Anal Fissure Surgery: Key Questions for Your Doctor

I would like to ask Dr. Ke about issues related to anal fissure surgery?

1.
The doctor mentioned that my anal fissure is caused by the excessive scarring from recent surgeries for hemorrhoids, fistulas, and skin tags.
I do not have an external anal tear; the fissure is located internally, and it causes pain and bleeding.
My bowel movements are not hard, but I need to exert some abdominal pressure to pass them.
While the stool passes through the anal opening, the fissure feels sharp but not very painful, although there is occasional bleeding (however, if the doctor uses an anoscope to dilate the anal opening during the examination, I experience significant pain during bowel movements that evening).
I consulted two different doctors, and both recommended surgical treatment.
Doctor A suggested making an incision on the external anal sphincter to allow the scar to heal naturally without cutting the internal sphincter.
Doctor B, however, recommended cutting the sphincter muscle beneath the fissure to allow it to relax.
I am confused about which doctor is correct.
It seems that Doctor A's approach makes more sense since my bowel movements are only slightly painful and occasionally bleed.
Would cutting the external sphincter provide more space for the anal opening, allowing the fissure to heal gradually? Or is it necessary to focus on cutting the internal sphincter for both internal and external fissures? (Note: I may have had a hemorrhoidectomy years ago, and I follow a vegetarian diet high in fiber, so while my stool is not hard, I still need to exert some abdominal pressure to pass it.)
2.
Regardless of whether the internal or external sphincter is cut, what is the risk of incontinence or other complications? (Both doctors I consulted are well-known physicians at a major hospital in Taipei.)
3.
Currently, the doctor has prescribed suppositories and ointment for me to use twice daily.
Can I apply the ointment directly onto the suppository for insertion? Is this suppository similar to those containing steroids, requiring a break after seven days of use to avoid harmful side effects? If I notice significant improvement in bleeding and pain after two or three days, can I reduce the usage to once daily while still adhering to the seven-day limit?
4.
I tend to be a nervous person, especially during painful episodes, which often leads to involuntary tightening of the anal muscles.
Will this affect the healing speed of the fissure after surgery or cause other adverse effects?
5.
Although it is possible that I may not undergo surgery, the fissure persists, and I occasionally experience slight bleeding without pain.
Should I still consider surgery to resolve this issue? I have read online that if an anal fissure persists, it may lead to ulcers or bacterial infections, resulting in inflammation of the anal glands, abscesses, fistulas, or other complications.
Is this true?
6.
If I undergo surgery for my internal anal fissure, will the doctor need to excise the fissured tissue or perform other procedures in addition to cutting the sphincter? What is the typical healing time? How long after the surgery can I return to work and resume walking exercises? (My job involves working in a restaurant, which requires frequent movement and occasional lifting of heavy objects.)
7.
With an anal fissure but no surgery, how many sitz baths should I take daily while using suppositories and topical ointments? If I do decide to have surgery, will I need to increase the frequency of sitz baths to promote healing? (Doctor B mentioned that rinsing with warm water is sufficient and that sitz baths are not necessary.)
8.
Regarding the surgery, I assume the doctor may prescribe stool softeners and pain-relieving anti-inflammatory medications.
Since stool softeners cause diarrhea for me, can I choose not to take them if I can tolerate the pain? (I consume a vegetarian diet and drink plenty of water, so my stool is not very hard, but I worry that not using a stool softener might affect the healing of the surgical site.) Additionally, will the doctor typically prescribe antibiotics? I have taken many antibiotics during previous surgical treatments and would prefer to avoid them to maintain good gut health.
Thank you for addressing these questions, doctor.

A Guo, 40~49 year old female. Ask Date: 2019/02/22

Dr. Ke Fangxu reply Surgery

1.
Incising the internal anal sphincter is appropriate because the internal sphincter is circular, allowing for incision; this is fundamental to anal fissure surgery.

2.
It will not cause incontinence; the cause of anal fissures is excessive anal pressure.
Incision of the sphincter can relieve the contraction pressure of the anus, returning it to a normal state.

3.
The steroid content in the medications is very low, and using them for a few weeks will not result in side effects.
If symptoms improve, the dosage can be reduced accordingly.

4.
Postoperatively, warm sitz baths can be used to alleviate discomfort.

5.
Surgery is not necessarily required for mild anal fissures.
Chronic anal fissures can indeed lead to the formation of anal fistulas, but other malignant changes will not occur.

6.
The treatment of the fissure may involve excision depending on the depth of the wound and the condition of the epithelial migration.
This decision will be made in the operating room under anesthesia.
Pain will be more pronounced in the first week post-surgery, but it will significantly improve by the second week, and walking will generally not be an issue.
Complete wound healing typically takes about 3-4 weeks.

7.
Sitz baths are generally recommended 3-4 times a day.
I suggest that office workers take warm sitz baths in the morning, after work, and before bed, as this can relieve pain, maintain cleanliness, and promote blood circulation.
Increased frequency can indeed facilitate wound healing.

8.
It is possible to avoid medications as long as there is no pain or constipation; medications are not necessarily required.
Personally, I do not prescribe antibiotics, but some physicians may have a habit of prescribing them, and you can request not to use antibiotics.

Reply Date: 2019/02/22

More Info

Understanding anal fissure surgery is crucial for patients who are considering this procedure, especially when faced with conflicting opinions from different doctors. Here’s a comprehensive response to your questions based on medical knowledge and practices.

1. Surgical Approaches: The choice between cutting the external anal sphincter (A doctor) or the internal anal sphincter (B doctor) depends on the specific characteristics of your fissure and your overall health. The internal sphincter is typically cut to relieve tension and promote healing, especially if the fissure is chronic. If your fissure is primarily due to scar tissue from previous surgeries, addressing the internal sphincter may be more beneficial. However, if the fissure is not deep and primarily symptomatic, an external approach might suffice. It’s essential to discuss these options thoroughly with your surgeon to understand the rationale behind their recommendation.

2. Risks of Incontinence: Both surgical options carry risks, including potential incontinence. However, the risk is generally low when performed by experienced surgeons. The key is to ensure that the procedure is tailored to your specific condition. Discuss your concerns about incontinence with your surgeon, as they can provide statistics and insights based on their experience.

3. Use of Medications: Combining a suppository with a topical ointment is generally acceptable, but you should confirm this with your doctor. The medications you are using may have specific instructions regarding their application. Regarding the steroid-containing suppositories, prolonged use can lead to side effects, so it’s crucial to follow your doctor’s advice on duration and frequency. If you notice improvement, it’s reasonable to discuss reducing the frequency with your doctor.

4. Impact of Anxiety on Healing: Anxiety can indeed affect healing, as stress may lead to muscle tension, including in the pelvic area. This tension can complicate recovery. It’s advisable to practice relaxation techniques and communicate your anxiety with your healthcare provider, who may offer strategies to help manage it during your recovery.

5. Need for Surgery: If your fissure persists and causes bleeding, even if it’s not painful, surgical intervention may be warranted. Chronic fissures can lead to complications such as infections or the development of fistulas. Addressing the fissure surgically can prevent these potential complications and improve your quality of life.

6. Surgical Procedure Details: During surgery, the surgeon may excise the fissure and any scar tissue, and they will likely perform a sphincterotomy (cutting the sphincter muscle) to relieve tension. The healing period can vary, but many patients return to normal activities within a few weeks. However, given your job involves physical activity, you may need to discuss a tailored recovery plan with your surgeon.

7. Sitz Baths: Sitz baths are beneficial for promoting healing and comfort. If you undergo surgery, increasing the frequency of sitz baths may help with recovery. Your surgeon’s advice on this will be crucial, as they may have specific recommendations based on your condition.

8. Post-Operative Medications: Softening stools is essential to prevent strain during bowel movements, which can jeopardize healing. If you can manage without a stool softener, discuss this with your doctor, as they may have alternative recommendations. Antibiotics are often prescribed to prevent infection post-surgery, but if you have concerns about their impact on your gut health, communicate this with your healthcare provider.

In conclusion, it’s vital to have open and honest discussions with your healthcare providers about your concerns and treatment options. Each case is unique, and your doctors can provide personalized recommendations based on your specific situation. Healing from an anal fissure can be a complex process, but with the right approach and care, you can achieve a positive outcome.

Similar Q&A

Understanding Anal Fissures: Treatment Options and Surgical Considerations

Hello Doctor: Last time I asked about the seriousness of anal fissures, and something quite unbelievable happened. I live in Taichung City and visited China Medical University Hospital twice. The first time, I simply told the doctor (Dr. Ke) that it might be an anal fissure, and ...

Dr. Ke Fangxu reply Surgery
Hello: In response to your question, you have an anal abscess rather than an anal fissure. An anal abscess typically presents with persistent worsening pain and sometimes fever. If the abscess is not too large, it can be treated with incision and drainage in an outpatient setting...

Choosing the Right Surgery for Chronic Anal Fissures: Pros and Cons

I would like to consult a physician regarding a condition I have been experiencing for three years, which involves internal and external hemorrhoids accompanied by anal fissures and bleeding. Initially, I applied medication and took sitz baths for five months, but the bleeding af...

Dr. Ke Fangxu reply Surgery
1. To my knowledge, there is only one type of surgery for anal fissures, which is the lateral internal sphincterotomy (LIS) you mentioned. Fissurectomy refers to the excision of the fissure itself; however, this step is optional. Once the sphincter is cut, the fissure will heal o...

Chronic Anal Fissure: When to Seek Surgery and What to Expect

Hello, Doctor. I would like to ask about my issue with anal pain during bowel movements. I have been diagnosed with chronic anal fissure. It has been four days since the examination, and I have a habit of using the restroom in the morning and evening, but I still experience pain ...

Dr. Ke Fangxu reply Surgery
Treatment for anal fissures can be quite troublesome, as the healing process is slow, yet it may not be severe enough to warrant surgery. However, if the pain is intense or significantly affects daily life, surgery may be necessary to resolve the issue. Personally, I have not hea...

Understanding Anal Fissures After Minimally Invasive Hemorrhoid Surgery

Hello, Dr. Ke. I would like to ask a question. I underwent minimally invasive surgery on August 4th for internal and external hemorrhoids as well as rectal prolapse. During my follow-up appointment on August 27th, the doctor mentioned that there was an anal fissure. Could you ple...

Dr. Ke Fangxu reply Surgery
There are various methods claimed to be minimally invasive surgery. It is difficult to answer this question without knowing the specific instruments and techniques you are using. Please discuss the subsequent treatment plan thoroughly with your surgeon.