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Anal fissure surgery

Anal fissure surgery is usually carried out when other treatments such as diltiazem cream or botulinum toxin A injections have been unsuccessful. The procedure involves your surgeon making a small cut in the ring of muscle that holds your anus closed (internal sphincter muscle) to stop it from going into spasm.

You will meet the surgeon carrying out your procedure to discuss your care. It may differ from what is described here as it will be designed to meet your individual needs.

Anal fissure surgery is used to treat anal fissure. An anal fissure is a small tear or ulcer (open sore) in the skin around the opening of your anus. The fissure can cause a sharp, searing or burning pain in or around your anus, especially when you open your bowels. This pain can last for a couple of hours after a bowel movement and is severe.

The internal and external anal sphincters are muscles that control the opening and closing of your anus by relaxing and tensing. Both muscles need to relax for you to have a bowel movement. You can tense or relax your external anal sphincter, but not your internal anal sphincter. Because of the pain of a fissure, your internal anal sphincter may go into spasm. This can increase the pressure within your anus, and make it even harder to have a bowel movement as well as preventing the fissure from healing.

Making a cut in your internal anal sphincter muscle stops it from going into spasm. This means you strain less when you go to the toilet and because of this, less stress is put on the fissure, giving it time to heal.

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An image showing an anal fissure

Details

  • Preparation Preparing for anal fissure surgery

    Your surgeon will explain how to prepare for your operation. For example if you smoke you will be asked to stop, as smoking increases your risk of getting a chest and wound infection, which can slow your recovery.

    Anal fissure surgery is usually done as a day case. This means you have the procedure and go home the same day.

    The operation is usually done under general anaesthesia, which means you will be asleep during the operation. Alternatively, you may have the surgery under spinal or regional anaesthesia. This completely blocks pain from your waist down and you will stay awake during the operation. You may be given a sedative with regional anaesthesia, which relieves anxiety and helps you to relax.

    You will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. However, it’s important to follow your anaesthetist’s advice.

    Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen, and you can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent for the procedure to go ahead, which you may be asked to do by signing a consent form.

    Your nurse will prepare you for surgery. You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs. You may need to have an injection of an anticlotting medicine called heparin as well as, or instead of, wearing compression stockings.

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  • Alternatives What are the alternatives?

    Anal fissure surgery is usually only recommended when other treatments are considered unsuitable or haven’t been effective. There are medicines you can try including the use of botulinum A toxin injections to produce a ‘chemical sphincterotomy’. Your doctor or surgeon should have already discussed these options with you and offered them before recommending anal fissure surgery.

  • The procedure What happens during anal fissure surgery?

    There are several different surgical techniques available to treat anal fissures.

    Lateral internal sphincterotomy

    This procedure has the best healing rate and is the most widely used procedure for anal fissures. In this operation, your surgeon will make a small cut in your internal anal sphincter muscle to the length of the fissure.

    Fissurectomy

    In this procedure your anal fissure is removed completely, leaving an open wound to heal naturally. This surgery can be used alone, with lateral internal sphincterotomy, or with medicines such as glyceryl trinitrate or botulinum A toxin injections. You may need to have a fissurectomy if you have an anal fistula (a tunnel-like structure between the skin around your anus and rectum) as well as an anal fissure.

    Advancement flaps

    The advancement flap is a technique that involves replacing the broken tissue in the fissure with healthy tissue. This type of surgery is more complex and is usually only recommended when other surgical options have been unsuccessful.

  • Anal fissure treatment on demand

    You can access a range of our health and wellbeing services on a pay-as-you-go basis, including anal fissure treatment.

  • Aftercare What to expect afterwards

    You will need to rest until the effects of the anaesthetic have passed and you may need some pain relief to help with any discomfort.

    You will usually be able to go home when you feel ready but sometimes you may need to stay in hospital overnight.

    Your nurse will give you some advice about caring for your healing wounds before you go home. You may be given a date for a follow-up appointment.

    You will need to arrange for someone to drive you home. Try to have a friend or relative stay with you for the first 24 hours.

  • Recovery Recovering from anal fissure surgery

    If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. You shouldn’t take any medicines that contain codeine because they can cause constipation. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.

    General anaesthesia and sedation temporarily affects your co-ordination and reasoning skills, so you must not drive, drink alcohol, operate machinery or sign legal documents for 24 hours afterwards. If you’re in any doubt about driving, contact your motor insurer so that you’re aware of their recommendations, and always follow your surgeon’s advice.

    You will need to remove your wound dressing before having a bowel movement. Carefully wash and dry the area afterwards.

    It can take several months to make a full recovery from anal fissure surgery, but this varies between individuals, so it’s important to follow your surgeon’s advice.

  • Risks What are the risks?

    As with every procedure, there are some risks associated with anal fissure surgery. We have not included the chance of these happening as they are specific to you and differ for every person. Ask your surgeon to explain how these risks apply to you.

    Side-effects

    Side-effects are the unwanted but mostly temporary effects you may get after having the procedure. After anal fissure surgery, you will feel sore and may find it difficult to sit down comfortably until the wound heals fully.

    Complications

    Complications are when problems occur during or after the operation. Most people are not affected. Complications of anal fissure surgery include:

    • infection – this can usually be treated with antibiotics, but occasionally can progress into an anal abscess and need further surgery
    • anal fistula – this can be treated with surgery
    • damage to your anal sphincter muscles – this may affect your bowel control and can lead to incontinence
    • repeat fissure – it’s possible the fissure may come back after surgery

    Speak to your doctor if you need more information.

  • FAQs FAQs

    Will I feel any pain when I open my bowels after the operation?

    Answer

    Yes, you may feel sore for a few days, or longer, after the operation.

    Explanation

    After having anal fissure surgery, your anus will feel sore, especially when you go to the toilet. If you need pain relief, you can take over-the-counter painkillers such as paracetamol and ibuprofen. You shouldn’t take any medicines that contain codeine because they can cause constipation. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.

    You will need to carefully wash and dry the area after having a bowel movement to reduce your risk of infection. You may find it helpful to have a bath.

    You should eat a healthy diet rich in fibre, fruit and vegetables and drink plenty of fluids to prevent constipation. Your doctor may prescribe laxatives to make your faeces softer and easier to pass.

    What are my options if the anal fissure doesn't heal after having a lateral internal sphincterotomy?

    Answer

    Your surgeon may suggest having another operation using an alternative technique, such as a fissurectomy or anal advancement flap.

    Explanation

    A lateral internal sphincterotomy has the best healing rate and is the most widely used procedure for anal fissures. However, if the fissure fails to heal or reoccurs your surgeon may suggest repeating the operation or using an alternative technique to help the fissure heal. There are two alternative options.

    • Fissurectomy – the fissure is surgically removed and the wound is left to heal naturally.
    • Advancement flaps – the broken tissue in the fissure is replaced with healthy tissue.

    Ask your surgeon for information about alternative treatment options.

    Is there any reason why anal sphincterotomy shouldn't be performed in women?

    Answer

    Anal sphincterotomy isn’t recommended as the treatment of choice for women of childbearing age because it may increase the risk of being unable to control bowel movements.

    Explanation

    Women who suffer trauma during childbirth are particularly at risk of developing problems with bowel control. A potential complication of anal sphincterotomy includes damage to your anal sphincter muscle, which can lead to problems with bowel control. For this reason, anal sphincterotomy isn’t recommended as the treatment of choice for women of childbearing age.

    The advancement flap technique is a better option and offers considerable advantages for women of childbearing age. This procedure involves replacing the broken tissue in the fissure with healthy tissue. The operation may involve using a tissue graft taken from another part of your body or using nearby skin or tissue flaps.

    What increases my risk of having an anal fissure?

    Answer

    The most common cause of an anal fissure is constipation.

    Explanation

    An anal fissure is a small tear or ulcer (open sore) in the skin around the opening of your anus. Straining too hard during bowel movement can cause the skin to tear. Having a diet rich in fibre, fruit and vegetables and drinking enough fluids can help prevent constipation.

    Other risk factors for anal fissures include:

    • inflammatory bowel disease, such as Crohn's disease
    • HIV infection
    • recurrent or chronic diarrhoea
    • sexually transmitted infections
    • certain medicines (eg nicorandil)

    Speak to your doctor if any of these risks applies to you. Your doctor will discuss with you how to best manage your circumstances and reduce your risk of having an anal fissure.

    Does nicorandil cause anal fissures?

    Answer

    Yes, current evidence suggests nicorandil may increase your risk of having anal fissures.

    Explanation

    Nicorandil is a medicine used to control angina (chest pain). Angina occurs when your heart muscles don't receive enough oxygen. Nicorandil works by relaxing blood vessels and increasing the supply of blood and oxygen to the heart, while reducing its workload.

    Studies have shown that nicorandil causes mouth ulcers. Some have suggested nicorandil may cause ulceration or bleeding in your stomach or intestines, including anal ulceration. These types of ulcers are very rare, but they usually only get better if treatment with nicorandil is stopped.

    For this reason, if you're prescribed nicorandil it's important that you consult your doctor immediately if you have any sign of ulceration or bleeding from your stomach or intestine. Signs to look out for include:

    • bleeding from your back passage (rectum)
    • pain, irritation or itching in your rectum
    • vomiting blood, or passing black, blood-stained faeces
    • ulcers in your mouth or rectum

    You should never stop taking nicorandil without consulting your doctor. If it's decided that you should stop treatment with this medicine, this will be done under the supervision of your doctor. If you have had anal fissures in the past, you should let your doctor know prior to starting treatment with nicorandil, so alternatives can be considered.

  • Resources Resources

    Sources

    • Cross KLR, Massey EJD, Fowler AL, et al. The management of anal fissure: ACPGBI position statement. Colorectal Disease 2008; 10(3):1–7. doi:10.1111/j.1463-1318.2008.01681.x
    • Anal fissures and fistulas. eMedicine. www.emedicine.medscape.com, published June 2012
    • Anal fissure. BMJ Best Practice. www.bestpractice.bmj.com, published April 2012
    • Anal fissure. American Society of Colon & Rectal Surgeons. www.fascrs.org, published 2008
    • Wolff BG, Fleshman JW, Beck DE, et al. The ASCRS textbook of colon and rectal surgery. 1st ed. Springer; 2007
    • Anal fissure. The Merck Manuals. www.merckmanuals.com, published October 2007
    • Akbar F, Maw A, Bhowmick A. Anal ulceration induced by nicorandil. BMJ 2007; 335(7626):936–37. doi:10.1136/bmj.39246.714896.BE
    • Personal communication, Mr Mark Potter, Consultant General Surgeon, Spire Murrayfield Hospital Edinburgh, 22 November 2012
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  • Author information Author information

    Produced by Krysta Munford, Bupa Health Information Team, December 2012.

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