Anal fissure is a common condition and, in simple terms, is an unhealed cut or split in the delicate skin of the anus. In almost all cases affects the mid-line at the back of the bottom passage.

It commonly causes pain on and after passing a bowel motion. Frequently some bleeding occurs immediately after having a motion. Occasionally it may cause itching and discharge.

2. What causes it?

Sometimes, but not always, constipation starts it. Generally, there is history of trauma in the anus. When a fissure is present the muscles that surround the anus [sphincters, internal and external] go into spasm or become tight. This continuous spasm increases the pressure within the anus and prevents the fissure from healing.

3. How can it be treated?

.  Conservatively. Some fissures [especially the acute ones] can be healed by simple dietary measures, especially if there is significant constipation. It is very important that a high dietary fibre intake is ensured in the form of green vegetables, fruit and bran containing foods [ie. All Bran, Bran flakes etc.] The use of stool softeners and fibre supplements [Fybogel, Regulan, lactulose] is also beneficial. In addition, warm sitz baths and the regular application of an anaesthetic ointment [lignocaine] 2-3 times per day onto and inside the anus will help.

.   Topical GTN therapy. GTN is an agent that relaxes the muscles around the anus [sphincters] and reduces the resting anal pressure which is abnormally high. GTN 0.2% in paraffin is applied to the perianal skin 3-4 times per day for a period of 4-6 weeks. At the end of this time about 70% of fissures will have healed. However, there is a significant recurrence rate [the fissure coming back] but the treatment can be used again. A possible side effect of GTN is headache. If this occurs and is a problem, you should reduce the number of times you use GTN per day. If this also fails then you may have to stop the treatment.

. Surgically [lateral sphincterotomy]. Surgery is reserved for chronic fissures that failed to heal, fissures that have recurred and when alternative treatments have failed. The aim of surgery is to reduce the spasm in the inner of the two sphincters by cutting it, to allow the fissure to heal. Do not worry, although part of the inner sphincter is cut, control of the bowel motions is not affected if control was normal before the operation. About 90-95% of fissures will heal with this operation. 5-10% will fail to heal and may need a further operation in the future.

Your Anal Fissure Operation

1. Before your operation

Lateral sphincterotomy is usually performed as a day case. Day case surgery means that you come to the hospital the day you are to be operated and after surgery, when you recover from anaesthesia [3-4 hours] your escort will take you home, with all instructions given to you before [by the surgeon] and after surgery [by the nursing staff].

2. Coming into hospital

You will be asked to come in or the morning of your operation without drinking anything after midnight. Please bring with you all the medicines you are taking to show to the doctor. A nurse will receive you in the ward, who will note your personal details and ask about any other conditions you suffer from. The surgeon who is to perform your operation, and the doctor who will give you anaesthesia will also visit by. Many people are concerned about anaesthetics, so please ask the anaesthetist if you have any specific worries so that he may reassure you. All of these people are ready to answer any questions that you may have, so please ask.

You will be asked to sign a consent form that the procedure has been explained to you and you agree to go ahead.

3. The operation

This is performed under general anaesthesia.

Surgery involves cutting of part of the inner anal sphincter through a small  [1-2cm] incision at the side of the anus. It is not necessary for the fissure to be cut out, however, if there is any loose skin next to the fissure [skin tag] this will be removed also. In addition, inspection of your bottom passage with a small telescope [proctoscopy, sigmoidoscopy]is carried out as well.

4. After the operation

.  There may be some bleeding and discharge for some days after the operation. It stops with regular bathing in a shower or bath.

.   It is very important that you do not get constipated. As part of the healing process you will be given lactulose or Fybogel which should be taken regularly for at least a month after the operation.

.  You may still experience some pain and bleeding for the first month after surgery. Remember, the fissure is not removed by this operation and takes on average 6-8 weeks to heal.

.   You will be seen in the outpatients’ clinic 8 weeks after the procedure.

.  Temporary difficulty with control of passage of wind from the anus occurs in about 20% of cases but returns to normal after 3 months. If you have ever had poor control or bowel incontinence inform the surgeon.