Anal Fissures: Surgical Options and Risks Explained

Anal fissure

Hello Doctor, recently I have been experiencing significant rectal bleeding (bright red) during bowel movements, not just a drop or two.
It is also painful during the process, and after finishing, I experience itching and pain that lasts for several hours.
Therefore, I went to see a doctor.
The doctor diagnosed me with anal fissures, which seem to be quite severe.
The doctor suggested that I should undergo surgery to cut the sphincter muscle, otherwise, it may not heal completely.
Should I consider having the surgery? After cutting the sphincter muscle, is there a possibility of causing anal incontinence or inability to contract the anal sphincter?

Yi, 20~29 year old female. Ask Date: 2006/12/05

Dr. Lin Minghui reply Gastroenterology and Hepatology

The symptoms of anal fissures include bleeding and pain during bowel movements, caused by hard stools passing through the anus.
Anal fissures can be classified as acute or chronic.
For acute cases, it is generally recommended that patients increase their fiber intake, drink plenty of water, avoid constipation, and keep their stools soft.
Soaking the anal area in warm water for 10-20 minutes can help relax the anal muscles.
Additionally, applying topical ointments may be beneficial.
Most individuals can achieve healing of 90% of acute anal fissures through non-surgical treatments.

If the fissure is chronic (lasting more than one month), it is important to investigate the underlying causes that prevent healing, such as inflammatory bowel disease or infections.
In cases where there is increased tension in the anal sphincter, such as internal anal sphincter hypertonicity or fibrosis, leading to pain and bleeding, surgical intervention to cut the internal anal sphincter may alleviate tension and promote healing of the fissure.
Surgery generally has minimal impact on normal bowel function.
For indications and potential complications of surgery, it is advisable to consult a colorectal surgeon.

Reply Date: 2006/12/05

More Info

Anal fissures are painful tears in the lining of the anal canal, often resulting from trauma during bowel movements, particularly when passing hard stools. They can lead to significant discomfort, bleeding, and itching, as you've described. The severity of your symptoms indicates that your fissure may be chronic, especially if it has persisted despite conservative treatments.

When it comes to surgical options for anal fissures, the most common procedure is lateral internal sphincterotomy. This involves cutting a portion of the internal anal sphincter muscle to relieve tension and promote healing of the fissure. While this procedure can be highly effective, it does come with potential risks and complications.

Risks of Surgery
1. Incontinence: One of the primary concerns with sphincterotomy is the risk of fecal incontinence. This occurs when the surgery weakens the anal sphincter, potentially leading to difficulties in controlling bowel movements. However, studies suggest that the risk of significant incontinence is relatively low, particularly when the procedure is performed by an experienced surgeon.

2. Recurrence: Although surgery can provide relief and promote healing, there is still a chance that the fissure may recur, especially if underlying factors such as constipation or diarrhea are not addressed.

3. Infection: As with any surgical procedure, there is a risk of infection at the surgical site.

4. Postoperative Pain: Some patients experience increased pain after the surgery, which usually resolves with time and appropriate pain management.

5. Changes in Sensation: Some patients report changes in sensation around the anal area post-surgery, which can be temporary or, in rare cases, permanent.

Non-Surgical Alternatives
Before proceeding with surgery, it is essential to consider non-surgical options, especially if your fissure is not chronic. These may include:
- Dietary Changes: Increasing fiber intake can help soften stools and reduce straining during bowel movements.

- Hydration: Drinking plenty of fluids can also aid in preventing constipation.

- Topical Treatments: Medications such as nitroglycerin ointment or calcium channel blockers can help relax the anal sphincter and promote healing.

- Sitz Baths: Soaking in warm water can relieve pain and promote blood flow to the area, aiding in healing.

Decision-Making
Ultimately, the decision to undergo surgery should be made after a thorough discussion with your healthcare provider. Considerations should include:
- The severity and duration of your symptoms.

- The effectiveness of conservative treatments you have already tried.

- Your overall health and any other medical conditions that may affect surgery and recovery.

If you decide to proceed with surgery, ensure that you choose a surgeon experienced in performing sphincterotomy, as their expertise can significantly impact the outcome and minimize risks.

In conclusion, while surgery can be an effective solution for chronic anal fissures, it is essential to weigh the potential benefits against the risks. Engaging in a detailed conversation with your healthcare provider will help you make an informed decision that aligns with your health needs and lifestyle.

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