Fissure
Symptoms
A sharp, stabbing pain during a bowel movement followed by a prolonged burning sensation is typical for anal fissures. Commonly, the pain will also cause the sphincter to spasm reflexively. Anal fissures are effectively found only to the front or rear. Minor bleeding (bright red in colour) sometimes occurs. Anxiety about the next bowel movement can cause constipation, which worsens the condition.
Causes
Evacuation oft hard stool caused by chronic constipation may damage the anal skin, furthermore anal stress in the sense of diarrhea is often the reason for anal fissures.
Aside from this, the insertion of objects for sexual pleasure or anal sex itself can also cause anal fissures.
Diagnosis
The diagnosis is usually based on details provided by the patient, an examination and a proctoscopy.
Treatment
Regulating bowel movements is the first step in treating a fresh (acute) anal fissure. Here, the long-term objective is to achieve well-shaped stools of a soft consistency. One proven remedy is the daily consumption of 1–2 tablespoons of psyllium seed husks, either with a glass of water or, better yet, sprinkled over yoghurt. Daily consumption of tea/tisanes or water should exceed 2 litres. Creams containing 0.2% nitroglycerine (Rectogesic®) or 2% Diltiazem relax the anal sphincter.
In general, a fresh anal fissure will heal completely within 6–12 weeks. With chronic fissures, symptoms have generally been present for longer than 3 months. If an attempt at conservative treatment has been as described above, but has not led to a healing of the condition, then we recommend surgical intervention. This involves excising the fissure plus its associated scar tissue. Often, pain from the wound is described as much more bearable almost as soon as the anaesthetic wears off. This pain also responds very well to medication containing ibuprofen or metamizole.
Stretching the sphincter muscles alone under anaesthetic is now viewed as an outdated approach, although both the internal and external sphincter must be stretched slowly during the operation so the fissure can first present itself. The partial transection of the sphincter muscles (sphincterotomy) is not favoured in Europe, although it is a form of treatment often applied in the USA. The problem with this method, however, is that an initial improvement can be followed by the onset of faecal incontinence at an advanced age (sometimes decades after the actual surgery). One particular cause of this is a weakening of the sphincter muscle due to ageing.