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Anal Fissure

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

The initial recommendations to help a fissure heal are usually non-operative. These include a high fiber diet, fiber supplements, emollient creams or ointments, 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 with these 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, can relax the internal anal sphincter, relieve pain and burning, and help fissures heal. Nitroglycerin preparations tend to produce more headaches, so Dr. Leiboff routinely uses 0.2% or 0.5% nifedipine ointment, with or without a topical local anesthetic mixed in. 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, surgical intervention is warranted, and most surgeons perform “lateral internal sphincterotomy.” This operation can be performed with a small incision (“open”), or through a smaller puncture (“subcutaneous lateral internal sphincterotomy”). Lateral internal sphincterotomy has a high success rate, 90 to 95%; but can have complications, such as bleeding, abscess 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 low but significant chance of causing mild incontinence (loss of control). Reported rates of incontinence after sphincterotomy vary greatly. This is partly because of discrepancies between what patients who had sphincterotomy tell their surgeon and what they report in questionnaires completed in a more private setting. 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. Researchers from the Cleveland Clinic warned that patients undergoing lateral internal sphincterotomy 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. There have been a number of malpractice cases against surgeons resulting from complications related to sphincterotomy. Still, lateral internal sphincterotomy remains the “standard of practice” in the USA.

Anal dilatation (sphincter stretch) is another way to treat anal fissure. An older method of anal dilatation was commonly used until lateral internal sphincterotomy was introduced in 1969. In this older method the surgeon inserted his fingers into the anus to spread the anal opening “manually.” This method was relatively uncontrolled, and occasionally resulted in some degree of incontinence. In the 1970’s lateral internal sphincterotomy became the preferred operation for anal fissure because studies showed it produced lower rates of incontinence than “manual dilatation.”

In the 1990’s Dr. Norman Sohn developed a procedure that stretches the sphincter muscle in a measured and controlled way that is less likely to produce incontinence than “manual dilatation” or lateral internal sphincterotomy. This procedure also avoids other postoperative complications, such as sphincterotomy site bleeding, abscess and fistula. Dr. Sohn and his partner Dr. Michael Weinstein treated more than 2000 fissures this way with excellent results. Dr. Sohn claimed to have an 87% fissure healing rate (95% pain relief with or without full healing) and an incontinence rate of 0.3%, although he did not publish these results. He preferred using special dilators and a simple, standardized method. Few surgeons have adopted “Standardized Anal Dilatation” due to a lack of awareness and training, and the negative reputation of “manual dilatation.” There are scientific studies that support the value of controlled anal dilatation, but there is a need for more studies to compare Standardized Anal Dilatation to lateral internal sphincterotomy. A study from Israel published in April, 2021 found that Standardized Anal Dilatation using Sohn’s Dilators is a simple, reliable, consistent, less traumatic, reproducible, and non-operator-dependent treatment for anal fissure, and that its beneficial effects are comparable to sphincterotomy, but it minimizes complications and does no long-term harm to anal sphincter function.

Dr. Leiboff performed lateral internal sphincterotomy for twenty years before switching to “Standardized Anal Dilatation” in 2008. He has had great success with this method with hundreds of patients, having to resort to lateral internal sphincterotomy only rarely (<5). Patients have come from other states and countries to have Dr. Leiboff perform Standardized Anal Dilatation. Dr. Leiboff feels that Standardized Anal Dilatation should be included in the armamentarium of all colon and rectal surgeons and presented as an alternative to sphincterotomy whenever informed consent is obtained for surgical management of anal fissure.

Lateral internal sphincterotomy and Standardized Anal Dilatation can both be performed with or without fissurectomy. Fissurectomy removes deformed skin around the fissure along with protrusions (e.g. sentinel piles or hypertrophied papillae) associated with the fissure, and/or cauterizes the fissure. When a subcutaneous tract (or pocket) has formed beneath anoderm distal or proximal to a fissure, unroofing the tract (“subcutaneous fissurotomy”), may be helpful.

There are other surgical options to cure anal fissure. Combining BOTOX® injection with Standardized Anal Dilatation and/or fissurectomy 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 not elevated, or are low, or if they have loose bowel movements, 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 tissue transfer operations take longer to do, but there are reports showing them to have high success rates.

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

For more information on this subject, click on fissure.

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