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They are millimetric tears that occur in the anal canal and extend to the outer sensitive skin layer. The location of the fissures, which mostly occur during difficult straining, is from the mucacutaneous junction to the dentate line.
After the fissure has formed, defecation becomes more difficult for two reasons. After the formation of the fissure, the patients squeeze their anus and cause the fissure to expand even more unknowingly during defecation. Unless defecation is performed for fear of pain, the stool becomes hard and the fissure deepens.
After the formation of the fissure, the patients squeeze their anus and cause the fissure to expand even more unknowingly during defecation. Unless defecation is performed for fear of pain, the stool becomes hard and the fissure deepens.
Although anal fissure can be seen at any age, it is often seen in young and middle-aged adults. It is seen with equal frequency in men and women, there is no gender discrimination.
Anal fissures are defined in two ways as acute and chronic.
There is no symptomatic difference between acute and chronic fissures. Fissures that do not heal within 15-20 days are considered chronic. Anal fissures are located in the anal canal in 99% of men, at 12 o’clock (toward the coccyx), in 1% of men at 6 o’clock (forward). In 90% of women, they are at 12 o’clock, 10% at 6 o’clock. Anal fissures are rarely located on the side walls.
After the formation of the fissure, the patients squeeze their anus and cause the fissure to expand even more unknowingly during defecation. Unless defecation is performed for fear of pain, the stool becomes hard and the fissure deepens. Although Anal fissure can be seen at any age, it is often seen in young and middle-aged adults.
It is seen with equal frequency in men and women, there is no gender discrimination.
Anal fissures are defined in two ways as acute and chronic. There is no symptomatic difference between acute and chronic fissures.
Fissures that do not heal within 15-20 days are considered chronic. Anal fissures are located in the anal canal in 99% of men, at 12 o’clock (toward the coccyx), in 1% of men at 6 o’clock (forward). In 90% of women, they are at 12 o’clock, 10% at 6 o’clock. Anal fissures are rarely located on the side walls.
The reason why acute fissures do not heal and become chronic is ischemia caused by sphincter pressure at the base of the fissure. Due to the pain in the anal canal, the severity of anal spasm (contraction in the anus) increases and anal ischemia (reduction of blood flow to the fissure) resulting from the spasm causes delay in wound healing. The unhealed wound continues to hurt and the cycle returns to the beginning. As this cycle repeats, it is inevitable for the fissure to become chronic.
In chronic anal fissures, the so-called fissure triad, skin tag outside the anal canal, enlarged papilla (hypertropic papilla) in the anal canal, and deep fissure base are structures formed after the fissure’s efforts to heal itself. If the treatment is delayed, complications such as abscess at the base of the fissure and fistulized chronic anal fissure develop. These complications may progress to anal stenosis and make the patient’s defecation torture.
Changing the person’s eating and defecation habits can improve acute fissures. If the chronicity does not end despite the regulation of habits, other conditions that may cause mechanical trauma to the breech should also be evaluated.
The main complaint is the pain in the rectum, which is exacerbated by defecation, which is slightly relieved, and a few drops of bright red blood that comes with the stool. Constipation may also accompany them. Pain in the anus Blood in stool Constipation How to diagnose anal fissure?
The diagnosis is made by combining the prediagnosis with the physical examination in the patient who comes with complaints of pain in the anus, blood in the stool, and constipation.
In anal fissure, physical examination begins with the visual evaluation of the breech area under good light, if chronicity is suspected, the presence of anal spasm is evaluated by gently pressing around the breech with the fingertip.
In the presence of more than one lateral fissure, the presence of underlying intestinal inflammatory diseases such as crohn’s, tuberculosis, syphilis, AIDS, anal abscess and anal cancer should be evaluated in the differential diagnosis.
Mechanical traumas that may lead to anal fissure should not be overlooked. It is important to detect and eliminate the factors underlying the fissure in order to prevent recurrence of the disease. With defecography and endoanal USG, the patient’s defecation function and underlying problems can be examined.
Up to 70% of acute fissure patients recover with a change in diet and defecation habits and a hot water sitz bath in addition to medication. Dietary habits should be turned to more water and fibrous food consumption, and defecation is ensured to be carried out regularly and without excessive straining. Medication includes relaxing anal pomades and pomades containing local anesthetics. Acute anal fissure treatment can be performed with some local drugs that have been developed in recent years.
GTN ointment: Ointment containing 0.2% isosorbide dinitrate is applied 3 times a day around the anus and towards the base of the fissure. It is very successful in reducing pain, it also reduces anal spasm, but it does not have a healing effect.
Side effects such as headache, hypotension, and burning in the rectum may alienate the patient from the treatment, making it difficult for the patient to adapt. Diltiazem Pomat: 2% diltiazem ointment is applied by applying it around the anus 3 times a day for 2-8 weeks.
It has a pain-reducing effect like GTN Pomat. Its curative effect is quite limited, there is a high risk of recurrence even when curative.
Botox Injection: An injection into the internal sphincter muscles paralyzes these muscles. It is the most effective method after sphincterotomy. It is highly effective, including chronic anal fissure. It can be considered the gold standard in patients with poor general condition who cannot tolerate even local anaesthesia.
The application of this method is quite easy and patient compliance is very high. The most important disadvantage of this method, which has a success rate of up to 90%, is that it causes temporary incontinence throughout the treatment process. Another disadvantage is that it may require repeat doses.
Treatment of acute fissure is carried out in line with the main purpose of preventing recurrence and chronicity. Surgical treatment is applied in patients who do not heal for more than 15-20 days despite this treatment..
Surgical treatment of anal fissure is usually performed with lateral internal sphincterotomy. In this operation, which we call lateral internal sphincterotomy, 20-25% of the breech internal sphincter is removed.
In this way, since the internal breech muscles (internal sphincters) that cause anal spasm will be reduced, anal spasm will also relax spontaneously. In addition, the blood supply of the fissure increases and the healing process is accelerated.
If present, hypertrophic papilla and spin tag are also surgically removed. Lateral internal sphincterotomy is a method with a success rate of up to 95%, as it reduces pain and anal spasm. However, in order to be effective and successful, it must be performed by an experienced and equipped surgeon.
