallest details visible during the procedure, the accuracy of the operation can be increased even further.
- Precision: Laser energy has a very focused effect and therefore allows unrivaled precision in cutting. Because minor bleeding is automatically stopped, the surgeon has the optimal view of the treatment area.
- Promote wound healing: The healing-promoting stimulation of the surrounding tissue, comparable to the effect of low level laser therapy (LLLT), through laser light is a “desired side effect” of laser surgery
- Detoxification: A chronic wound is itself a collection of germs in the pockets and corners of which parasite germs live en masse and prevent the crack from healing.
For this reason, the HeumarktClinic has been promoting laser fissurectomy with a diode laser instead of surgical fissurectomy with a knife for almost a decade. The laser anal fissure operation includes the laser removal of the anal fissure, the removal of all scars that prevent wound healing, the transformation of the diseased tissue into healthy tissue, and the restoration of the elasticity of the narrowed, stiff anus. A fine-tissue examination to rule out malignant degeneration is also possible in rare, suspicious cases.
After laser surgery of the anal fissure
After laser anal fissure surgery, the wound is not sutured to avoid additional pain, infection, and scar tissue. The external wound may seem quite large to the patient, but the drainage it ensures is crucial for healing. After a bowel movement, the wound is only cleaned with running water in the shower, with a sitz bath or simply with a damp toilet paper or baby cloth when on the go.
Healing usually begins from the 10th postoperative day. Now the secretion of wound fluid and the pain of the wound also decrease. Towards the end of the third week, the restrictions are usually hardly present anymore. Only in a few individual cases did the scar heal completely after a year.
Sometimes a stretcher or dilator, a conical pin made of plastic or glass, is prescribed with which the patient can regularly stretch the anus themselves. This is intended to relieve the muscle spasm and prevent the edges of the wound from sticking together prematurely. The procedure is often painful and therefore difficult to carry out. A comparative study of acute anal fissure stretching with the finger or with a plastic pen found better results in patients who massaged the anus with the finger. The “Fissure Pen” advertised on the Internet aims in the same direction. Its special shape and the PTFE material are intended to enable longer stretching with better patient comfort.
To combat these outdated methods, the HeumarktClinic uses medicinal muscle relaxing therapy during the operation, which keeps the narrowed rectum elastic, easy to open for at least 4-5 months and enables pain-free wound healing and tear healing. .
The wound will after laser fissure treatment not sewn, to avoid additional pain, infection and scar tissue. The external wound may seem quite large to the patient, but the drainage it ensures is crucial for healing. After a bowel movement, the wound is only cleaned with running water in the shower, with a sitz bath or simply with a damp toilet paper or baby cloth when on the go.
After the procedure, you will be unable to work for approximately two weeks. Normally healing begins from the 10th postoperative day. Now the secretion of wound fluid and the pain of the wound also decrease. Towards the end of the third week, the restrictions are usually hardly present anymore. Only in a few individual cases did the scar heal completely after a year.
Sitz bath and ointments for anal fissure
The sitz bath is a classic proctological treatment that allows for gentle cleansing and is very pleasant due to its relaxing effect. Bath additives with synthetic tannins or chamomile are said to have an anti-inflammatory effect.
Topical nitrates release nitric oxide (NO), which has a relaxing effect on the internal sphincter. In collective statistics, this therapy principle with a cure rate of 49% was superior to treatment with a dummy drug (placebo) with a cure rate of 37%. Further studies showed a significant reduction in pain with nitrate ointment. The main side effects include headaches, which often lead to treatment being discontinued. After stopping therapy, the anal fissure relapses in up to 50% of cases.
Calcium antagonists also have a relaxing effect on the smooth muscles of the internal sphincter and improve blood circulation. Various recipes, ie ointment preparations to be mixed by the pharmacist, are widely used. In prospective studies, healing rates of 68% were found after 8 weeks of use. The main advantage of these substances over the literary ones is their better tolerability. A formulation containing diltiazem and lidocaine is the standard for primary treatment of anal fissure in our practice. We successfully use calcium antagonists as a 0,2 – 0,3% cream.
A plant extract from hibiscus - myoxinol - acts as a natural immune stimulator and thus promotes healing in a natural way. Fissure patients also need other ointments with strong inflammation and pain relief effects and we regularly prescribe them.
Pain-free with BTX for anal tear
BTX, which is actually the most powerful muscle relaxant, can be one effective treatment method for anal fissures be. BTX is a natural protein that influences muscle movement and is used in medicine for various therapeutic purposes. It blocks the release of acetylcholine at the presynaptic nerve of the neuromuscular junction. The effect is a temporary weakening of the internal sphincter for about 3 months. When treating an anal fissure, BTX is injected into the internal sphincter of the anus. This muscle is usually very tense, which can make healing an anal fissure difficult because the tension can affect blood flow and the healing process. By injecting BTX into the sphincter, it causes a temporous relaxation of this muscle. This reduces pressure on the anal fissure, improves blood circulation and promotes healing. The dose is described as 40-100 units. Cure rates of up to 75% with a recurrence rate of up to 53% (in a Spanish study with 100 patients over 3 years) are reported. The application is limited by the high price and the costs are not covered by statutory health insurance. The HeumarktClinic's decades of know-how ensure that the patient receives the right injection site in the right dose, thus avoiding incontinence and ensuring the necessary muscular relaxation.
By injecting BTX into the sphincter, it causes a temporous relaxation of this muscle. This reduces pressure on the anal fissure, improves blood circulation and promotes healing. The relaxed muscles allow for better wound healing while relieving pain and discomfort during bowel movements.
BTX treatment for anal fissures is usually well tolerated and does not require general anesthesia, but injections are preferred during the operation so that the patient can be spared the pain of a separate treatment. The procedure can be performed on an outpatient basis, and most patients can resume normal activities afterward.
However, it is important to note that the effects of BTX temis porous and usually subsides after a few months. In some cases, repeated use may be necessary to maintain full effect. The underlying disease should also be eliminated, which most often presents itself as hemorrhoids.
How to promote healing of anal fissure yourself?
In many cases, an acute anal fissure heals on its own. Normal bowel movements are important. A diet rich in fiber and drinking enough water can support stool regulation. Dietary supplements such as psyllium husk can also help with stool regulation. The pharmacist will explain how to take dietary supplements to regulate stools. Eating a diet rich in fiber can also reduce the risk of recurrence of anal fissures.
In summary, it can be stated that in numerous studies the medications mentioned appear to be superior to sole stool regulation and anal care in terms of pain, healing rate and recurrence rate. Significant differences between the representatives of this group could not be demonstrated.
How is anal fissure diagnosed?
The doctor makes the diagnosis based on the medical history (anamnesis) and a physical examination with inspection and possible palpation and proctoscopy. Additional ultrasound examination shows possible purulent ducts, causal hemorrhoids.
If the symptoms persist for a long time, further examinations may be necessary for more detailed clarification. The extent of the defect can be determined more precisely with a rectumoscopy (proctoscopy). Other illnesses can also be clarified as possible causes.
Surgical treatment of anal fissure
Anal fissure: When does surgery need to be done?
In many cases, an anal fissure can be treated conservatively. However, surgery is indicated if conservative treatment methods are unsuccessful or in the case of chronic anal fissures with wound healing problems. The decision to undergo surgery depends on the patient's individual situation and should be made in consultation with an experienced proctologist or specialist. The AWMF 2020 expert guideline on anal fissures recommends surgical treatment for chronic anal fissures that persist for longer than 8-12 weeks and do not respond to conservative therapeutic measures.
The surgical technique depends on the type and severity of the anal fissure, as follows:
Classic fissurectomy: The crack is cut out with a scalpel
Lateral sphincterotomy: The sphincter is cut and notched
In the so-called lateral sphincterotomy, the sphincter is cut and notched on one side. This is intended to relax the sphincter muscle. However, high insufficiency rates speak against the procedure and represent it as an outdated concept. But even with fissure excision, the sphincter can also be partially excised and weakened. At the Heumarkt Clinic, we therefore recommend neither lateral sphincterotomy, nor classic surgical fissurectomy (tear removal) or other types of sphincter-weakening operations. Instead, the fissure is treated with laser the sphincter reversibly with BTX and with success but without incontinence.
Anal fissure operation using an advancement flap: Anal Advancement Flap
One way to cover the tear is to use a flap, such as the anal advancement flap. Tissue with a good blood supply is moved into the wound in order to achieve healing. Healing rates of up to 96,7% with complete healing after one month in almost 50% of cases were reported in a 2021 study. At the HeumarktClinic, flap surgery is recommended for deep, chronic tears where there is a large tissue defect; the most reliable way to heal is to cover them with a well-perfused teartem Mucous membrane-muscle flap is possible. At the HeumarktClinic, the advancement flap is connected with a relieving suture anchored in the muscles. This eliminates the wound tension and the sliding flap heals even faster, usually within 8-10 days. Our excellent results in terms of healing rates over 90% are also confirmed by studies: in one Study from 2021 up to 96,7% complete healing is reported.
How long does the healing process take?
The healing time after fissure treatment depends on the type of therapy. After laser treatment it takes between four and six weeks, after surgical fissure removal it takes much longer up to six months. Aftercare is also important, whereby wound infections, for example, should be avoided. BTX treatment accelerates healing significantly. Anal hygiene should also be strictly adhered to and regular anal douches should be used. Re-introductions for further instructions to promote healing are elementary.