Tears or cracks developing around the anus are called anal fissure disease. They cause severe pain and light red colored blood droplets especially during defecation. This pain may continue after defecation, and itching around the anus is also one of the most common complaints. It usually develops due to hard stool, too much straining during defecation, chronic constipation or diarrhea. Another cause is excessive contraction of the muscles around the anus (internal sphincter spasm). Patients avoid defecation since they are afraid of pain during defecation, and this leads to hard stools, which makes the defecation more painful. It can be diagnosed with a simple examination.



In more than 80% of anal fissure patients, generally there is a single fissure on the posterior side of the anus. In case there are fissures in different parts of the anus and in the presence of multiple fissures, patients should first be investigated for other intestinal diseases. The diagnosis and treatment of female patients with anal fissure is of great importance. In women with long term complaints of constipation, the fissure is seen on the vaginal side of the anus in presence of possible pelvic floor disease (often rectocele). A detailed examination must be performed for these patients in terms of pelvic floor diseases. Otherwise, only fissure-oriented treatments in these patients will not be successful.



Treatment of acute fissures is easy. Generally, successful results can be obtained with the removal of the cause, application of hot water, administration of local creams and diet recommendations. If this crack on the anus region persists more than 6-8 weeks without recovery, than chronic anal fissure is diagnosed. In addition to the pain and itching complaints, chronic anal fissure bleeding can be a palpable mass in that region. This coarsening on anus skin, which develops due to prolonged inflammation, is called a secondary papilla. Most patients consider this papilla as a hemorrhoid. In the presence of chronic anal fissure, only 10% of patients recover spontaneously. In this case, different and advanced treatment methods should be used since conservative treatments do not work most of time. The purpose of the treatment is to remove spasm on the internal muscle layer surrounding the anus and controlling the gas and stool incontience. The first line treatment for this is topical cream application with glyceryl trinitrate or nifedipine active ingredients. If the patient does not benefit from this treatment, the injection of Botulinum toxin (BOTOX) will be used to remove the spasm of internal muscle. The effect of this treatment starts in 1-2 weeks and lasts about 6 months. During this time, intra-anal pressure is reduced, and anal fissure healing is achieved. Its application is very simple, it takes 5 minutes in the outpatient clinic conditions and it has no side effects. Patients can immediately return to work after the procedure. In a 6-month period, 60% of the patients recover fully, whereas in 3-year follow-ups, anal fissure could be repeated in 1 in every 3 patients.



Surgical treatment is performed by cutting a part of the inner muscle surrounding the anus to provide relief for the inner muscle. This operation is called lateral internal sphincterectomy. The success of the operation is over 90%. Although most patients are worried that they will not be able to control gas and stool after this surgery, this risk can be eliminated if the correct treatment is applied to the right patient.