Anal fissure K60.20

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 15.01.2024

Synonym(s)

anal fissure; Anal ulcer; Torn Bowel

Definition
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Polyätiological symptom with a longitudinal tear of varying depth in the mucosa of the distal anal canal with pain of varying intensity, especially in defecation (lasting minutes to hours).

Etiopathogenesis
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Chronic constipation (excessive stretching of the anal canal when hard stool masses pass through it), poor blood circulation due to venous congestion in haemorrhoidal diseases, chronic inflammation, chronic viral or bacterial infections, sexual practices.

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Manifestation
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Predominantly occurring in middle adulthood.

Localization
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Mostly rear commissure (6 o'clock in lithotomy position).

Clinical features
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Initially superficial defect ( anal rhagade); this merges into the chronic fissure, i.e. linear ulcer reaching down to the fibres of the inner sphincter muscle with inflammatory infiltration of the surrounding tissue. At the distal end of the fissure there are usually mariscs, the so-called pre- or sentinel fold. Symptoms are severe, burning, cramp-like pain during defecation, which can last for hours. Radiation in back, legs, genitals possible. Stool retention and chronic spasm of the inner sphincter muscle with consecutive fibrosis occurs.

Diagnosis
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Examination under local anaesthesia: local anaesthetic injections into the sphincter region, followed by digital examination and proctoscopy.

Differential diagnosis
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Differential diagnosis of anal ulcerations which may occur under the image of an anal fissure.

Acute/chronic anal fissure
Anal eczema
lichen sclerosus
lichen planus
ulcerative colitis
M. Crohn
M. Behçet
Bacterial infections
Streptococcus ulcer
Sexually transmitted diseases
syphilis acquisita
Molle ulcer
inguinal granuloma
Streptococcal dermatitis, perianal
Candidosis
herpes simplex
Cytomegalovirus ulcer
Idiopathic anal ulcers in HIV infection
Anal tumors:

Traumatic ulcers.

Complication(s)
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Fistula formation, periproctitic abscess.+

Therapy
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Superficial acute fissure: anal hygiene and warm sitz baths with anti-inflammatory additives (e.g. chamomile extract) or astringents (e.g. Tannosynt, Tannolact) and appropriate ointment therapy. If pain persists, use of anesthetic ointments/supplements/lap inserts (e.g., Xylocain 2% gel), if necessary in combination with anti-inflammatory additives (e.g., Faktu ointment/supplement, Hämo-ratiopharm cream/suppository, Posterisan ointment/suppository, DoloPosterine N ointment/supplement). Stool regulation e.g. with wheat bran/flaxseed or swelling agents such as Agarol, if necessary injection of local anesthetics. Possibly careful bougienage of the anal canal with sphincter dilators.
Chronic fissure:
- Conservative therapy: Glycerol nitrate-containing ointments (e.g., hydrophilic isosorbide dinitrate rectal cream 1% (NRF 5.9.) and suppositories (e.g., hydrophilic glycerol trinitrate rectal cream 0.2% (NRF 5.10.) or calcium antagonist-based ointments (smooth msuculature relaxant) such as a 2% diltiazem hydrochloride ointment (Rp.: Diltiazem hydrochloride 2.0, base cream DAC ad 100.0; the NRF offers a 2% diltiazem hydrochloride gel - NRF 5.6. or Hydrophilic diltiazem hydrochloride cream 2%, NRF 5.7). Headache is less common with the diltiazem formulation.
- Surgical therapy (different procedures): E.g. lateral sphincterotomy according to Parks with transection of the internal sphincter, primary wound closure, fissurectomy according to Gabriel with excision of the entire ulcer/fissurectomy, secondary healing.
- Injection of 20 units of botulinum toxin 2 times/day for 6 weeks (in clinical trials).

Notice. Glucocorticoids should be used with restraint!