Chronic Anal Fissure


Introduction

The chronic anal fissure is a small wound or ulcer, with fibrous edges, which is located in the inner part of the margin of the anus. It shows with stinging, stabbing pain and bleeding during deposition; as well as pain, tension or stinging after defecation, and have variable duration.

The main cause of pain is the hypertonia of the internal anal sphincter, secondary to the fissure. This part of the anus muscle contracts unintentionally and the symptoms will improve only when relaxed due to the effect of medication or after surgery.

It is a frequent pathology in patients with constipation although it can occur in people who are not constipated, due to other reasons, including stress.



Treatment

The initial treatment is a medical one with dietary and hygienic measures, as well as with the application of healing ointments that produce muscle relaxation of the anus. If there is no satisfactory response, the injection of botulinum toxin A type (which produces a stronger and faster relaxation than ointments) may be helpful.

Surgery is indicated when the conservative treatment (ointments and botulinum toxin) has not worked: the internal sphincterotomy consists of making a small cut of the lower part of the involuntary anal musculature.

Surgical healing is achieved in 98% of cases. The infiltration of Botulinum A toxin is a very non-invasive method, which can be carried out in consultation and allows a significant improvement in 80% of patients after 3-4 days application. It is an option specially recommended for women, in which the operation of sphincterotomy (cutting off part of the muscle) increases the premature or late risk to mild anal incontinence since anal musculature is shorter and thinner compared to the male one.

Improvement with ointments occurs in 65% of patients and it is usually achieved more slowly (7-21 days). The complete cycle of treatment is 3 weeks and must be completed, despite the improvement, if a lasting effect wants to be achieved.



Post-treatment

Due to medication or surgery, the involuntary anal sphincter relaxes, the anal pain disappears and the fissure can heal spontaneously within 2-4 weeks by stopping bleeding. With ointments or botulinum toxin the improvement occurs between 3 and 21 days; however, pain decreases immediately in 24h, in case of surgical treatment, and the patient can go back to work the day after surgery.


Benefits

The degree of satisfaction of the operated patients is high since they go from almost constant and desperate pain, to its absence in a few hours with an important positive impact on their emotional state and quality of life.



Expert opinion

Dr. Domenico Fraccalvieri
Dr.  Domenico Fraccalvieri

Patients with anal fissures become irritable, less focused on work or other activities, and interpersonal relationships with family members, colleagues, and friends are damaged. The degree of satisfaction of the operated patients is high since they go from almost constant and desperate pain, to its absence in a few hours, with an important positive impact on their emotional state and quality of life.

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