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Anal fissure surgery
Published by Bupa's health information team, August 2008.
This factsheet is for people who are planning to have anal fissure surgery called anal sphincterotomy, or who would like information about it.
An anal fissure is a small tear in the skin around the opening of your anus. An anal sphincterotomy procedure involves making a cut in the anal sphincter muscles (the ring-like band of muscle that opens or closes the anus).
Your care will be adapted to meet your individual needs and may differ from what is described here. So it's important that you follow your surgeon's advice.
About anal fissure
An anal fissure is a small tear in the skin around the opening of your anus. During bowel movement the tear causes a sharp, searing or burning pain in or around your anus.
The pain makes your anal sphincter muscle go into spasm (tenses of its own accord) making the anal fissure more painful. The pain can last for up to an hour after each bowel movement.
You may also notice a streak of bright red blood on the toilet paper or drops of blood in the toilet bowl after each bowel movement.
The anus with an anal fissure
Diagnosis of anal fissure
Anal fissure is usually diagnosed by physical examination of the anus. Your GP will ask about your symptoms and may refer you to a colorectal surgeon to confirm diagnosis. The examination is usually done under anaesthetic to minimise discomfort.
What are the alternatives?
The initial treatment is with topical medicines to help relax the sphincter muscle. These include glyceryl trinitrate and calcium channel blocking agents. Your GP may also suggest eating plenty of fruit and vegetables, and drinking lots of fluid to make your faeces softer, and may prescribe mild laxatives.
Your surgeon may suggest you have botulinum A toxin injected into the internal sphincter muscle to help it relax. This is usually done under anaesthesia and the treatment effects last about five months.
Surgery is usually only recommended if medicines or botulinum A toxin injections don't help.
Preparing for your operation
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.
Your bowel has to be completely empty before the operation. To achieve this, you will need to follow a special diet for a day or two and you may be given laxatives to take the day before surgery.
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 procedure. Alternatively you may prefer to have the surgery under spinal or regional anaesthesia. This completely blocks feeling from waist down and you stay awake. A sedative may be given with a spinal or regional anaesthesia to help you relax.
Your surgeon will advise which type of anaesthesia is most suitable for you.
If you are having a general anaesthetic, you will be asked to follow fasting instructions. Typically, you must not eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow occasional sips of water until two hours beforehand.
At the hospital your nurse may check your heart rate and blood pressure, and test your urine. You may be given a bowel washout (an enema). A tube is passed into your rectum and the remaining contents of your bowel are flushed out using water.
Your surgeon will usually ask you to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.
Your nurse will prepare you for theatre. You may also be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs.
About the operation
An anal sphincterotomy procedure involves making a cut in the anal sphincter muscles to stop 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.
The cut is made into the sphincter muscle using a surgical blade. A pad dressing is put into your anus to help stop bleeding.
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. If you are prescribed antibiotics it's important you finish the course. Your nurse will give you some advice about caring for your healing wounds and a date for a follow-up appointment.
You will need to arrange for someone to drive you home. You should try to have a friend or relative stay with you for the first 24 hours.
Recovering from anal fissure surgery
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 temporarily affects your co-ordination and reasoning skills, so you must not drive, drink alcohol, operate machinery or sign legal documents for 48 hours afterwards. If you are in any doubt about driving, please contact your motor insurer so that you are 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. You may be advised to have a bath or shower before your district nurse's visit. It may help to take a painkiller an hour beforehand, as having your dressing replaced can be uncomfortable. The wound usually only leaks mildly but you may find it helpful to wear a sanitary pad for the first few days.
You will need to remove the wound dressing before having a bowel movement. Carefully wash and dry the area afterwards.
The fissure can take several months to heal.
What are the risks?
Anal sphincterotomy is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.
These are the unwanted but mostly temporary effects of a successful treatment, for example feeling sick as a result of the general anaesthetic.
You will feel sore and find it difficult to sit down during the first week.
This is when problems occur during or after the operation. Most people are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).
Complications specific to anal fissure surgery are listed here.
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 faecal incontinence (although this is extremely rare).
Urgency and reduced ability to hold - you may find that you need to get to the toilet more quickly to open your bowels than you did before.
Repeat fissure - it's possible the fissure may re-occur.
The exact risks are specific to you and differ for every person, so we have not included statistics here. Ask your surgeon to explain how these risks apply to you.
Anal fissure surgery Q&As
See our answers to common questions about anal fissure surgery, including:
- Nelson RL. Treatment of anal fissure. BMJ 2003; 327:354-355
- Collin EE, Lund JN. A review of chronic anal fissure management. Tech Coloproctol 2007; 11:209-223
- Ayantunde AA, Debrah SA. Current concepts in anal fissures. World J Surg 2006; 30:2246-2260
- Morris PJ, Malt RA (eds). Oxford Textbook of Surgery. New York: Oxford University Press, 1994: 1139-1141
- Nelson R. Operative procedures for fissure in ano. Cochrane Database of Systematic Reviews, 2005.
This information was published by Bupa's health information team and is based on reputable sources of medical evidence. It has been peer reviewed by Mr William Garrett, MBBS, BSc, FRCS, FRCS(Gen Surg), Consultant Colorectal Surgeon, and by Bupa doctors. The content is intended for general information only and does not replace the need for personal advice from a qualified health professional.
Publication date: August 2008.