An anal fissure is a cut or tear of the lining of the anal canal. This problem most commonly occurs after a hard bowel movement, or after frequent bowel movements. It is just inside the bottom of the anus (anal verge) and can be seen on physical exam by simple inspection. In males, the fissure occurs about 98% of the time in the posterior midline, and 2% of the time in the anterior midline. In females the fissure occurs about 90% of the time in the posterior midline and 10% of the time in the anterior midline.
Symptoms may include pain, burning, itching and bleeding (typically bright red blood either streaky on the toilet tissue or dripping into the bowl). Pain is the hallmark of a fissue, and typically occurs following bowel movement and may last from minutes to hours. If the fissure is acute (of several days duration), many times it heals on its own. If on the other hand it does not heal properly, it becomes chronic and can lead to spasm of the internal anal sphincter. Proper management of a chronic anal fissure, includes keeping the stool soft, to help break the spasm and not lead to further tearing, of the anal lining. The best way to medically treat fissures in our experience, includes drinking 6-8 glasses of fluids per day, high fiber diet, including supplementing with psyllium products such as Konsyl or Metamucil or Citrucel (methylcellulose). In addition, mineral oil, Kondremul or LiquiDoss add further softening to the stool. Sitting in a tub of warm to hot water helps to relax the sphincter. This may be beneficial prior to and after bowel movement.
In our experience, if a fissure has not healed completely within 8 weeks, the chances of it healing without operative intervention are slim. We have not been convinced that the nitro-paste or Botulinum toxin injection helps a significant number of people for a significant time. Suppositories cause discomfort when inserting, and actually sit above the anal canal so can’t possibly help in healing the fissure. At the same time creams sit just below where the fissure is located, unless the patient can put this into the anal canal through a nozel, but this again often causes more discomfort, so usually is not of great benefit.
In our practice we perform an outpatient sphinterotomy that takes on average 3-5 minutes. This is performed under intravenous sedation (twilight sleep) with local anesthesia. A 5mm incision is made just outside the lower border of the internal anal sphincter. A plane is then developed in the inter-sphinteric plane behind the internal sphincter, and then between the anoderm and the internal anal sphincter, snipping the lower one-third of the muscle, which typically coincides with the length of the fissure. The patient receives immediate relief from pain and typically has only minimal discomfort over the next several days. If we perform the procedure on a Thursday or Friday, the patient is typically able to return to work by Monday.
An important point to keep in mind is that fissures may wax and wane. Meaning that the discomfort may become tolerable for some period of time, but if someone has an episode of diarrhea or a hard BM, the symptoms start all over again. We recommend that anyone with problem of the ano-rectum see their physician for evaluation. Never assume it’s only hemorrhoids. No one should have to suffer for long periods of time, and have their problem create an adverse affect on the quality of their life.