What is anal fissure? The causes, diagnosis and treatment methods will be discussed in this article.
Causes of Anal fissure
Anal fissure is a wound, a mucosal defect that occurs at the junction of the anoderm (the epithelium of the anal canal) and the mucosa of the rectum. The shape of the defect is more often linear, elliptical wounds and triangular wounds occur.An acute fissure that first appears brings very painful sensations to the patient, mostly during defecation. The disease is socially significant, ranking third among proctologic nosologies and occurs more often in young, able-bodied individuals.
Causes of the formation of a wound defect, fissure – trauma to the rectal mucosa or anoderma (from hard feces, as a consequence of constipation; with an increase in intra-abdominal pressure, pregnancy, childbirth, lifting weights; after anal sex or use of sex toys (we strongly recommend to quit this type of sex); after medical procedures – for example, enemas; as a result of chronic inflammatory diseases of the GIT, dysbiosis of the large intestine; alcohol abuse, prolonged diarrhea, etc.)
The defect may heal spontaneously or under the influence of pharmacological drugs – this is what happens in 90% of cases of acute fissures. The remainder are at risk of falling into the ranks of patients with chronic anal fissure (CAF).
Transition of the acute form of the disease to the chronic form occurs under the influence of a number of factors:
- Persistent spasm of the internal sphincter of the anal canal (ISAC).Sphincterometry in a number of studies showed spasm of all fibers of the internal sphincter in 87% of subjects and the distal portion in the remaining 13% – that is, all subjects had spasm of the ISAC;
- An acute fissure that first appears brings very painful sensations to the patient, mostly during defecation. The disease is socially significant, ranking third among proctologic nosologies and occurs more often in young, able-bodied individuals.
The period determining the chronicity of the fissure is usually 1.5-2 months. A defect that exists in the anoderm for more than 8 weeks is diagnosed as a chronic anal fissure. The duration of the pathological process determines the subsequent choice of therapy.
Chronic fissure requires more aggressive treatment tactics, more often with the use of surgical methods, because pathological changes appear in the fissure area, preventing normal tissue healing. These are the destruction of elastic fibers of the muscular layer at the bottom of the ulcer, the formation of scar tissue at the fissure edges, the formation of granulations in the distal part of the linear defect (the so-called “watchdog” tubercle), and the appearance of hypertrophy, thickening of the rectal crypt in the proximal part of the fissure (the so-called anal papilla).
Symptoms of anal fissures
In acute fissures:
- Stabbing pain during defecation. The nature of the pain is individual, sometimes patients describe it as a feeling of “broken glass” in the anus. Sharp discomfort, the pain is short-lived – a few minutes during defecation.
- Blood of a scarlet, unchanged color. It is secreted at the beginning of the act of defecation, more often in the form of scarlet streaks, drops on the feces.
- Total blood loss during acute pathology is insignificant and does not lead to anemization of the patient. The most significant manifestations for patients are sharp painfulness during stool. If profuse bleeding is noted, this may indicate concomitant hemorrhoids.
In chronic fissures:
- The pain sensations are somewhat different from those of acute pathology. The duration of the pain may be up to several hours. Their intensity is usually stronger. Pain is described by patients as stinging and stinging. The pain may be absent during defecation and begin 20-40 minutes afterwards.
- The discharge of blood is insignificant. In most cases, it may not be present at all.
- Sphincterospasm. Appears as difficulty in defecation.
- The triad of the above symptoms, especially pain and sphincterospasm, can cause a fear of defecation, aggravating stool disorders and thus preventing adequate healing of chronic anal fissures. Chronic inflammation in the area of the anodermal defect leads to destruction of elastic fibers in the anoderm, which causes the latter to lose its plasticity and changes the course of regeneration processes in it.
- Another symptom occurring in a small percentage of cases is itching in the wound area.
Many studies indicate the presence of a concomitant chronic inflammatory process in the anorectal area in fissures. Cryptitis, proctitis, and papillitis complicate the course of the disease. The sequence of diseases appearance – whether the fissure was formed first, or the primary ones were chronic inflammatory processes in the intestine – when combining these nosologies the answer to the question is strictly individual, the therapy of such combined pathologies practically does not differ.
Pathogenesis of anal fissure
In most cases, the formation of an acute fissure is the result of trauma to the anoderm or mucosa of the rectum. The traumatic agent is most often dense fecal masses. Constipation, whether alimentary, atonic, reflex or neurogenic, leads to superficial damage to the integrity of the anal canal.
The second key to fissure formation, especially chronic anal fissure, is persistent spasm of the internal anal sphincter (IAS). While the external sphincter, which consists of transverse striated muscle fibers, is arbitrarily regulated, the internal sphincter, which includes smooth muscle cells, is involuntarily regulated. The basal tone of the internal sphincter of the anal canal is controlled most of the time by the sympathetic part of the nervous system, and therefore the sphincter is in a state of maximum contraction almost all the time (this provides up to 85% of the basal tone, the hemorrhoidal nodes supplement the rest of the internal sphincter of the anal canal’s obstructive function). When measured, the AS nasal tone value is 90-100 mmHg, which is almost equal to the pressure values in the branches of the inferior rectal artery.
Mechanisms regulating the internal sphincter of the anal canal tone:
- Autonomous postganglionic nerve parasympathetic and sympathetic fibers;
- Nerve plexuses (Auerbachian and Meisnerian) in the colon wall. These formations control both peristalsis and local reflexes, including the inhibitory reflex, which relaxes the the internal sphincter of the anal canal. The plexuses belong to the noradrenergic ones, and nitric oxide, being a mediator in the synapses of these fibers, leads to relaxation of the internal sphincter of the anal canal;
- The level of extracellular Ca transported through L-type channels.
The occurrence of a primary mucosal defect is thought not to result in physiologically rapid healing in a number of patients due to the peculiarities of GI structure – small size of the anorectal angle, reduced blood perfusion in the anterior and especially posterior commissural area and insufficiency of the rectal inhibitor reflex. Instrumental studies revealed frequent cases (up to 85%) of underdevelopment of the terminal branches of the internal sternal and inferior rectal arteries feeding the endothelium and underlying tissues in the area of the ischiorectal fossa. Studies that allowed establishing this fact: postmortem angiography and Doppler flowmetry in healthy individuals.
Detailed studies of the microbial flora of anal fissures sufferers have confirmed the facts of disturbance of symbiont equilibrium in the microflora of the distal parts of the large intestine (including a sharp decrease or disappearance in its composition of lacto and bifidobacteria), increase of persistent potential of pathogenic microorganisms (increase their antilysocim activity).
Increased levels of proinflammatory cytokines, antibodies to endothelium, and decreased production of nitric oxide have additional pathological effects.
All of the above factors, in varying degrees of severity, contribute to disorders in the regeneration and chronicization of anal fissures.
Classification and stages of anal fissure development
Classify anal fissures by the duration of the pathological process:
- Acute fissures;
- chronic fissures.
Acute fissures are considered defects of the mucosa, anoderm that appeared 4-8 weeks ago, without the presence of scarring, connective tissue overgrowths in the area of the bottom and edges of the wound.
Chronic fissures of the anus appear as a result of long-term non-healing acute fissures, they are characterized by the presence of connective tissue in the area of the bottom, the presence of a hypertrophied anal papilla and granulations in the form of a “watchdog” tubercle. Prolonged, untreated or inadequately treated fissures can lead to the development of callous tissue in the area of the defect (so called callous fissure).
According to the location of the wound defect, posterior fractures are more common, and anterior or multiple fractures are less common. Their location along the midline is characteristic.
Posterior fissures are formed in the anatomically “weak” area of convergence of fibers of the muscles of the external anal sphincter, due to which mobility and elasticity of the wall are reduced here.
Multiple fissures can be located opposite each other, the so-called “mirror” location.
Anterior fissures are usually diagnosed in women, due to the peculiarities of their anatomical structure (rigidity, low mobility of the anterior wall is due to the attachment of the rectovaginal septum to it).
The location of fissures on the lateral walls of the anal canal is not common.
Complications of anal fissure
Complications are a direct consequence of chronic inflammatory processes in the perianal area.
Paraproctitis. Persistent, pathogenic strains of microorganisms with increased antilysocyme activity, or even relatively “harmless” aerobic bacteria in crypts, with reduced blood perfusion, become sources of infectious complications – paraproctitis. Predisposing factor to the development of fistulas of the rectum are features of the structure of the crypt, or rather, its size and the structure of the anal gland (its branching). The deepest crypts themselves serve as an entrance gate for infection, obstructing the outflow of anal glands that open into them. And taking into account that the largest crypts are located at the back wall of the rectum, and most anal glands open there too (their discharge ducts are in the 7-12-hour area), the favorite localization of anal fissures at the back wall, in the 6-hour area, carries additional risks of developing paraproctitis.
Pectenosis. Pectenosis is a scarring change in the walls of the anal canal, leading to persistent narrowing of the anal canal. Chronic inflammatory processes in anal fissures invariably lead to the development of fibrous changes in tissues, when normal muscular and elastic fibres in the area of the surface epithelial defect are replaced by connective tissues. Sometimes such processes have a rather extensive localization and the fibrous replacement occurs throughout the entire circumference of the sphincter (especially in case of multiple fissures). The developing scar changes lead to irreversible stenosis (narrowing) of the anal canal. Such a condition requires complex reconstructive surgery with radical excision of fibrous tissue.
Worsening constipation due to fear of defecation. Severe, burning pains during or after stools cause psychological changes, the so-called “fear of defecation”. This psychosomatic condition closes the pathological circle, intensifying problems with bowel emptying and resulting in additional trauma to the walls of the rectum.
Diagnosis of anal fissure
During the diagnostic examination, a simple anal fissure is differentiated with anal canal polyp, mucosal cancer of the distal rectum and anoderma, tuberculosis and syphilitic ulcers (hard chancre in a primary syphilitic complex). In addition, a careful examination of the rectal mucosa should be performed to rule out a fissure accompanying nonspecific ulcerative colitis or Crohn’s disease. The latter nosologies are especially likely in multiple fissures, in the absence of sphincter spasm.
After interviewing the patient, an examination of the anorectal area, a finger examination, and anoscopy are performed. Rectoanoscopy is necessary to study the state of the rectal mucosa in order to rule out pathological processes in the large intestine (Crohn’s disease, nonspecific ulcerative colitis, malignant neoplasms, etc.)
- At acute fissure an elliptic, linear or even triangular-shaped superficial defect of epithelium of the border area (in the place of transition of anoderma into rectal mucosa) is found. The edges of the defect are often irregularly shaped and uneven. During examination, small bleeding from the wound is possible.
- With a chronic process, fibrous changes may be found at the edges of the fissure – granulations (“watchdog” tubercle) in the distal part of the rupture and overgrown tissues of a hypertrophied anal papilla (sometimes mistaken for a fibrous polyp of the anal canal). The edges of the fissure are smoothed, elevated. Sphincter fibers are visualized at the bottom.
If there is significant spasm of the sphincter, severe pain syndrome, it is often not possible to fully visualize and diagnose a chronic fissure. Also difficulties arise when a patient is overweight, when the anal fissure is relatively deep and it is not possible to fully examine the anal canal. In such cases a blockade with anesthetics can be applied.
Treatment of anal fissures
Acute anal fissures
Acute anal fissures are indicated for conservative therapy.
- Pathogenetically sound and mandatory component in the complex treatment is normalization of stool, prevention of constipation. Soft stools will exclude additional traumatization of the wound surface.
- Sphincter spasm reduction measures will provide a normal course of the reparative process: application of 0.4% nitroglycerin ointment 2 times a day or other nitric oxide donor – 1% isosorbit dinitrate ointment 3 times a day with treatment duration of 8 weeks. Side effects of nitroglycerin drugs (headaches, tachycardia, orthostatic hypotension, tachycardia) prompt early discontinuation of treatment in 20% of cases.
Adequate replacement is chosen among nifedipine ointment (2% diltiazem gel) or botulinum toxin injections. The latter are relatively well tolerated by patients, have a persistent effect even after 1 injection – up to 2-3 months. The dosage is selected individually, based on the patient’s weight and method of administration. Of the few negative effects can be called the temporary development of anal sphincter failure, incontinence.
If there is no effect from conservative treatment, there are signs of chronic fissure, complications arise (pectenosis, fistula) – these are indications for surgical treatment.
In some cases, treatment begins with medications described in the above section. The main method of treatment is still surgical treatment. With indications for surgical treatment, excision of the fissure with dosed lateral sphincterotomy of the anal canal becomes the operation of choice. A reasonable amount of dissection is the length of the incision corresponding to the length of the fissure itself, and avoiding dissection of the muscle fibers above the dentate line (to prevent incontinence). In the postoperative period nitroglycerin ointments are used for additional sphincterodilating effect. There is reliable data on the positive effect of topical metronidazole after fissurotomy.
Topical antibiotic therapy in most cases significantly reduces the duration of the pain syndrome (up to 5 days instead of the standard 28) and reduces the clinical and objective manifestations of nonspecific proctitis significantly earlier than in patients without antibiotic therapy.
Prognosis and Prevention
Logical measures regarding the prevention of anal fissures are to eliminate the causes that contribute to their appearance:
- Correction of diet, treatment of constipation and normalization of stool. Consumption of sufficient amounts of ballast substances: dietary fiber, fiber. Maximum exclusion from the diet of refined foods, high-carbohydrate foods (products of pastry, bread of the highest grade, confectionery products, etc.). Inclusion in the menu a large number of vegetables, dairy products.
- If nutritional correction does not lead to normalization of stools, use pharmaceuticals (osmotic and contact laxatives).
- Exclusion of other factors that lead to traumatization of the rectal mucosa.
- Treatment of chronic diseases of the gastrointestinal tract.
- Elimination of intestinal dysbiosis.
With timely treatment and complete prevention, the prognosis of the disease is favorable, in most cases there is a complete cure.
Case #1: I am very worried about an anal fissure. I got it in August. In the area of the anus I found cracks and a small bump, It is accompanied by itching, which extends to the genitals, after I often leave blood on the toilet paper after defecation. I went to the doctor. I was prescribed Posterizan forte suppositories, ointment Aurobin ointment and a diet. I was very badly constipated (acute stools), despite Despite a good diet. But I found a way out – Red Slim tea (with hibiscus). I drink it once a day. It seemed to me that the crack has tightened up, because lately I haven’t I haven’t had any pain or bleeding lately. But today I had sharp stools again and some blood. I realized that the crack had not gone away. I don’t know what to do. to do. Should I have an operation? Or is it better to resume treatment and, Maybe it will help, because I’m less constipated now than I was than when I was being treated. I realize that I can’t leave it as it is. Lately my defecation has been hurting again and for a few days there is quite a lot of blood, not just a few drops, but a lot of smeared all over the paper. Moreover, even if the constipation has passed and the stools soft. Then it gets better, and after a while it happens again. I’m afraid. I was offered laser treatment, but is it effective? I had similar problems with my relatives.
Answer to case #1:
All your fears are perfectly justified, it can turn into cancer. One of the factors of anal fissures is hemorrhoids. In this case there is a complex treatment: in addition to the treatment of anal fissures In this case, the treatment of anal fissures is complex: in addition to the treatment of anal fissures, the cause, hemorrhoids, also requires treatment. The same causes Injury to the anal canal, constipation and diarrhea. Rather often anal fissures after childbirth. First of all, what you should not do in case of anal fissures is Do self-treatment with folk remedies. If constantly anal fissures arise constantly, it is necessary to apply to the clinic. With acute anal fissures, conservative treatment is indicated. In the transition to the chronic stage, surgical intervention is possible. The scars and papillae around the fissure must be removed (to do the surgery). This papilla and scars will reopen the fissure. But now there is a more modern method of infrared photocoagulation of anal fissures. This is a virtually painless method. You will need 2-3 sessions to finally solve this problem. Anal fissures are complicated by fistulas of the rectum, with the skin in the The skin of the anus becomes wet, and a strong itching occurs. If you don’t contact If you don’t see a doctor, the fissure can cause an ulcer, which is much harder and takes longer to heal. Difficult and longer to treat.
Anal fissures are usually poorly amenable to conservative treatment. It must You must either have it excised or treated with photocoagulation. Otherwise, you’ll be plagued periodic exacerbations. Photocoagulation can also be used to treat a fissure on an outpatient basis. You need to see a proctologist.
Case #2: Another woman shared her experience treating anal fissures at the initial stage.
…I had a microfissure a year ago. I suffered for many months, then I took laxatives for about a week and everything went…
Case #3: I’ve had a crack in my anus for about a year now. And now it heals and then it reopens. I’ve been using all the ointments they advertise and write about. It doesn’t help me much, I mean it eliminates the problem for a while, but after that I get it all over again. I am exhausted. I began to think about surgery.
What is the difference between hemorrhoids and anal fissures?
Hemorrhoids are inflammation of the internal venous nodes in the rectum, accompanied by their enlargement, prolapse, and sometimes bleeding. An anal fissure is a longitudinal tear in the rectal mucosa, which usually forms between the dentate line and the edge of the anal passage. An anal fissure occurs as a complication of hemorrhoids, but can also be diagnosed as an independent disease.
Can hemorrhoids be confused with anal fissures to the touch?
In the early stages of the development of anal fissure, the symptoms of this disease are very similar to other proctological diseases, and hemorrhoids in particular, because it can be inside the rectum and not accompanied by external manifestations. Therefore, conducting an independent examination and not being a specialist in this field, you can easily make a mistake. Diagnosis of the disease and its therapy should always be carried out by a proctologist.
What is easier to cure – hemorrhoids or anal fissure?
The method of treatment of anal fissure, as well as the treatment of hemorrhoids, is determined on a case-by-case basis and depends on the severity of the pathology. Very often anal fissure occurs as a result of the development of hemorrhoids and then the treatment must be carried out comprehensively. The treatment of anal fissure differs greatly from that of hemorrhoids: as a rule, to treat fissures at an early stage non-surgical correction of the disease is used, and only if therapy fails to produce the desired result, radical methods are used – excision of anal fissures by surgery. The most modern and painless method of excision today is radiofrequency surgery, which eliminates the pathology.
What is the difference between anal fissure and rectal fissure?
These concepts are synonymous with the same proctological disease – anal fissure, a pathological process occurring in the body, which results in the formation of a longitudinal tear, located along the midline of the posterior hemisphere of the anal opening.
Can an anal fissure be reborn?
Anal fissure by and large is a benign disease, and neglecting it can cause fistulas, which constantly accumulate inflammatory processes in the rectum. These diseases can be precancerous and can later provoke rectal cancer.
What kind of infection causes rectal fissures?
As a matter of fact, anal fissures are the result of mechanical damages, such as defecation disorders, frequent constipation or diarrhea, excessive muscle tension while defecating, the use of some (mostly laxatives) medicines, bile stagnation, hemorrhoid removal, anal sex.
What should I do if I have been diagnosed with a rectal fissure?
Of course to treat it! And specific doctor’s recommendations on what to do if you have a cracked rectum depend on whether the fissure is still acute – or already chronic.
People who have fresh fissures of the anus have a good chance of treating them quickly and safely at home. But again, this treatment should be prescribed and supervised by the attending physician. And the treatment boils down to the following:
- normalization of stool in order to mechanically sparing the rectum during emptying (dietary diet, taking light laxatives);
- Medical treatment of the anus and perianal area with special ointments, preventing the occurrence of spasm.
What is a deep anal fissure, and what to do if the crack in the anus becomes chronic? These questions are unfortunately topical for 8 out of 10 patients who visit a colorectal surgeon. Chronic fissures with a large number of connective tissue cicatricial changes and severe spasm of anal sphincter need not conservative but surgical treatment. And here it is better to choose radiofrequency surgery.
What does a proctologist usually prescribe for a fissure of the rectum?
If this fissure is fresh, acute, and it is not more than a month – then the proctologist will prescribe a conservative treatment regimen. Of all the things that are suitable for anal fissures in order to normalize stool and reduce the hypertonicity of the anal sphincter, the following important points can be highlighted:
- taking soft laxatives containing the prebiotic lactulose (a product of the processing of milk sugar – lactose), as well as phytopreparations (bark of peels, senna leaves);
- diet therapy (plenty of water, figs, apricots, raisins, beets, dairy products, whole-grain products rich in fiber);
- If necessary, additional medication (pills, rectal ointments, creams, suppositories) may be prescribed. They will reduce inflammation, decrease sphincter spasm, and accelerate repair (healing) of the anal fissure.
How long does it take to treat an acute anal fissure?
The duration of treatment of an acute anal fissure under the supervision of a proctologist will be 10-12 days. During this time, you will need to adjust the stool, and systematically treat the fissure area with local healing agents. This is not much longer than self-treatment at home, but the likelihood of relapse will be practically eliminated. Early visit to the doctor will avoid the chronicity of the process.
Chronic fissure and aloe treatment – how effective and safe is it?
The most popular folk medicine recipes are based on the use of aloe. As is known, aloe has anti-inflammatory and healing properties and can alleviate the suffering of the patient and relieve the acute condition of the disease. From it make rectal suppositories, put pieces of the plant to the sore spot, make a variety of local preparations based on the juice. Treatment of hemorrhoids in the initial stage of the disease in this way is quite possible and periodically used as the first conservative stage in the treatment process. However, before treating anal fissures with folk methods, you should remember that self-treatment is fraught with extensive negative consequences.
What is a rectal fissure excision, and how does it happen during surgery?
In order to better understand what anal fissure excision is, and how it occurs during surgery, you should become a little familiar with the principles of the impact on living tissue of various energies (laser, radiofrequency).
In hardware medicine, which now rightly occupies a leading position not only in the aesthetic sphere, but also in general medical practice, there is a concept: selective thermolysis. Selective means selective. Lysis means destruction. Targeted destruction of what the patient came to get rid of. Thermolysis means destruction by thermal (heat) exposure. But unlike the classic surgical excision with a scalpel, this destruction of a defect is sparing, gentle with respect to healthy tissues in particular, and to the body as a whole.
Radio-surgical excision of anal fissure implies the impact on the altered scar tissue, including the fissure itself and painful areas around the anus, with radio waves of high frequency – about 3.8-4 MHz. The surrounding healthy tissue remains untouched. But rough fibrous scars, a fissure, a sentinel polyp – all of these are vaporized by the heat.
A radionuke is not a scalpel that sheds blood and damages healthy areas, which then leads to the formation of a rough post-operative scar. It works clean, bloodless, non-contact. No infection for you. Therefore, excision of the anus fissure with a radiofrequency scalpel is the optimal choice for both the modern surgeon and the modern patient.
What kind of anesthesia is given for excision of a rectal fissure?
When excising an anal fissure with the radiofrequency method, no anesthesia is used at all. Surgery for anal fissures is completely painless and safe. By applying to your clinic for help, you can be sure of a sparing method of treatment and not worry about whether it hurts to dissect a rectal fissure.
How does cauterization of an anal fissure occur?
Anal fissure cauterization is called electrocoagulation, and is performed with an infrared laser. Laser coagulation of fissures is modern and widely used, but it is quite painful and is not indicated in all cases. It is not suitable for chronic fissures, and is only effective for fresh rectal tears (3 to 4 weeks at most).
It is much more painless and effective to undergo radiofrequency treatment, which, just like laser treatment, is called cauterization.
The essence of cauterization is laser or radiofrequency excision of the scarred perianal tissue together with the fissure. It takes place under local anesthesia.
What to do when a rectal fissure is accompanied by the occurrence of succour in the feces?
Proctologists have a saying: hemorrhoids are when there is a lot of blood and little pain, and anal fissure is when there is a lot of pain and little blood. Indeed, the fissure of the rectum can bleed. Bleeding is the main symptom (besides pain, spasm) of an anal fissure. The bloody discharge indicates that the fissure will never heal because it is constantly traumatized, and the sphincter is hypertonic. What is important here is not to fight the symptoms, but to eliminate the root cause. That is, the fuller treatment of anal fissure.
Sucrose from anal fissure has a bright scarlet color. And its secretion is usually scarce. In hemorrhoids, the color of the blood is also bright scarlet – but there is usually a lot of it. But if the blood from the anus is dark, almost black in color, staining the stool completely, this may be a signal of internal bleeding from the upper stomach. The dark color of the blood means the fact that on the way to the rectum it has already had time to clot. In this case you should immediately see a doctor.
Is it possible to heal an anal fissure on its own?
Many patients wonder if anal fissure can disappear without treatment. Yes, it can. But only if it’s fresh, and it’s not more than one week old.
It is possible to disappear without formation of fibrous changes, like watchdog polyp, only if you follow strictly complex measures. This stool normalization, diet, the use of emollients and regenerating rectal means. Well, if already time is missed, and the fissure acquired a chronic course – the best way out would be a gentle surgical treatment with a radiofrequency scalpel. In addition to bloodless excision of the fissure and painless intervention, radiofrequency treatment provides fast postoperative recovery and excellent cosmetic results.
An anal fissure is an unpleasant problem that cannot be ignored. At different stages it requires a different approach to treatment. Therefore, we recommend not delaying a visit to a proctologist in order to get rid of an anal fissure quickly and without surgical intervention.