Colon and Rectal Surgeons
of Kansas City

Anal Fissure

Anal fissures are an extremely common problem and in fact represent the most common cause of rectal pain and bleeding in the adult population. Usually anal fissures will heal very rapidly within 24-48 hours given normal bowel movements. The anal canal is similar to the lining of the mouth or gums and will heal quickly if given the opportunity. Anal fissures are usually caused by constipation or diarrhea, but occasionally will occur with normal bowel movements.

Seventy-five percent of anal fissures that last over one week will eventually resolve with aggressive medical management including bulk forming agents such as Konsyl and topical creams and ointments (2.5% Analpram). Hot baths and the application of heat are very important for the healing process. Sitting on a heating pad even if there is no pain will significantly help. If bowel movements continue to be hard the addition of a small amount (1-2 tablespoons) of Milk of Magnesia will soften the stools.

Occasionally anal fissures will not heal and become a chronic problem. This is mainly secondary to spasm of an involuntary muscle (the internal sphincter). The spasm produces the majority of the discomfort and cuts off the deep blood supply to the fissure thereby impairing the healing process. Brittle scar tissue will form over the fissure and the passage of bowel movements will tear the brittle scar tissue causing pain and subsequent muscular spasm. Occasionally 0.2% nitroglycerin can be applied to the fissure and can sometimes improve healing; however this could occasionally cause side effects such as dizziness and headache.

For those that continue to have symptoms despite aggressive medical treatment, a minor outpatient surgical procedure is usually extremely effective and curative. The operation is called a partial internal sphincterotomy. This procedure takes approximately 15 minutes  and has a 98% success rate. Complications are very few and bowel movements should be improved immediately. Expect a minor amount of spotting of blood and discharge for approximately 2-3 weeks. There is a 2-3 % chance of infection which may necessitate a minor surgical procedure to drain and resolve the infection, however this is quite uncommon. There have never been problems with control of bowel movements in this practice, although it is reported in the surgical literature. The external sphincter musculature and pelvic levator floor are the main control muscles and they would not be touched with this procedure.

After surgery, hot baths would be recommended as frequently as possible. Continue the high fiber diet. A topical anesthetic such as Xylocaine may be used if desired. Avoid constipation or diarrhea by continuing to take bulk forming agents.

By partially cutting the internal sphincter musculature just to the level of the furthest portion of the anal fissure or anal ulcer, blood supply will be allowed to heal the fissure. This will also avoid spasm and pain. It would be advisable to irrigate the bottom area after bowel movements in a shower. Otherwise the wound should be kept as dry as possible by placing an unwrapped gauze pad next to the wound during the day and at bedtime. Expect occasional spotting of blood and mucous drainage until the wound completely heals.

For more information please visit:
The American Board of Colon and Rectal Surgeons
http://www.fascrs.org