What is the difference between haemorrhoids and fissures?

By Cristiano Antonino On Jun 6, 2022

Haemorrhoids are an extremely common benign disorder of the anal area, so much so that the ISS estimates that about 50% of adults suffer from it from time to time

However, despite its widespread occurrence, there is still frequent confusion with another well-known benign problem in the anal area: fissures.

What are haemorrhoids

The haemorrhoid tissue is a naturally occurring, richly vascularised tissue in the body that serves to

cushion the passage of faeces in the anus/rectum;
perform a continence function.

This tissue, due to individual predisposition and other reasons, can dilate, bleed and leak from the anal canal, leading to often disabling symptoms.

Haemorrhoids can be divided into:

internal, present within the last part of the rectum;
marginal or external, in the external area of the anal canal.

What are fissures

Rhagades, or fissures, are small lesions and wounds of the mucous membrane lining the anus, which become chronic.

When the 2 problems occur

The 2 problems can occur at any age and, although not frequently, also at the same time.

This is particularly the case when haemorrhoidal prolapse causes the anal mucosa to rupture and create a small cut on which the fissure is established.

Symptoms of haemorrhoids

Characteristic symptoms of haemorrhoids include:

bleeding, sometimes even on toilet paper, often without pain or with little pain that disappears after defecation;
sensation of lack of cleansing;
visual presence and detectable by touch of excrescences located in the anal area, at the time of cleaning and/or washing;
presence of excess external anal tissue that, in some cases, the patient must manually reposition inside after defecation.

Symptoms of fissures

With regard to the symptoms of fissures, on the other hand, it is mainly to be found in the presence of intense and protracted pain after each defecation for a duration of a few minutes to several hours.

Causes of haemorrhoids

Haemorrhoids can be caused by several factors, including:

family predisposition: one cannot really speak of genetic factors, but there is a family propensity for the development of haemorrhoids linked to the laxity of the connective tissue that supports the haemorrhoid tissue;
pregnancy and childbirth: this is due both to the propulsive action of childbirth and because certain hormones in this phase tend to relax the connective tissue to allow the passage of the baby with the possibility, therefore, of developing prolapses also at haemorrhoidal level, especially in cases where there is a predisposition;
chronic constipation and diarrhoea: they can damage the haemorrhoidal tissue and the anal canal, in the first case due to defecatory effort and in the second due to the acidity of the stools.

Causes of fissures

The causes of fissures are determined by:

constipation and defecatory straining: they arise mainly due to dry stools (faecal bolus) that cause a small lesion at the anal level;
chronic diarrhoea: as with haemorrhoids, chronic diarrhoea also inflames the anal tissue, making it more susceptible to the development of tears;
stress: this can lead to sphincter hypertone, i.e. constant contraction of the sphincter muscles, which can lead to defecatory strains, hence to injury, as well as hinder vascularisation of the area and healing of the fissure.

Specialist examination for haemorrhoids and fissures

Both fissures and haemorrhoids are benign conditions that can, however, in some cases affect the quality of life of sufferers.

If the symptoms experienced are frequent, a specialist should be consulted for appropriate evaluation.

Symptoms, such as pain and bleeding, or related elements, such as diarrhoea or constipation, can also be traced back to other pathologies that are not necessarily worrying, but for which a precise diagnosis is required, which can be obtained through a thorough specialist examination.

The visit to the doctor should not cause concern or embarrassment.

The inspection and exploration of the anal cavity and, where possible and necessary, an anoscopy, i.e. the insertion for a few seconds of a disposable instrument into the first 4 to 5 cm of the anal canal, in order to view it from the inside (ed.), is carried out with the utmost delicacy.

In addition, if the examination is particularly painful, the specialist can always prescribe a brief medical treatment and reschedule the examination following this.

The importance of early diagnosis in the case of fissures

Early diagnosis, particularly in connection with fissures, can lead to a less invasive therapeutic approach.

In fact, in the first phase, which can last up to a few months, the pathology is determined by a hypertonus of the anal sphincter, for which medical and/or physical therapy can be decisive, but if the painful symptoms continue without any therapy, surgery may be the only option.

Beware of ‘do-it-yourself’ treatments

In addition, one must beware of do-it-yourself cures with poorly targeted medication or laxatives, even herbal ones: in the first case, they may be ineffective, while in the second, they may be excessive and drastically accustom the organism, which without them will then find it difficult to evacuate.

Treatment for haemorrhoids and fissures

The therapy adopted for the treatment of the 2 conditions must be tailored to the individual person based on his or her clinical history and several factors including age and comorbidities.

For children, for example, surgery is generally not considered, but instead a medical and dietary corrective approach is implemented.

Rhagades and medical therapy

In the phase of anal sphincter hypertonus, it is possible to intervene on fissures, with good success rates, using medical therapy that may include

topical drugs that chemically relax the anal sphincter muscles;
dilators which, contrary to popular belief, are introduced into the anal area a few minutes a day and allow mechanical stretching of the muscle;
moisturising and protective creams, such as simple Vaseline, to be used before defecation to protect and lubricate the mucous membrane when passing stools.

Rhagades and surgical therapy

If the need arises or if the fissure is no longer in its initial phase, minimally invasive surgery can be used.

The operation lasts about 20 minutes and is generally performed under loco-regional anaesthesia, i.e. spinal anaesthesia performed at the level of the last vertebrae, and under day surgery.

The fissure is removed and then an anoplasty is performed: to promote healing, a small flap of skin of a few millimetres, maximum 1 cm, is slid from the anal margin to the previously affected area of the fissure.

One important thing that should be made clear is that the procedure no longer involves the much-feared sphincterectomy, i.e. the cutting off of part of the sphincter, and cases of post-operative incontinence are now almost anecdotal.

The surgical route for haemorrhoids

In the case of haemorrhoids, on the other hand, if conservative therapy with topical creams is not sufficient to counteract persistent symptoms, a surgical route is available.

Nowadays, the types of operations for the correction of haemorrhoids are manifold and are selected by the specialist and the patient taking into consideration the needs and clinical picture of the subject.

In fact, the pathology is no longer classified by degrees, but according to the disorders it causes.

The current trend is not to remove, except in special cases, but to reposition the haemorrhoids in their proper place or to ‘burn’ them.

Here too, we speak of minimally invasive techniques, performed under generally loco-regional anaesthesia in day surgery or more rarely with 1/2 nights’ hospitalisation.

The various surgical options may include technologies such as:

laser;
radiofrequency;
mechanical suturers (Stapler);
suture threads;
ultrasound.

Pain and post-operative care

Choloproctology has made great strides over time, both diagnostically and therapeutically, and even if post-operative pain cannot be considered to have completely disappeared, this should not preclude a surgical procedure, as it is generally well tolerated and controllable pharmacologically.

For the removal of both fissures and haemorrhoids, no special dressing is required and, after a rest period of about 2 weeks and a check-up with the specialist, it is possible to return to normal daily activities

What to eat for haemorrhoids and fissures

Fundamental aspects that accompany both medical and surgical courses in relation to haemorrhoids and fissures are:

the patient’s lifestyle;
an adequate diet that allows the formation of stools of the right consistency and tends not to irritate the intestine and its mucous membrane.

To be avoided, therefore, are extremes such as: