ANAL FISSURE

DIAGNOSIS
What is an anal fissure?
An anal fissure is a tear in the lining of the anal canal. It is caused by trauma to the anal canal such as a large hard bowel movement or diarrhea causing a chemical injury.
What are the symptoms of anal fissure?
Severe anal pain that is worse with a bowel movement. The pain is often described as being similar to a cut, sandpaper, glass, burning, or knife like pain in the anal canal. There is often a little blood on the toilet paper when wiping after a bowel movement. Sometimes there is a small lump of tissue on the outside of the anus that is confused for a hemorrhoid. Patients often avoid defecation because of the pain.
How is an anal fissure diagnosed?
A simple office examination by your physician is all that is needed to make the diagnosis. Gentle separation of the buttocks and inspection of the anal canal reveals the tear in the posterior midline (90%) of the time and in the anterior midline (10%) infrequently. Sometimes there is too much pain with the examination in the office and an examination under anesthesia in the operating room is required.

Why doesn’t the fissure heal?
Anal fissures occur in the posterior and anterior midline of the anal canal. These locations have a poor blood supply and unfortunately a good blood supply is essential for healing. Moreover, the fissure causes anal pain and spasm of the anal canal muscles which further impairs blood supply and prevents healing. Constipation and withholding of bowel movements (due to fear from pain) results in repetitive injury when a hard BM is passed.

Medical Treatment

Prevention of constipation
The single most important aspect of treatment for an anal fissure is the prevention of constipation. You need to take a fiber supplement such as Benefiber, Metamucil, Citrucel, or Konsyl. We recommend:
1. One tablespoon of any of these in 8 ounces of water or juice twice daily. 2. Please drink 8 glasses of water daily. 3. Eat a diet high in fiber including fruits and vegetables (30 grams/day)
Warm soaks in a bath tub
Sit in a bath with warm water four times daily for ten minutes. This will help relax the anal canal.
Medicated ointments
Several medicated ointments help relax the anal canal muscles. The ointment helps improve blood flow to the anal canal and thereby promotes healing of the fissure. Place a small amount of the ointment on your finger and rub it directly into the anal canal three times a day for at least 8 weeks.

1. Nifedipine 0.4% This is a special compounded medication that only comes from certain pharmacies.  This can be verified prior to writing the prescription.

2. Nitroglycerin 0.4% This is more readily available as most pharmacies can make this medication, however it often causes a self-limited  (20 minute) headache.

SURGICAL TREATMENT
How often does a fissure heal with medical treatment?
Anal fissures are either acute or chronic.
1. Acute anal fissures heal with medical management 90% of the time.

2. Chronic anal fissures heal 60% of the time with medical management.

What surgical procedure is performed? A lateral internal sphincterotomy is the operation for an anal fissure. This is performed in the operating room with general anesthesia or local anesthesia with sedation.
1. It is an outpatient procedure.

2. Your surgeon will divide a small portion of the internal anal sphincter for the length of the fissure. 3. This breaks the spasm in the anal canal and allows for better blood flow and consequently relief of the pain and usually (90%) healing of the fissure.
Potential complications of the surgery

3. Incontinence: There is a 15% chance of incontinence to flatus with the surgery. There is also increased fecal urgency with diarrhea. Incontinence to solid stool is <1%.

4. Recurrence: There is a 10-20% chance of recurrence. The best way to prevent recurrence is to take a daily fiber supplement and drink plenty of water.

5. Infection: There is a small chance (<5%) of  an abscess or fistula at the surgical site.

6. Non Healing: The pain almost always resolves with sphincterotomy but sometimes the fissure and the bleeding can persist (5%).