Anal Fissure: Causes, Symptoms and Treatment Options

Anal fissures are painful injuries to the mucous membrane of the anal canal. They are common and can cause significant discomfort and inconvenience. In this guide, we take a closer look at the causes, symptoms and treatment options for this common health problem.

Contents

An anal fissure is an injury to the mucous membrane in the centre of the anal canal (anoderm) that causes pain, particularly during bowel movements and constipation. Anal fissures occur both as an acute and a chronic condition. This guide provides medical information and practical advice and introduces a new method of self-treatment using FMS Dilators.

Causes and Development of Anal Fissures

Anyone can develop an anal fissure, but they occur particularly frequently between the ages of 30 and 40. Here is an overview of the main causes and contributing factors:

1. Bowel Movements and Toilet Habits
2. Bowel Diseases
3. External Causes (often related to sexual practices without adequate preparation)

1. Bowel Movements and Toilet Habits

The most common cause of anal fissures is probably hard stools and constipation. The harder the stool, the greater the pressure required for evacuation, which is why proper nutrition is important. However, correct behaviour during bowel movements also plays a major role. If a person adopts an unsuitable position, passing stool becomes more difficult and an anal fissure may develop. In this case, the condition is referred to as a primary anal fissure. We have illustrated correct toilet posture in our Hemorrhoids Guide.

2. Bowel Diseases

People with certain bowel disorders have an increased risk of developing anal fissures. The reason is usually not a single cause but rather a vicious cycle of pain, muscle spasm and impaired blood circulation.

Conditions such as chronic diarrhoea, inflammation of the rectal area (for example cryptitis), hemorrhoids, or inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis often lead to persistent irritation of the anal region. This irritation can trigger a reflex spasm of the internal anal sphincter. The resulting increase in muscle tone raises pressure within the anal canal while simultaneously reducing blood flow to the mucous membrane.

Poorly supplied, tense tissue is considerably more vulnerable to small tears during bowel movements. Once an anal fissure develops, the pain further increases sphincter spasm. Reduced blood flow prevents proper wound healing, allowing the fissure to persist or become chronic.

In these cases, the condition is referred to as a secondary anal fissure, because it is not primarily caused by hard stools or mechanical strain but rather occurs as a consequence of an underlying bowel disease.

3. External Causes

Anal penetration without adequate preparation, as well as other extreme sexual practices involving the anal region, such as inserting unsuitable or excessively large objects into the anus, can cause painful anal spasms, injuries to the mucous membrane and anal fissures. Anal fissures may also have long-term consequences.

It should be noted that sexual practices themselves are rarely the actual cause. More often, the problem results from insufficient caution or awareness when people explore physical limits, either alone or together. In particular, when objects are inserted into the body under the influence of alcohol or drugs and can no longer be removed independently, medical assistance or emergency treatment is often required.

Diagnosis

The appropriate specialists for pain or problems in the anal region are a proctologist or a gastroenterologist. In most cases, a description of the symptoms together with visual inspection and physical examination of the anal area is sufficient to establish a diagnosis.

In approximately 90% of cases, the fissure is located at the 6 o’clock position (from the examiner’s perspective when the patient is lying on their back, towards the coccyx). It usually extends lengthwise towards the centre of the anal canal, parallel to the coccyx. Less commonly, fissures occur at the 12 o’clock position (towards the perineum), and only rarely at other locations around the sphincter. During palpation (diagnostic examination by touch), a thickening can often be felt and, in some cases, a very painful ulcer may be detected. A high level of tension in the anal sphincter (increased sphincter tone) is also frequently present and may progress to painful anal spasms.

When establishing the diagnosis, hemorrhoids and perianal venous thrombosis must be excluded. Occasionally, a doctor may perform a proctoscopy (examination of the rectum) under local anaesthesia – usually after the acute phase has passed – in order to rule out other conditions. If symptoms have been present for up to three months, the fissure is still classified as acute. Beyond this period, it is generally considered chronic. Chronic anal fissures have a somewhat different appearance: the wound edges become partially scarred due to repeated spasms, resulting in a hypertrophic (enlarged) anal papilla. Swelling is usually present, and in some cases a skin tag (Mariske), also known as a sentinel tag, may develop.

Symptoms of Anal Fissures

The first noticeable symptoms are usually sharp stabbing or burning pain during bowel movements, often accompanied by fresh, bright red bleeding. The discomfort frequently continues after leaving the toilet, and the anus may itch or weep afterwards. If these symptoms persist for several days, a vicious cycle often develops: out of fear of further pain, the patient delays bowel movements. This results in even harder stools and greater strain on the anal sphincter. The fissure enlarges because of the recurring constipation, the pain intensifies and painful anal spasms develop. These spasms reduce blood flow, which in turn worsens constipation and further delays healing.

Treatment of Anal Fissures

FMS Dilators are ideal for an effective yet particularly gentle treatment approach. Here you can learn exactly how FMS Dilators work and are used for anal fissures.

An important part of treatment for anal conditions is always to prevent constipation and maintain soft stools. Some doctors prescribe medications such as laxative suppositories combined with pain-relieving ointments. However, soft stools can also be achieved through natural measures. Foods rich in fibre – including wholegrain products, cereals, potatoes, vegetables, legumes and fruit, particularly dried prunes – are highly recommended, together with adequate fluid intake. By contrast, sweets such as cakes and chocolate should be reduced. Thorough chewing of food is also important. Proper behaviour during bowel movements matters as well: avoid hurried pushing or straining under time pressure and take your time.

Good hygiene is equally important. After gently wiping the anal area dry, it should be cleaned with water or a damp washcloth. Moist toilet tissues should be avoided because they often disrupt the natural skin flora and are environmentally harmful. To keep the skin supple and promote wound healing, an ointment may be applied. These recommendations are essentially the same as those described in detail in our guide to the treatment of hemorrhoids. If symptoms have not improved after three months, surgical treatment known as a fissurectomy may be performed in hospital. During this procedure, the altered tissue around the fissure is removed, creating a fresh wound that usually heals well. However, in many cases this can be avoided.

The most important aspect of treating an anal fissure, anal tear or anal spasm is to reduce the constant pressure exerted by the anal sphincter by relieving muscular tension.

In conventional medicine, treatment usually follows a stepwise approach. During the acute phase, ointments are prescribed and applied several times daily. These contain a local anaesthetic together with a relaxing agent. The aim is, first, to make bowel movements less painful and thereby prevent delaying them, and second, to reduce excessive muscle tension. As an alternative to surgery in chronic cases, Botox injections may be administered into the sphincter muscle. This calms and temporarily paralyses the muscle, reducing tension. However, temporary incontinence may occur as a side effect, although this usually resolves as the Botox effect diminishes.

Ointments and Botox address symptoms but do not preventively change the physical or psychological factors that contribute to the condition. These can only be influenced through active treatment carried out by the patient.

Relaxing the Anal Sphincter with Dilators

Dilatation (stretching) of the anus using stretching rods known as dilators (originally called dilatators) directly addresses the root cause of the problem. In addition, treatment can be carried out independently by the affected person, without requiring contact with a doctor, and can therefore be performed at any time according to individual needs.

However, treatment with traditional dilators is not without disadvantages:

• The conical shape of conventional dilators does stretch the tissue, but the deeper the dilator is inserted, the greater the pressure it creates. This may cause the fissure to reopen.
• Materials such as silicone or plastic do not offer particularly good glide properties.
• Available sizes are often too widely spaced. The treatment of anal fissures requires very fine size gradations and therefore a comprehensive range of dilators in order to select the most suitable set.

The Alternative: Therapy with FMS Dilators

FMS Glass Dilators Are Also Suitable for the Treatment of:

• Hemorrhoids
• Incontinence
• Vaginismus
• and for prostate massage.

Frequently Asked Questions

What Is an Anal Fissure?

An anal fissure is a tear in the mucous membrane of the anus, usually located at the central rear position of the anal canal (towards the coccyx).

What Are the Typical Symptoms of an Anal Fissure?

Sharp pain occurs during and after bowel movements, often accompanied by bleeding that is visible on the stool or toilet paper. Because of the pain, people frequently suppress the urge to defecate. This leads to harder stools, which aggravate the fissure during evacuation – creating a vicious cycle.

What Should I Do If I Have an Anal Fissure?

You should first ensure that your stools remain soft. This requires adequate fluid intake and a suitable diet. Proper sitting posture on the toilet is also important. Medical treatment options include creams that provide pain relief and reduce spasms, as well as Botox injections. As a self-treatment approach, gentle stretching (improving flexibility) of the anus can be very helpful.

What Causes an Anal Fissure?

Possible causes include repeatedly delaying bowel movements despite the urge to defecate. This results in hard stools that are eventually forced out, often in an unsuitable sitting position. Anal fissures may also occur as a consequence of chronic bowel disease or as a side effect of chemotherapy. Other causes include careless sexual practices and severe tension resulting from psychological trauma.

Is Surgery Necessary for an Anal Fissure?

No, not necessarily. There are a variety of medical, natural and self-treatment approaches that can successfully treat anal fissures. If the condition persists for more than three months, it is generally considered chronic, and surgery is often recommended.

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