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.
https://www.flickr.com/photos/195571589@N04/53334019968
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
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