Colon and Rectal Surgeons of Long Island, P.C.

Anal Fissure

An anal fissure is a tear or cut in the special skin of the anus, which may cause 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, and sitz baths.  If the fissure was caused by hard stools, treatment of the fissure should include stool softeners, increased water intake and exercise. Fifty percent of fissures will heal by themselves or with non-operative measures.

A fissure is usually associated with high pressures of the internal anal sphincter.  The internal anal sphincter is the inner most muscle of a group of muscles that surround the anal opening and control the passage of gas and feces.  Most patients with anal fissure have evidence of an overactive internal anal sphincter.  Measures to relax the internal anal sphincter are often effective in treating fissures.

Special medicated creams such as nitroglycerin and nifedipine relax the internal anal sphincter and are used to relieve pain and burning and to help healing of fissures.  Injection of BOTOX® directly into the internal anal sphincter can also be an effective treatment. BOTOX® (Botulinum Toxin Type A) is a purified neurotoxin which produces a temporary localized muscle paralysis.

For chronic, non-healing anal fissures, or recurrent fissures, or fissures that are very painful, more aggressive measures to reduce the anal sphincter pressure are usually necessary.  Most fissures can be successfully treated by anal dilatation (stretching of the muscles) or internal sphincterotomy (cutting the internal anal sphincter muscle).  Both methods can be performed with or without fissurectomy.  Fissurectomy means that the deformed skin around the fissure is removed along with any protrusions (e.g. sentinel tabs or hypertrophied papillae) associated with the fissure, and/or the fissure bed is cauterized.

Anal dilatation (sphincter stretch) for the treatment of anal fissure was first described in 1838 and was commonly used until subcutaneous lateral internal sphincterotomy was introduced in 1969.  The manual methods used in the past stretched the anal sphincter muscle in a relatively uncontrolled manner, often resulting in some degree of incontinence (loss of control).  Lateral internal sphincterotomy became the standard operation for anal fissure because it produced lower rates of incontinence.

Despite its predominance, anal sphincterotomy can produce complications.  Bleeding and infection are potential complications of all surgical procedures, and may occur after sphincterotomy.  Thrombosed hemorrhoids may occur, as can delayed healing of the sphincterotomy surgical site.  Persistence or recurrence of the fissure is possible. Reported rates of incontinence after sphincterotomy vary greatly.  For example, in a study of 585 patients who underwent lateral internal sphincterotomy at the Mayo clinic between 1984 and 1996, some degree of fecal incontinence occurred in 45 percent of patients at some time in the postoperative period.  However, by the time of survey (a mean of >5 years after lateral internal sphincterotomy) 6 percent reported incontinence to flatus, 8 percent had minor fecal soiling, and 1 percent experienced loss of solid stool.  In a study of 298 patients who underwent a sphincterotomy at the Cleveland Clinic between 1992 and 2001, temporary incontinence was reported in 31 percent of patients and persistent incontinence to gas occurred in 30 percent. Stool incontinence was not a significant finding.

In 1992 Dr. Norman Sohn showed that anal dilatation, when performed in a precise and controlled manner, successfully cured 93 to 94 percent of anal fissures with fewer complications than anal sphincterotomy. In 1997 he reported on a series of 319 patients with fissures treated by balloon dilatation.  88% of patients healed within 3 months.  With acute or severely painful anal fissure, pain relief usually occurred within 12 hours.  Invariably, the patients could return to work or resume their normal activities the day after the procedure.  There were two cases (0.6%) of temporary incontinence to flatus and one case of permanent incontinence to flatus.  There were no cases of temporary or permanent incontinence to liquid or solid stool, and there were no problems with soiling.  Two patients (0.6%) developed thrombosed hemorrhoids following the dilatation. 

Despite these favorable reports, surgeons have been slow to adopt Dr. Sohn’s method.  However, in January 2008 a study was published comparing controlled dilatation (using a pneumatic balloon) with lateral internal sphincterotomy.  Fissure-healing rates at six weeks after the operation were 83 percent in the dilatation group and 92 percent in the sphincterotomy group.  But the rate of postoperative anal incontinence was significantly lower in the dilatation group.  Minor soiling was observed in 4 of the 24 patients (16%) who had dilatation.  In all four the disturbances disappeared by 12 months.  In the sphincterotomy group 7 of 25 patients (28%) reported deterioration in continence at the first postoperative week.  Four of the 25 patients (16%) had continence disturbances at two years after the operation.

Dr. Leiboff has performed subcutaneous internal sphincterotomy since 1989 with good success. In his experience minor incontinence to flatus, where gas is passed unexpectedly, occurs about 5 to 10% of the time after internal sphincterotomy, and usually resolves, so that impairment persists in only 2 to 5% of patients.  However, after reviewing the work of Dr. Sohn and others performing controlled anal dilatation, Dr. Leiboff has switched to precise, controlled dilatation, as his primary operative approach. If your surgeon recommends cutting your sphincter muscle to treat your fissure, come see Dr. Leiboff for a second opinion.

For more information on this subject click on fissure.