Anal Fissures: Surgical Options and Management Tips

Please inquire about anal fissure surgery and bowel movement issues?

Hello, Doctor.
I have been experiencing anal fissures (located at the six o'clock position, towards the back) for about 1 to 2 years, with episodes of healing and recurrence.
Typically, I feel discomfort during bowel movements, as if the anus is being stretched, which feels somewhat swollen or indescribably strange.
After seeing a doctor, I was diagnosed with an anal fissure, and after undergoing an anoscopy, I noticed blood when wiping the next morning after a bowel movement.
Generally, I do not see blood when wiping after using the restroom, nor do I experience severe pain during bowel movements.
I have consulted several doctors; some believe that the tightness of the anal sphincter is the cause, while others think that the sphincter is normal and that constipation is the issue.
One doctor mentioned that the location of the fissure shows signs of repeated fissures.
To address this issue, one doctor suggested a sphincterotomy (to be performed on one side) along with cleaning up the scarring from the recurrent fissures.
However, based on my situation, the doctor felt that surgery might not be necessary and left the decision to me.
I am somewhat inclined to undergo surgery to resolve the recurring fissures and the tightness of the sphincter, but I am also concerned about potential complications or other issues arising from the surgery.
Therefore, I would like to ask the following questions:
1.
I have read that sphincterotomy generally does not lead to incontinence, but is there a possibility of developing incontinence in old age?
2.
Is it necessary to suture the incision site after a sphincterotomy, or is it left open? Will there be pain during bowel movements post-surgery? How should I care for the wound afterward?
3.
I consulted a medical center in central Taiwan, and the doctor said that only the sphincterotomy is needed, and there is no need to address the location of the recurrent fissures.
Is it essential to treat the site of the recurrent fissures?
4.
I usually have a bowel movement every morning without constipation issues.
The front part of the stool is about 2 to 3 centimeters long and tends to be drier compared to the back.
The stool diameter is about 1 to 1.5 centimeters, not exceeding the size of a five-dollar coin.
I found online that the average stool diameter is about 2 centimeters, but my stool is thinner than average, yet I still experience fissures.
Does this indicate that my sphincter is indeed tighter, leading to a narrower anal canal?
5.
I have had issues with internal hemorrhoids in the past and have undergone rubber band ligation several times (approximately 6 to 7 times).
Could this frequent ligation have caused the sphincter to become tighter or the anal canal to narrow?
6.
After bowel movements, when I apply ointment with my finger inside the anus, I sometimes notice a small amount of stool residue on my finger.
Is this normal? Should I apply the ointment again after rinsing with water?
7.
If I do not experience pain during bowel movements, does that mean I am not having fissures? Or is there still a chance of developing fissures without feeling pain? Could this lead to issues like sentinel piles or other complications over time?
I apologize for the numerous questions, and I appreciate your response.
Thank you.

Mr. Zhou, 30~39 year old female. Ask Date: 2022/02/05

Dr. Ke Fangxu reply Surgery

1.
No.

2.
There is no need for sutures; postoperative pain during bowel movements is unavoidable but should be less severe than before the surgery.
Wound care can be managed with sitz baths.

3.
It is not necessary to remove them; they can heal on their own regardless of whether they are excised.

4.
It is possible.

5.
Ligating internal hemorrhoids will not cause anal stenosis.

6.
It is normal to have a small amount of feces in the anal canal; just clean it slightly before applying medication.

7.
If there is no pain or bleeding from an anal fissure, no treatment is necessary.
Sentinel hemorrhoids are a common issue associated with anal fissures; if there is no discomfort, excision is not mandatory.

Reply Date: 2022/02/05

More Info

Understanding anal fissures and their management is crucial for anyone experiencing this painful condition. Anal fissures are small tears in the lining of the anus, often resulting from trauma during bowel movements, particularly when passing hard stools. They can cause significant discomfort, bleeding, and can become chronic if not properly managed.

Surgical Options for Anal Fissures
When conservative treatments, such as dietary changes, stool softeners, topical anesthetics, and sitz baths, fail to provide relief, surgical options may be considered. One common surgical procedure is the lateral internal sphincterotomy, which involves cutting a portion of the anal sphincter muscle to relieve tension and promote healing of the fissure.
1. Risks of Surgery: While the risk of postoperative incontinence is low, it is not zero. Most studies suggest that the risk of significant incontinence is minimal, but there is a possibility of developing some degree of fecal incontinence later in life, particularly if the surgery is performed on a tight sphincter. It’s essential to discuss these risks with your surgeon to make an informed decision.

2. Surgical Technique: The procedure typically involves making a small incision in the sphincter muscle, which may or may not require suturing. In many cases, the incision is left open to heal naturally. Postoperative pain can vary; however, many patients report that the pain from the fissure itself is often more severe than any discomfort experienced after surgery.

3. Management of the Surgical Site: After surgery, it is crucial to maintain good hygiene and follow your surgeon's instructions for wound care. This may include taking sitz baths, applying prescribed ointments, and avoiding straining during bowel movements.
4. Addressing Chronic Fissures: If there are signs of chronic fissures or scarring, some surgeons may recommend addressing these areas during the procedure. This could involve excising the scar tissue or performing additional procedures to promote healing.

5. Bowel Habits and Fissure Formation: Your description of bowel habits suggests that while you may not be constipated, the consistency and size of your stools could still contribute to fissure formation. A narrower anal canal due to tight sphincter muscles can lead to increased pressure during bowel movements, making fissures more likely.
6. Impact of Previous Treatments: Repeated treatments for hemorrhoids, such as rubber band ligation, can potentially lead to changes in anal tone or scarring, which may contribute to tightness in the anal sphincter. This could be a factor in your ongoing fissure issues.

7. Post-Defecation Hygiene: It is not uncommon to notice some residual stool after wiping, especially if the stool is soft. However, if you are using ointments, it is advisable to clean the area gently with water after applying the medication to avoid irritation and ensure proper healing.

8. Monitoring for Fissures: Just because you are not currently experiencing pain does not mean that fissures cannot develop. It is possible to have a fissure that is asymptomatic. Regular monitoring of your symptoms and maintaining a healthy diet to ensure soft stools can help prevent recurrence.

Conclusion
In summary, if you are considering surgery for your anal fissures, it is essential to weigh the benefits against the potential risks. Consulting with a colorectal surgeon who specializes in this area can provide you with tailored advice based on your specific situation. They can help you understand the surgical options available, the expected outcomes, and the best course of action to alleviate your symptoms and improve your quality of life. Remember, maintaining a healthy diet, staying hydrated, and practicing good bowel habits are key components in managing and preventing anal fissures.

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