Chronic Anal Fissures: Treatment Options and Surgical Insights

Chronic anal fissure-related issues?

Hello Dr.
Ke: A month ago, I inquired and returned for a follow-up with the doctor.
The situation is that I have applied two different ointments.
The first one is Yizhi Kang, which causes itching when applied to the anal area, so I had to stop using it.
The second one is Xiyu Zhi; since the wound is located at the 7 o'clock position on the right side, very close to the outside (I can't feel it when I touch the outer skin), applying Xiyu Zhi gives a cooling sensation from the menthol, and it creates a strong urge to defecate.
After enduring that, the pain subsides, but the skin starts to feel tight and uncomfortable, so I had to stop using it as well.
During the follow-up, the doctor said that if the ointments are uncomfortable, I can stop using them, and also mentioned that using suppositories for several months is not advisable since they have lost their effectiveness.
Walking causes slight pain at the wound, and lying flat causes discomfort when pressure is applied to the buttocks, so I can only lie on my side.

I usually go to the bathroom twice a day, and if I want to go only once, I have to eat less, which creates a conflict between eating and bowel movements.
I visited a private clinic that charges out-of-pocket, where they provided a particularly cooling ointment.
The clinic claimed that this type of treatment helps with hemorrhoid swelling and can also treat anal fissures and promote healing.
However, I found the cooling ointment to be extremely painful.
Is it possible that continued use of a cooling ointment could worsen the wound? Or can it still stimulate the wound to heal? Adjusting my diet to have slightly more liquid stools seems to reduce the pain compared to softer stools, but after a sitz bath, the discomfort remains.
Although I can tolerate it, I find it hard to concentrate.
Ideally, stools should be soft, but the pain is more pronounced this way.
If surgery is necessary, since the wound is very close to the outside (about 1 cm), will the surrounding skin also need to be excised? Last time, it was mentioned that surgery typically does not involve suturing, and there is no need for dressing changes.
I have seen others say that their surgical wounds took a month to heal, so I have to use sanitary pads all day.
Post-operative bowel movements can be very painful (it may take a week or two for the pain to lessen), while others say that post-surgery, the pain is significantly reduced.
Why is there such a large discrepancy? It feels like there are wounds both internally and externally after surgery.
If the surgery damages the outer skin, would I need to apply ointment as well? Besides cutting the internal sphincter, are there other methods available? For instance, are there any repair techniques?
Will I need to take laxatives before surgery, similar to a colonoscopy? How much of the internal sphincter needs to be cut? I have seen a type of surgery referred to as "closed" surgery, which is performed between the internal and external sphincters; I wonder if it operates on the same principle? Is that why there is also an external wound? If minimally invasive surgery is performed, does that mean it will be less painful or result in smaller wounds? Thank you!

TED, 50~59 year old female. Ask Date: 2023/06/03

Dr. Ke Fangxu reply Surgery

1.
It is personally not recommended to apply irritating ointments, as I have not heard of any evidence suggesting that irritating a wound can aid in healing.

2.
If only a sphincterotomy is performed, then the skin will not be excised.

3.
A sphincterotomy involves making a small incision at the anal opening to cut the internal sphincter, which is located between the internal and external sphincters; without an opening, how can the internal sphincter be cut?
4.
The incision from a fissure surgery is typically only 3-5 mm in size, as there is no minimally invasive sphincterotomy procedure.

Reply Date: 2023/06/03

More Info

Chronic anal fissures are a common condition that can cause significant discomfort and impact quality of life. They are often characterized by pain during bowel movements, bleeding, and a sensation of tearing or burning in the anal area. Understanding the treatment options and surgical insights for chronic anal fissures is crucial for effective management.

Treatment Options
1. Conservative Management: Initially, conservative treatments are recommended. This includes dietary modifications to ensure softer stools, such as increasing fiber intake and hydration. Stool softeners may also be prescribed to ease bowel movements. Warm sitz baths can provide relief and promote healing by increasing blood flow to the area.

2. Topical Medications: Various topical treatments can be used to alleviate symptoms and promote healing. Common options include:
- Nitroglycerin ointment: This helps to relax the anal sphincter, increasing blood flow to the fissure and promoting healing.

- Calcium channel blockers: Topical agents like diltiazem can also be effective in relaxing the sphincter muscle.

- Botulinum toxin (Botox): Injections can temporarily paralyze the anal sphincter, reducing spasm and pain, allowing the fissure to heal.

3. Surgical Options: If conservative treatments fail, surgical intervention may be necessary. The most common surgical procedure for chronic anal fissures is lateral internal sphincterotomy. This involves cutting a portion of the internal anal sphincter to relieve tension and pain, promoting healing of the fissure.
- Surgical Considerations:
- Extent of Surgery: The surgery typically does not involve removing skin around the fissure unless there is significant scarring or other complications. The goal is to minimize damage to surrounding tissues.

- Healing Process: Post-surgery, patients may experience discomfort, but many report significant pain relief after a few weeks. The healing time can vary, and while some may heal quickly, others may take longer, especially if there are complications or if the fissure has been chronic.

- Postoperative Care: After surgery, maintaining soft stools is crucial to prevent recurrence. Patients are often advised to continue sitz baths and may need to use topical medications for comfort.

4. Minimally Invasive Techniques: There are newer techniques, such as the use of laser therapy or other minimally invasive procedures, which aim to reduce pain and recovery time. These methods may involve less tissue damage and quicker healing, but their availability and effectiveness can vary.

Concerns About Surgery
- Skin Involvement: If the fissure is very close to the external skin, there may be some risk of involving the surrounding skin during surgery. However, surgeons aim to preserve as much healthy tissue as possible.

- Postoperative Pain: Pain after surgery can vary widely among patients. Some may experience immediate relief, while others may have discomfort for a longer period. Factors influencing this include the extent of the fissure, the surgical technique used, and individual pain tolerance.

- Need for Further Treatment: In some cases, additional treatments may be necessary if the fissure does not heal adequately or if new fissures develop.

Conclusion
In summary, chronic anal fissures can be effectively managed through a combination of conservative treatments and surgical options. It is essential to have an open discussion with your healthcare provider about the best approach for your specific situation, including the potential risks and benefits of surgery. If surgery is considered, understanding the procedure, recovery expectations, and postoperative care will help in making an informed decision. Always consult with a qualified healthcare professional to tailor the treatment plan to your individual needs and circumstances.

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