Anal fissure

Last Updated: 2022-03-11

Author(s): Anzengruber F., Navarini A.

ICD11: DB50.0

Bowel rupture, anus rupture.

Anal tearing of the mucosa with consequent painful defecation.

Age peak: middle adulthood.

  • Surgical interventions
  • Sexual practices
  • Crohn's disease
  • Stenoses
  • Chronic constipation with consequent hard bowel movements
  • Hemorrhoids
  • Chronic viral infections
  • Chronic bacterial infections

Mostly occurring at 6 o'clock in lithotomy position, poorly healing cleft-shaped fissure/rhagade extending from the linea dentata to the outer skin. The internal sphincter may also be affected. There may be severe, cramping pain during defecation. It is not uncommon for patients to have a marked fear of defecation due to this dolor. Consequently, spasms of the sphincter muscle may occur.

  • Anamnesis
    • Occurrence after sexual practices, surgery, etc?
  • Typical clinic
  • Due to spasm, clinical examination is useful only after local anaesthesia has been performed. Inject local anaesthetic into the sphincter and it will work.
  • Digital rectal examination
  • Proctoscopy

Anal, rear commissure is typical (lithotomy position 6 o'clock).

  • Fistula formation
  • Periproctitic abscess

The aim is to remove the excessive sphincter tone

General measures

  • Stool regulation with wheat bran
  • Anal dilator (insertion with lubricant)

Surgical measures

  • Sphincterotomy
  • Fissurectomy

Nitrates

  • Glyceryl trinitrate
  • Rectal ointment 3x daily for 4-6 weeks
  • Side effect: temporary headache

Botulin toxin

  • Intrasphincteric injection. Dose 20 U in 1 mL, may be repeated after one week.

For persistent pain

  • Topical anaesthetics in the form of ointments / suppositories / others

  1. Lund JN, Scholefield JH. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. The Lancet 1997;349:11-4.
  2. Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. Botulinum Toxin Injections in the Internal Anal Sphincter for the Treatment of Chronic Anal Fissure. Annals of Surgery 1998;228:664-9.
  3. Fruehauf H, Wegmueller B, Bauerfeind P, Fried M, Thumshirn M. Therapy of Chronic Anal Fissure: Efficacy and Safety of Botulinum Toxin A Injection Compared to Topical Nitroglycerin Ointment. Z Gastroenterol 2005;43.