Anal fissure is a slit-like defect of the mucous membrane of the anus, more often its posterior wall. It is characterized by itching, intense burning pain, which increases during and after defecation, slight discharge of scarlet blood, spasm of the sphincter. Due to intense pain, patients develop rectophobia, neurogenic disorders develop: aggression, apathy, irritability. Constant traumatization and irritation leads to the formation of a long-term non-healing ulcer, its infection and suppuration. Treatment includes diet, local and general drug therapy. According to the indications, operations are carried out.
ICD 10
K60.0 K60.1 K60.2
General information
Anal fissure is a defect of the mucous membrane of the anus, usually linear or ellipsoid in shape, arising on the wall of the anal canal. It is usually located along the median line of the back wall. The length of the defect is usually no more than 1 centimeter, however, this is a very serious disease that can have dangerous consequences. Anal fissures are distinguished by their duration of existence: acute (formed recently) and chronic (long-existing).
Among diseases of the rectum, anal fissures are very common and are the third most common proctological diagnosis after inflammation of the rectum and hemorrhoids. Anal fissure is more common in women aged 25-40 years (more than 60% of cases). An acute (freshly formed) crack of the anus looks like a slit with smooth, smooth edges. The muscles of the anal sphincter form the bottom of the crack. Gradually, granulations form at the bottom and edges, which are covered with fibrin.
A long-existing crack is characterized by compacted edges (due to the proliferation of connective tissue) with signs of trophic disorders. On the inner (sometimes on the outer) edge of the crack, a connective tissue tubercle (“sentinel tubercle”) is formed, which can become the basis for the development of a fibrous polyp.
Causes of anal fissure
The most common causes of anal fissures, according to experts in the field of clinical proctology, are frequent constipation and diarrhea, hemorrhoids, heavy physical work, sedentary work, alcohol abuse and spicy food, mechanical damage to the mucous membrane of the anal canal by a foreign object or dense feces. Diseases that contribute to the appearance of cracks in the anus include inflammation of the large intestine (including proctitis).
In 70% of cases, a crack occurs in people suffering from pathologies of the stomach, small intestine, liver, pancreas and biliary system. In a similar number of patients, pathology is combined with hemorrhoids. Long-existing chronic hemorrhoids contribute to a decrease in the elastic properties of the anal mucosa (as a result of pectinosis), which results in a tendency to its defects. The area of the scallop line of the anal canal wall is the most vulnerable in case of tension.
Pathanatomy
In the vast majority of cases (85%), an anal fissure occurs on the posterior wall along the median line (for 6 hours). This is explained by the specifics of the structure of the anal canal – in this place the blood supply to the sphincter is weakest, the canal wall is most vulnerable to stress during defecation or when foreign bodies enter the rectum. In 8-9% of cases (mainly in women), a crack may occur on the anterior wall, in extremely rare cases it is localized on the sides of the anal canal. In 3-4% of cases, a combination of cracks in the front and back walls is detected.
Symptoms of anal fissure
Pathology is characterized by a rather specific clinical picture. With a long-existing disease, there is a rather pronounced pain symptom and tonic spasm of the sphincter after defecation. The spasm may persist for several hours. Tonic spasm is one of the factors in the formation of a vicious circle that contributes to the progression of the disease: anal fissure causes persistent spasm, which provokes ischemia of the tissues of the walls of the anal canal and prevents the healing of the defect.
Acute anal fissure is manifested by spasm of the anal sphincter, pain during defecation, bloody discharge from the anus. Pain syndrome is, as a rule, the main complaint of patients with this pathology. The pain occurs at the beginning of defecation, quite pronounced, often persists for a long time. There may be an irradiation of pain in the perineum or in the sacrum. Intense pain of defecation can cause patients to postpone this act, which leads to constipation.
Spasm of the anal sphincter is a reflex, associated with an intense pain symptom, tonic spasm is one of the main elements of the pathogenesis of the disease. The spasm caused by pain worsens blood supply, increases pain and interferes with tissue regeneration and crack healing.
Spotting from the anal canal is usually sparse (bloody streaks in the feces or traces of blood on paper), associated with injury to the mucosa during defecation. If there are pronounced bleeding, then concomitant diseases can be assumed: hemorrhoids, tumors, etc. The existing 3-4 weeks untreated acute anal fissure becomes chronic. At the same time, there is a thickening and compaction of its edges, the formation of a rough scar, the formation of a “guard bump” on the inner edge.
Unlike the acute process with chronic anal fissure, pain most often occurs after defecation and worries for a longer time. With prolonged sitting in a sitting position, the soreness increases. A constant pain symptom significantly reduces the quality of life of patients, causing irritability, sleep disorders, neurosis. Often, patients with chronic anal fissure have a fear of defecation, they often use laxatives.
With prolonged constipation during intense defecation, there may be bleeding from the anus. Sometimes there is suppuration of the anal fissure and a purulent discharge appears from the anus. With a chronic crack, the tonic spasm of the sphincter is less intense and does not last long. Anal itching is often noted. Chronization of the process may be accompanied by inflammatory processes of the terminal parts of the intestine: sphincteritis, proctitis, proctosigmoiditis.
Diagnosis of anal fissure
As a rule, an anal fissure is detected when examining the area of the anus. To conduct the examination, the patient’s buttocks are carefully bred, and the anus area is studied. After dilution of the walls of the anal canal, a mucosal defect is detected. Sometimes (with small cracks in the depth of the canal), proctologists perform a finger examination, while simultaneously noting the existing tonic spasm of the sphincter. Conducting a finger examination in the presence of a visible crack is impractical due to possible damage to the mucous membrane.
In patients with an unhealed anal fissure, a pronounced pain symptom and a spasmodic sphincter, instrumental methods of examining the rectum are not performed, or if there are indications (heavy bleeding, suspected proctitis, tumor formations, purulent complications) are performed using local anesthesia. Diagnostic rectoromanoscopy at a height of up to 20-25 cm can be performed after the crack has healed to monitor the condition and identify concomitant pathologies.
Differential diagnosis does not cause any particular difficulties. The anal fissure is differentiated from the incomplete internal fistula of the rectum. With this pathology, spasm of the sphincter is not noted, the pain symptom is less intense, the main clinical manifestation is the separation of pus from the anus. Palpation of the mucosal defect is not painful, a depression (fistula cavity) is found at the bottom.
It is also necessary to exclude the possibility that the crack is not a manifestation of rectal infections (syphilitic gum, tuberculous lesion, fungal or parasitic infection, damage to the rectum in Crohn’s disease). To do this, a thorough anamnesis is collected, the timing and causes of occurrence, and the features of the course are revealed.
Patients with a history of suspected HIV infection (drug addiction, promiscuous sexual relations, homosexuality) may suffer from various diseases of the rectum associated with acquired immunodeficiency syndrome. The detection of anal fissures in such patients is often accompanied by an unusual clinical picture.
Complications
Anal fissures can become infected and complicated by ascending (moving up the intestine) inflammation of the mucous membrane of the terminal parts of the intestine (sphincter, rectum and sigmoid colon). When infection penetrates into the deep layers, paraproctitis can develop. Pathology can be complicated by severe profuse bleeding, with regular small blood loss, iron deficiency anemia sometimes occurs. In men, inflammation can spread to the prostate gland (prostatitis).
Anal fissure treatment
The main goals of therapy for this disease are anesthesia, removal of tonic spasm of the sphincter, normalization of the stool and healing of the crack. Treatment can be carried out by conservative methods and with the help of surgical intervention. Timely access to a doctor, with a fresh (no more than a week) uncomplicated crack with smooth edges, allows you to heal the crack faster and more effectively with the help of therapeutic agents. Conservative therapy is a sufficient measure and leads to a cure in 65-70% of cases.
One of the significant factors is the observance of a diet aimed at activating the work of the intestine and facilitating bowel movements. The diet should be nutritious, balanced, rich in plant components and fermented milk products. It is recommended to exclude spicy, salty and bitter foods, irritating to the mucous seasonings, alcohol. Beetroot, prunes, apricots, dried apricots and figs have a positive effect on the intestines. Beets can be consumed boiled, together with vegetable oil or sour cream. Fruits should be infused in boiling water a little before use. Such a diet helps to soften the stool and facilitate defecation.
Therapeutic methods for the treatment of anal fissures are represented by drugs of local and general action. For local treatment, warm baths with a weak solution of manganese are prescribed (10-15 minutes up to 3 times a day), nitroglycerin ointment to relieve spasm of the sphincter (used in small quantities, since the absorption of nitroglycerin into the general bloodstream affects cardiac activity and the nervous system), botox (botulinum toxin, interrupts the passage of nerve signals into the muscles, with local exposure to the sphincter also helps to relieve spasm), candles and ointments with painkillers (novocaine, lidocaine, anesthetic), melituracil and sea buckthorn oil to accelerate healing (also in candles or ointments).
General treatment may consist in taking laxatives and calcium channel blockers (diltiazem, nifedipine) to relieve tonic spasm. In addition, there are such methods of treating anal fissure as infrared coagulation (chronic cracks are treated when there is no spasm and scarring changes occur), laser or radiofrequency coagulation (removal of perianal tissue under local anesthesia with a laser or radio waves), drug blockade, surgical treatment.
Indications for surgical treatment: deep chronic fissure with pronounced scarring of the edges, accompanied by significant spasm, resistant to conservative treatment. In such cases, excision of the defect is performed. Often anal fissure is accompanied by hemorrhoids. As a rule, in such cases, an operation to remove hemorrhoids (hemorrhoidectomy) with simultaneous excision of the crack is recommended. The choice of treatment tactics depends on the patient’s condition, the course of the disease, and the existing complications. Self-medication and delay in contacting a doctor can lead to the development of complications, make subsequent treatment longer and unpleasant.
Prognosis and prevention
Prevention of anal fissure consists in proper nutrition, an active lifestyle, timely treatment of diseases accompanied by stool disorders. Regular walks, walking, physical education contribute to the prevention of stagnant phenomena in the pelvic area. An anal fissure quickly identified and treated conservatively in a timely manner is completely cured in 60-90% of cases. Inadequate treatment, self-medication, delaying medical treatment contributes to the development of chronic anal fissure, which worsens the prognosis and may lead to the need for surgical treatment. Surgical excision of the anal fissure leads to recovery in the vast majority of cases.
