Anal fissure - Causes, symptoms and treatment. MF.

Anal fissure or anal fissure The is a linear defect in the mucosa of the anal canal. Usually it is located on the back of the middle line( at 6 o'clock) or the front midline( 12 hours) of the anus, in the latter case more often in women. When combined with chronic hemorrhoids, the anus of the anus can be located on the side walls of the anal canal. Anal fissure can be acute when the disease lasts up to 4 weeks, and chronic during a longer course.

The figure shows the anatomical structure of the rectum and its closure.

Causes of anal fissure.

Acute anal fissure can occur during and after difficult labor or with unconventional sexual intercourse.

The most common cause of anal fissure is a mechanical trauma caused by the passage of dense stools through the sphincter of the anus during defecation.

The process of occurrence of an anal fissure is as follows. Constant mechanical trauma of the rectal mucosa, especially the crypt Morgani( folds of the rectal mucosa in the anal canal region), leads to the appearance of linear ruptures of the mucous membrane in the most immobile areas, namely the posterior( in men) or the anterior( in women) midline. At the same time, the sensitive nerve endings are exposed, which causes a sharp spasm of the sphincter of the anus and severe pain in the act of defecation. Given that the problem of constipation and stiff stool does not disappear, there is a permanent trauma to the mucous membrane, which leads to the appearance of persistent pain syndrome and spasm of the sphincter, which in turn inhibits the healing of the formed cracks. The presence of pathogenic microflora in the rectum leads to a constant infection of the mucosal wound, which supports active inflammation. Over time, there is a thickening of the edges and deepening of the crack, which makes the nerve endings even more unprotected and intensifies pain. The vicious circle closes, which leads to the transition of the disease to the chronic stage.

The presence of chronic hemorrhoids aggravates the situation. This disease causes deterioration of blood circulation in the mucosa of the anal canal, which leads to a decrease in its ability to regenerate( heal).

With normalization of the stool and anesthesia, remission of the disease may occur, which can last for months and even years, but with the first constipation or diarrhea, the anal fissure may reappear.

Symptoms of an anal fissure.

The clinical picture of the anal fissure is quite typical and bright. There are three main signs of this disease: pain in the anus, spasm of the anal sphincter and bleeding from the anus.

When combined with chronic hemorrhoids, hemorrhoids prolapse and more profuse bleeding are added to these symptoms.

The main signs of an anal fissure is the pain in this area. In acute anal fissure, pain occurs during and for 20 minutes after the act of defecation, after which it passes. Pain has an intense aching or pulsating nature. In the chronic anus of the anus, pain does not completely disappear, they are most intense during and for 40 minutes after the act of defecation, and can also be disturbed by prolonged forced sitting. Pain syndrome causes spasm of the muscular sphincter of the rectum, and spasm of the sphincter leads to increased pain.

Bleeding from the rectum with a crack in the anus are neobylny character, arise during defecation and are associated with a mechanical trauma of the epithelium of the mucosa of the anal canal.

The figure shows the appearance of the crack in the anus( a crack is shown by an arrow).

Examination for suspected anal fissure.

If these symptoms occur, you should consult a proctologist-surgeon, if there is no proctologist in the medical institution, you can be examined by a general surgeon of the polyclinic.

Sometimes a simple examination by a specialist to make the correct diagnosis. Examination is performed on the gynecological chair or in the knee-elbow position. When diluting the buttocks, you can see a portion of the anus of the anus in the form of a longitudinal or triangular shape of a red ulcer that extends into the anal canal.

Further, if possible, a digital rectal examination is performed to assess the density of the edges of the ulcer, its length, the presence or absence of spasm of the sphincter of the rectum, which is necessary for choosing the tactics of treatment. Often rectal examination can not be performed due to severe pain syndrome.

In specialized departments of proctology perform sphincterometry, electromyography and electromanometry - studies that allow using instruments to establish the degree of spasm of the sphincter, which allows optimal selection of treatment.

For the diagnosis of concomitant pathology, it may often be necessary to perform a sigmoidoscopy - an endoscopic examination of the rectum for 25 cm, but this research is performed only after self-healing or surgical treatment of an anal fissure.

The clinical picture of the anal fissure is similar to chronic paraproctitis( fistula of the rectum).However, the pain in the fistulas of the rectum is less pronounced and purulent discharge from the anus appears to the fore.

With proctitis( inflammation of the rectum), there may be similar symptoms, but there will be no ulcerative defect.

Sometimes the appearance of an anal fissure is the first manifestation of Crohn's disease. When an anal fissure, it is necessary to pass tests for syphilis and HIV infection. Rarely, the cause of the appearance of an ulcer of the anus can be parasitic disease( actinomycosis) or tuberculosis of the rectum.

Treatment of an anal fissure.

Treatment of anal fissure should begin with conservative measures that last for an average of 6 weeks. You should lead an active lifestyle, engage in exercise therapy.

First of all, you need to change the diet. From the diet should be excluded from spicy, fried foods and alcohol. With constipation, you should eat foods rich in vegetable fiber - vegetables and fruits in raw and cooked form. It is especially recommended to eat beets, carrots, tomatoes, deciduous lettuce, zucchini, pumpkin, cauliflower. In high quantities, you need to eat fresh sweet ripe fruits and berries, especially apples in raw form and in the composition of dishes. Dried fruits and berries should be eaten in a soaked form and dishes, preference in this case give prunes. It is necessary to limit the use of buns, white bread, as they contribute to the development of fermentation processes in the intestine. Garnish from croup is used in limited quantities in the form of crumbly porridges and casseroles. The most useful are buckwheat and oatmeal. From meat products low-fat varieties of meat( beef, chicken, rabbit) are used, which are used in the form of cutlets, stews in baked and stewed. Useful soups on non-fried broth. With a good tolerance of eggs, use soft-boiled and in the form of omelets up to 2 pieces per day. Useful milk, kefir, fermented baked milk, fresh cottage cheese in kind and in dishes( puddings, cheesecakes).The purpose of the diet is the normalization of the consistency of the stool. In many cases, after reaching a soft stool, it is possible to achieve healing of the acute fissure of the anus.

In addition to diet, you should use healing candles, which there are quite a lot. For each patient, they are selected individually. Among the most common are the ultraproject, procto-gliwenol, hepatrombin. You can also use ointments, they usually have a special tip, which allows them to enter into the anus. Among the ointments can be noted ointment aurobin. Ointments and suppositories should be applied 2 times a day, after a stool and before staging a candle or introducing an ointment, a warm sedentary bath with a weak solution of potassium permanganate or a decoction of chamomile is needed. When applying ointment to the anal canal, a column of ointment 1 cm long is injected.

Antibacterial treatment is not prescribed.

This treatment does not affect one of the links of the vicious circle, which prevents the healing of an anal fissure, namely spasm of the sphincter of the rectum. To eliminate it, ointments containing nitroglycerin are currently used. Using 0.4% nitroglycerin ointment, it is most effective, eliminates spasm of the sphincter and pain syndrome, has a minimal pronounced side effect. Apply nitroglycerin ointment 2 times a day for not more than 8 weeks. A relatively new direction is the injection of botulinum toxin( botox) into the anus of the anal sphincter, which eliminates its spasm.

The ineffectiveness of conservative treatment during this period serves as an indication for surgical treatment conducted by a proctologist surgeon.

The essence of surgical treatment consists in excision along the plane of a crack within the healthy mucosa of the anal canal. In the presence of a spasm of the sphincter, a dissection of its internal portion is made-a sphincterotomy. In older people, sphincterotomy is not used, relaxation of the sphincter is achieved medically with nitroglycerin ointment. Usually the wound heals on the 5th-6th day after the operation. In the postoperative period dressings are necessary for the surgeon in the polyclinic with antiseptic ointment( Levomekol).

Complications of anal fissure.

The main complication of the anal fissure is the development of acute paraproctitis due to infection through the defect of the mucosa of the anal canal into the pararectal( around the rectum) cellulose with subsequent purulent inflammation of the latter. Treatment of acute paraproctitis is surgical.
An anal itch and proctitis( inflammation of the rectum) is often accompanied by an anal fissure.

Prevention of development of an anal fissure.

A number of rules must be observed.

• Maintaining an active lifestyle.
• Compliance with personal hygiene rules. After the act of defecation, it is necessary to wash it.
• Compliance with diet. It is necessary to fight against constipation and diarrhea in time.
• Timely treatment of chronic hemorrhoids.
• Unconventional sexual contacts should be avoided.
• Do not abuse alcohol.

As As-Samarkandi said: "If the disease is not defined, it is impossible and treat it."Therefore, in time, contact a specialist. Be healthy!

Surgeon-physician Tevs DS