Colon and Rectal Surgeons of Long Island, PC

Anal Fissure

An anal fissure is a tear, cut or ulceration of the special skin of the anus, which causes pain, bleeding, itching or burning. A fissure can be caused by passing a hard dry bowel movement, or by diarrhea or inflammation. Fissures often persist and may require special measures to heal.

The initial measures recommended to help a fissure heal are usually non-operative. These measures include a high fiber diet, fiber supplements, soothing and emollient creams, lubricating suppositories and sitz baths. If the fissure was caused by hard stools, treatment should include stool softeners, increased water intake and exercise. Most fissures will heal by themselves or with non-operative measures.

A fissure is usually associated with high pressures of the internal anal sphincter, the innermost muscle of a group of muscles that surround the anal opening and control the passage of gas and stool. Most patients with anal fissure have evidence of an overactive internal anal sphincter. Measures to relax this muscle are often effective in healing fissures.

Special medicated creams or ointments, nitroglycerin, diltiazem and nifedipine, relax the internal anal sphincter and are used to relieve pain and burning and help fissures heal. Injection of BOTOX® directly into the internal anal sphincter can also be an effective treatment. BOTOX® (Botulinum Toxin Type A) is a purified neurotoxin that produces a temporary localized muscle paralysis. It can be administered in the office without anesthesia.

When fissures fail to heal with non-surgical treatment, or when the fissure is chronic, recurrent or extremely painful, more aggressive measures to reduce the anal sphincter pressure are warranted, and most surgeons perform “lateral internal sphincterotomy (LIS).” LIS has a high success rate, 90 to 95%; but can have complications, such as bleeding, infection, thrombosed hemorrhoids and fistula. There can be delayed or non-healing of the sphincterotomy surgical site, and persistence or recurrence of the fissure. This operation, in which anal muscle fibers are cut, has a significant chance of causing mild incontinence (loss of control). Reported rates of incontinence after sphincterotomy vary greatly. What surgeons will tell their patients about this operation also varies greatly. Some surgeons tell their patients they have never seen incontinence in any of their own patients. Others quote minor incontinence rates up to 30%; most quote rates in between. This is partly because of discrepancies between what patients tell their surgeon and what they report in questionnaires completed in a more private setting. Researchers from the Cleveland Clinic warned that patients undergoing LIS need to be informed about the potential risks for incontinence to flatus (gas), which may occur in up to 30 percent of cases and could be permanent.

Anal dilatation (sphincter stretch) is another way to treat anal fissure. An older method of anal dilatation was commonly used until LIS was introduced in 1969. In this older method the surgeon inserted his fingers into the anus and spread the anal opening "manually." This was relatively uncontrolled, and often resulted in some degree of incontinence. In the 1970's LIS became the standard operation for anal fissure because it produced lower rates of incontinence than uncontrolled manual dilatation. In the 1990's Dr. Norman Sohn developed “Standardized Anal Dilatation.” This procedure stretches the sphincter muscle in a measured and controlled way that is significantly less likely to produce incontinence. This method also reduces the chances of other complications, such as bleeding and infection. Dr. Sohn treated more than 2000 fissures this way and claimed to have an 87% fissure healing rate (95% pain relief with or without full healing) and an incontinence rate of 0.3%.

Both LIS and Standardized Anal Dilatation can be performed with or without fissurectomy. Fissurectomy removes deformed skin around the fissure along with protrusions (e.g. sentinel tabs or hypertrophied papillae) associated with the fissure, and/or cauterizes the fissure.

There are other surgical options to cure anal fissure. Fissurectomy in combination with BOTOX® injection is effective. Other operations do not weaken the anal sphincter and are particularly useful when it is suspected or proven that the patient’s anal sphincter pressures are already low, or if they have loose bowel movements, or urgency, or already have problems with control. Fissurectomy alone can be performed. Adjacent skin (dermal flap) can be moved into the anus to cover the fissure. Adjacent skin and fat can also be moved to cover the fissure (V-Y anoplasty). Both these tissue transfer operations take longer to do but are reported to have high success rates.

If you have a fissure, you should discuss these options with your surgeon, and choose the one best for you.

For more information on this subject, click on fissure.