Anal fissure surgery

Published by Bupa’s Health Information Team, November 2010.

This factsheet is for people who are having surgery to treat an anal fissure, or who would like information about it.

Anal fissure surgery usually involves making a cut in the ring of muscle that holds the 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.

About anal fissure surgery

Anal fissure surgery is used to treat anal fissures. An anal fissure is a small tear or ulcer (open sore) in the skin around the opening of the anus. The fissure causes 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 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.

Making a cut in the internal 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.

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 to produce a ‘chemical sphincterotomy’. Your doctor or surgeon should have already discussed these options with you and offered them to you before recommending anal fissure surgery.

Alternative treatments include the following.

• Medicines to help relax the sphincter muscle, such as local anaesthetic, glyceryl trinitrate and calcium channel blocking agents.
  
• Laxatives to make faeces softer and easier to pass.
  
• Botulinum A toxin injected into the internal sphincter muscle to help it relax.
  

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. This means you will be asleep during the operation. Alternatively, you may have the surgery under spinal or regional anaesthesia. This completely blocks pain from waist down and you will stay awake during the operation. A sedative may be given with regional anaesthesia. This 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 theatre. 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.

What happens during anal fissure surgery

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

Lateral internal sphincterotomy

A lateral internal sphincterotomy 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 the internal sphincter muscle to the length of the fissure. A pad dressing will be put into your anus to help stop any bleeding.

Fissurectomy

The anal fissure is removed completely leaving an open wound to heal naturally. The procedure can be used alone or with lateral internal sphincterotomy or medicines such as glyceryl trinitrate or botulinum A toxin injections. Fissurectomy is often used for the treatment of anal fissure in children to prevent permanent damage to the internal sphincter muscles.

Advancement flaps

The advancement flap is a technique that involves replacing the broken tissue in the fissure with healthy tissue. This type of procedure is recommended if you’re at risk of being unable to control your gas and bowel movements (faecal incontinence).

What to expect afterwards

You will need to rest until the effects of the anaesthetic have passed. You may need pain relief to help with any discomfort as the anaesthetic wears off.

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

You may need to have the wound dressed daily until it fully heals. Your nurse may arrange for a district nurse from your GP surgery to visit you at home.

You may be prescribed a course of antibiotics and laxatives. 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.

Recovering from anal fissure surgery

If you have been prescribed antibiotics, it’s important to complete the whole course.

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

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.

The district nurse will visit you, if required, to change your wound dressing and to check that the wound is healing properly. It may help to take a painkiller an hour beforehand because having your dressing replaced can be uncomfortable.

You will need to remove the 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.

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 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 progress into an anal abscess and require further surgery
  
• damage to anal sphincter muscles – this may affect your bowel control and can lead to incontinence
  
• repeat fissure – it’s possible the fissure may re-occur

For answers to frequently asked questions on this topic, see Common questions.

For sources and links to further information, see Resources.