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.

When fissures fail to heal with non-surgical treatment, surgery may be necessary. Most surgeons in the United States cut the anal sphincter muscle when they operate for anal fissure. This type of surgery for anal fissure, called "sphincterotomy", has a significant chance of causing mild incontinence (loss of control). In 2005, researchers from the Cleveland Clinic warned that patients undergoing this operation need to be informed about the potential risks for residual flatal (gas) incontinence, which may occur in up to 30 percent of cases and could be permanent.

Dr. Leiboff is one of the few surgeons who perform surgery for anal fissure in a safer way. He does not cut the sphincter muscle. Instead he stretches the 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.

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 stool. 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.

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.

Special medicated creams or ointments, such as nitroglycerin 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.

More aggressive measures to reduce the anal sphincter pressure are usually necessary for chronic, non-healing anal fissures, recurrent fissures, or fissures that are very painful. 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 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.

Anal dilatation (sphincter stretch) for the treatment of anal fissure was described in 1838 and was commonly used until lateral internal sphincterotomy was introduced in 1969. The surgeon inserted his fingers into the anus and spread the anal opening "manually." This older method was relatively uncontrolled, and often resulted in some degree of incontinence. In the 1970s, lateral internal sphincterotomy became the standard operation for anal fissure because it produced lower rates of incontinence than manual dilatation.

Lateral internal sphincterotomy remains the predominant surgical treatment for anal fissure. However, there can be complications to this procedure, 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. Reported rates of incontinence after sphincterotomy vary greatly, and are often quoted to be in the range of 2 to 10%.

In 1992 Dr. Norman Sohn showed that anal dilatation, when performed in a precise and controlled manner, successfully cured 93 to 94% of anal fissures with fewer complications than anal sphincterotomy. He subsequently treated more than 2000 fissures by "Standardized Anal Dilatation" and claims to have had an 87% fissure healing rate (95% pain relief with or without full healing) and an incontinence rate of 0.3%.

Dr. Sohn’s work has been supported by other studies, including a prospectively randomized controlled trial published in January 2008.  In this trial fissure-healing rates at six weeks after the operation were 83% in the dilatation group and 92% 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. The disturbances disappeared by 12 months in all four. 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 performed subcutaneous internal sphincterotomy for 20 years with good results. However, he now performs "Standardized Anal Dilatation" to avoid the incontinence and wound problems associated with sphincterotomy. Results have been excellent. If your surgeon recommends cutting your sphincter muscle to treat your fissure, see Dr. Leiboff for a second opinion.

For more information on this subject, click on fissure.