Anal Fissure
Occurring in young people with pain, blood and burning - during and after bowel movements.
Anal fissures are small breaks in the very painful anal skin (anoderm), which are often caused by hard stools or strong pushing. The main symptom is burning pain during bowel movements and 1-2 hours afterwards.
As the anal fissure is a laceration, large amounts of blood can also be discharged. Patients often report a painful tearing of the anal skin. The pain can be so severe that patients avoid bowel movements and become constipated (proctogenic constipation), which worsens the situation. This starts a cycle that needs to be stopped.
We have extensive experience in the treatment of anal fissures, especially in young people, and always try to avoid surgery. However, if surgery is necessary, we perform it safely, painlessly and without complications.
A new feature is the combination with BOTOX or autologous blood (PRP) during surgery, which leads to a significant reduction in pain and faster wound healing. Don't be afraid and trust us.
Acute an Chronic Anal Fissures
A distinction must be made between the acute and chronic form of anal fissure, as the treatment is different. The definition is not entirely standardized.
Acute anal fissure: We see the acute form as a fresh tear with pain and blood that has the best chance of healing. The most important goal for good healing is a well-formed, regular and soft bowel movement. It is helpful to increase the amount you drink each day and, if necessary, to switch to a high-fiber diet. If this alone is not enough, stool regulators such as psyllium husks should be taken.
Creams that promote blood flow to the sphincter muscle, which leads to better wound healing, can be used to support this. Ointments with a local anaesthetic can also be administered. This often results in complete healing within a few days.
Anyone can develop an acute anal fissure in the course of their life. They occur more frequently in women after childbirth, for example, in combination with iron supplements or after anal sex.
Chronic Anal Fissure
Chronic anal fissure: If an anal fissure has been present for longer than 6 weeks, a clear change in the fissure has already occurred. The fresh tear has turned into a firm scar and the outermost part of the internal sphincter muscle is included in this process.
In addition, so-called secondary formations develop due to the chronic irritation.
These include the externally visible and palpable outpost fold, which is often misinterpreted as a hemorrhoid. This is a pure skin fold (mariscus). In the anal canal, a so-called hypertrophic anal papilla forms at the end of the anal fissure.
These are regular small protrusions from the mucous membrane that can grow up to 3 cm in size and then protrude from the anus.
Drug Therapy for Anal Fissures
If a fissure persists for several weeks, treatment with medication alone is initially indicated. An ointment with the active ingredient Diltiazem is usually used, as it has fewer side effects such as dizziness and headaches. This therapy can last up to 3 months and in many cases leads to a cure. However, secondary formations that have already developed, such as the outpost fold or the hypertrophic anal papilla, remain. Only surgery can help here.
If the pain is very severe and an examination is not possible, a diagnostic procedure under anesthesia is often necessary to rule out a malignant cause of the symptoms. This can easily be done on an outpatient basis. If the diagnosis of a chronic anal fissure is confirmed, surgical treatment can be carried out in the same session. We recommend the additional administration of Botox for faster and less painful healing.
Please note: The prescription with e.g. diltiazem, isorbide dinitrate or glycerol trinitrate is not covered by the statutory health insurance companies (AOK, Barmer, TK...). You have to pay for these prescriptions, which cost between 25€ and 30€, yourself and will not be reimbursed by your health insurance company.
This is why the prescriptions are printed on a green private prescription and not on a pink prescription. This is not an oversight on our part, even if the pharmacy claims it is.
Botox Therapy for Anal Fissure
Significant improvement in surgical results for anal fissures with less pain and faster wound healing
Botulinum toxin A is a powerful neurotoxin which is considered to be the cause of botulism.
The toxin inhibits the transmission of excitation from the nerve cells to the muscle, causing the muscle strength to weaken or fail completely for a certain area, depending on the dosage of the toxin.
Botox leads to a significant improvement in surgical results for anal fissures with less pain and faster wound healing
Botox is now used in various areas of medicine. Mainly in aesthetic medicine, where, for example, the fine facial muscles are partially paralyzed, causing the skin to smooth out and wrinkles to disappear. The treatment of armpits or hands is also known to reduce perspiration.
With all therapies, however, it should be borne in mind that the Botox is broken down by the body after several monthsand the effect wears off. For this reason, six-monthly treatments are common in aesthetic medicine.
The situation is slightly different for anal fissures, but the therapeutic effect is similar. Patients with a chronic anal fissure, i.e. one that has been present for a long time, generally have higher muscle pressure in the internal sphincter muscle. This leads to a lack of blood flow and subsequent wound healing disorders.
The botulinum toxin injection immobilizes a small part of the sphincter muscle for 4-6 months, allowing the wound to heal calmly and painlessly due to the improved blood flow.
The Botox begins to take effect after three days and 75% of patients experience a significant improvement in pain symptoms within the first week. According to the literature, the remission rate after a therapeutic session is around 80%, in our own experience it is over 90%. It is not necessary to repeat the injection.
What needs to be considered afterwards?
The effect usually sets in after a few days and the maximum muscle paralysis appears after 4-7 days. After 4-6 months, the effect of the paralysis diminishes and muscle activity is completely restored.
Side effects such as bleeding, bruising and infections are very rare. The only undesirable side effect is anal incontinence, i.e. the inability to hold out diapers and stool. The risk of (temporary) minor incontinence is increased with weak muscle pressure and in women of advanced age and after several deliveries.
However, if incontinence occurs, the rate is less than 5% and lasts for about 2 weeks. The main symptoms are involuntary leakage and smearing of stool. Patients are not able to hold their stool with the usual dosage.
Important: This is a so-called "off label ” therapy. Botox is therefore not approved as an official medication for the treatment of anal fissures and is therefore not covered by statutory health insurance. It is an IGeL service that we usually use during an operation under anesthesia. However, it can also be used as an alternative to Diltiazem ointment. However, not every patient is suitable for this form of therapy.
Patients with private insurance should clarify with their insurance company whether the costs will be covered before the operation. Complications or major side effects are not to be expected.
Botox can be used safely as a treatment option with or without surgery
Laser Therapy for Anal Fissure
New procedure with minimal wound pain and faster mobility
In gentle laser therapy, the fissure is obliterated with particular precision using targeted heat.
The penetration depth and damage to the internal sphincter muscle is very low, which leads to significantly less pain in the healing phase.
The advantages
- The risk of incontinence is greatly minimized.
- The treatment is generally perceived as very painless.
- Severe scarring is avoided to a large extent.
- The risk of infection is significantly reduced due to the reduced trauma.
In the classic anal fissure, there is a deeper wound (ulcer) with so-called secondary formations such as the outpost fold (mariscus) and the hypertrophic anal papilla inside.
These structures must be removed for new and firm wound healing. Until now, this has only been possible by excision, which damages the neighboring structures due to the depth of penetration, resulting in increased pain.
In laser therapy, the fissure is irradiated with the diode laser and precisely removed thanks to the exact setting. The sphincter muscle is optimally protected and the risk of incontinence is reduced to a minimum compared to conventional methods.
Due to the low penetration depth of the light beam, laser therapy is generally painless and places little strain on the body. Due to the precise working method, no larger and deeper wounds occur. The fissure can heal faster and more safely.
With laser therapy, anal fissures can be removed with extreme precision. The laser ensures ideal hemostasis and a minimal wound surface, so that patients receive the gentlest possible treatment.
Important: Unfortunately, laser therapy is not yet covered by statutory health insurance. We can therefore only offer this surgical procedure as a self-pay service.
You are welcome to contact us for a cost estimate.
Privately insured patients must clarify the cost coverage with their health insurance company before the operation.
You are welcome to book an appointment with our doctors.
We look forward to hearing from you.