Chronic Anal Fissures: Surgery Options and Treatment Concerns

Anal fissure surgery issues?

Some time ago, I developed an anal fissure due to gastrointestinal issues.
Although my gastrointestinal problems have been resolved and the fissure has healed, I still experience recurrent pain after several days of soft stools.
Medical examinations continue to show that I have a fissure.
As a result, I often need to take sitz baths and use suppositories.
If I only take sitz baths, the pain returns after a few days of soft stools.
This cycle has significantly impacted my quality of life and work.
The hospital has prescribed a non-steroidal suppository to avoid the side effects associated with long-term steroid use.
I once considered surgery for a permanent solution, but the hospitals I consulted believe that my anal sphincter is too lax for surgery to be appropriate.
Therefore, I have to manage this as a "chronic condition" with sitz baths, suppositories, and pain medication.
I would like to ask if it is true, as the hospitals say, that a lax sphincter makes surgical intervention unfeasible? Additionally, even though I am using a non-steroidal suppository at night, will prolonged use still lead to thinning or atrophy of the mucosa like steroids do?

Wunai, 50~59 year old female. Ask Date: 2023/03/29

Dr. Ke Fangxu reply Surgery

Anal fissures can be classified into two types based on the pressure of the sphincter muscle.
If the sphincter pressure is excessively high, surgical intervention tends to yield better outcomes.
Conversely, if the sphincter pressure is insufficient, the results of surgery may be less favorable.
However, if the pain and discomfort significantly impact daily life, surgical treatment can still be considered, although the likelihood of poor treatment outcomes may be higher.
Suppositories that do not contain steroids will, of course, not produce steroid-related side effects.

Reply Date: 2023/03/29

More Info

Chronic anal fissures can be a frustrating and painful condition that significantly impacts one's quality of life. It seems that you have been dealing with this issue for quite some time, and I understand how distressing it can be to experience recurrent pain and discomfort despite managing your bowel habits. Let's delve into the treatment options and concerns regarding surgery for chronic anal fissures.

Understanding Chronic Anal Fissures
Anal fissures are small tears in the lining of the anal canal, often caused by trauma during bowel movements, particularly when passing hard stools. Chronic fissures are those that persist for more than eight weeks and can be associated with underlying conditions such as inflammatory bowel disease or anal sphincter dysfunction. In your case, it appears that the initial cause was related to gastrointestinal issues, which have since resolved, but the fissure remains problematic.

Treatment Options
1. Conservative Management:
- Sitz Baths: Regular sitz baths can help soothe the area and promote healing. This is a common recommendation for managing discomfort associated with anal fissures.

- Topical Treatments: Non-steroidal topical agents, such as nitroglycerin ointment or calcium channel blockers, can help relax the anal sphincter and increase blood flow to the area, promoting healing. It’s good to hear that you are using non-steroidal suppositories to avoid the side effects associated with steroids.

- Dietary Modifications: Increasing fiber intake and ensuring adequate hydration can help produce softer stools, reducing the strain during bowel movements.

2. Surgical Options:
- Lateral Internal Sphincterotomy: This is a common surgical procedure for chronic anal fissures. It involves cutting a portion of the anal sphincter muscle to relieve tension and allow the fissure to heal. However, as you mentioned, if your sphincter is already lax, surgeons may be hesitant to perform this procedure due to the risk of incontinence.

- Fissurectomy: This involves removing the fissure and surrounding scar tissue, which may help in some cases, but it does not address the underlying sphincter tension.

- Botulinum Toxin Injection: This is a less invasive option where botulinum toxin is injected into the sphincter muscle to temporarily paralyze it, reducing spasms and allowing the fissure to heal.

Concerns Regarding Surgery
Your concern about the laxity of the anal sphincter and its implications for surgery is valid. Surgeons often assess the risk of incontinence when considering surgical options. If your sphincter is already relaxed, they may recommend conservative management instead of surgery. However, it is essential to have a thorough discussion with a colorectal surgeon who specializes in anal fissures. They can evaluate your specific situation and determine if you are a candidate for surgical intervention.

Long-Term Use of Suppositories
Regarding your question about the long-term use of non-steroidal suppositories, while they are generally safer than steroid-based treatments, prolonged use of any topical agent can potentially lead to local irritation or changes in the anal mucosa. It is crucial to monitor for any adverse effects and discuss them with your healthcare provider. Regular follow-ups can help ensure that your treatment plan remains effective and that any complications are addressed promptly.

Conclusion
Chronic anal fissures can be challenging to manage, and it is understandable that you are seeking a more definitive solution. While surgery may not be the first-line option due to your sphincter condition, exploring all available treatments with a specialist is essential. They can provide tailored advice and help you weigh the risks and benefits of each option. In the meantime, continue with conservative measures and maintain open communication with your healthcare team to optimize your management plan. Your quality of life is paramount, and there are pathways to relief and healing.

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