Chronic Anal Fissures: When to Consider Surgery?

I would like to consult a doctor regarding a suspected case of chronic anal fissure?

I have had both external and internal hemorrhoids for about four years, and after treatment, I have been managing my internal hemorrhoids over the past two years, with no external hemorrhoids remaining.
About a year ago, I experienced pain after bowel movements, and a doctor diagnosed me with an anal fissure and prescribed an ointment, which helped alleviate the issue.
Recently, however, I have been experiencing pain again after bowel movements, and for a few days, there was slight bleeding when wiping.
My stools are somewhat hard, but I wouldn't classify it as constipation since I can pass them relatively easily, although they are not very smooth.
I visited a private clinic in Taipei (the kind that requires out-of-pocket payment), where the doctor noted that I have a small internal hemorrhoid and a chronic anal fissure.
He mentioned that the chances of self-healing are low and recommended a minor surgical procedure that would take about 30 minutes to an hour, with no need for hospitalization, but the cost would be over NT$30,000.
I would like to ask the doctor the following questions:
1.
I had a rubber band ligation for my internal hemorrhoids at a hospital in Taipei about two months ago, and the doctor did not mention any severe anal fissure condition at that time.
Would this situation be classified as an acute or chronic anal fissure?
2.
If it is indeed a chronic anal fissure, is surgery absolutely necessary? What degree of severity would require surgery?
3.
I found online that most anal fissure surgeries at hospitals typically require at least one day of hospitalization.
Why do some clinics claim that patients can go home within an hour after the procedure?
4.
Would you recommend that I go to a larger hospital for further examination before making a decision?
I apologize for the many questions, and I appreciate your assistance, doctor.
Thank you.

Hong Hong, 30~39 year old female. Ask Date: 2022/06/26

Dr. Ke Fangxu reply Surgery

1.
This needs to be examined; it cannot be determined solely based on a written description.

2.
Surgery for anal fissures is generally only recommended if there is severe pain that affects daily activities; if there is no significant pain, surgery is not necessary.

3.
Please consult the clinic physician in detail; I personally have not performed outpatient surgery for anal fissures, so I cannot answer your questions.

4.
If symptoms improve, it is also possible to continue monitoring.

Reply Date: 2022/06/26

More Info

Chronic anal fissures can be a painful and distressing condition, often resulting from trauma to the anal canal, typically due to the passage of hard stools. Given your history of hemorrhoids and recent symptoms, it’s understandable that you’re seeking clarity on your situation and the potential need for surgery.

1. Acute vs. Chronic Anal Fissures: The distinction between acute and chronic anal fissures is primarily based on the duration of the symptoms. An acute fissure is typically less than six weeks old, while a chronic fissure persists for more than six weeks. Given that you have been experiencing pain and occasional bleeding after bowel movements for some time, it is likely that you are dealing with a chronic fissure, especially since your symptoms have recurred after previous treatment.

2. Surgical Considerations: Surgery is not always necessary for chronic anal fissures. Many fissures can heal with conservative measures such as dietary changes to ensure softer stools, increased fluid intake, and the use of topical treatments like nitroglycerin ointment or calcium channel blockers. However, if conservative treatments fail and the fissure persists, surgical intervention may be considered. Surgery is typically recommended when:
- The fissure has not healed after several weeks of conservative treatment.

- There is significant pain or bleeding that affects quality of life.

- There are associated conditions, such as anal stenosis or recurrent hemorrhoids, that complicate the situation.

3. Outpatient Surgery: The fact that some clinics offer outpatient procedures for anal fissures, allowing patients to go home the same day, is not uncommon. Many fissure surgeries, such as lateral internal sphincterotomy, can be performed under local anesthesia and do not require an overnight hospital stay. However, the decision to perform outpatient surgery depends on the specific technique used, the patient's overall health, and the surgeon's preference. It's essential to ensure that the facility is equipped to handle any potential complications that may arise.

4. Seeking a Second Opinion: Given your ongoing symptoms and the recommendation for surgery, it may be beneficial to seek a second opinion from a colorectal surgeon or a gastroenterologist at a larger hospital. They can provide a thorough evaluation, including a physical examination and possibly additional imaging or diagnostic tests, to confirm the diagnosis and discuss all available treatment options. This can help you make a more informed decision regarding surgery versus continued conservative management.

In summary, while chronic anal fissures can be challenging, there are various treatment options available. Surgery is typically considered when conservative measures fail, and it’s essential to weigh the risks and benefits with your healthcare provider. Seeking a second opinion can provide additional insights and help you feel more confident in your treatment plan. Remember, maintaining a high-fiber diet, staying hydrated, and practicing good bowel habits are crucial in managing your symptoms and preventing future fissures.

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