An anal fissure is a split or tear in the lining of the lower rectum. It can cause pain or bleeding, usually with defecation. The pain typically occurs with or directly follows defecation, persists for several minutes to several hours and then subsides only to recur with the next bowel movement. In some cases the pain can be continuous and intensely severe.

In many cases fissure symptoms are erroneously attributed to hemorrhoids when in reality they are due to fissures. In patients with chronic rectal pain, the cause is more likely to be an anal fissure rather than hemorrhoids.

The precise cause of anal fissures is unknown. It is believed that trauma or injury following a hard bowel movement can cause a scratch, or a very large caliber bowel can cause the rectum to split, and these can result in an anal fissure. In most cases there are no predisposing causes.

Occasionally Crohn's disease, a condition that can cause colitis or ileitis, can predispose to the development of anal fissures. The diagnosis of an anal fissure can usually readily be made by spreading the buttocks in the posterior (back of rectum) or anterior (front of rectum) midline positions, revealing the fissure. Examination with an anoscope is sometimes necessary to visualize it.

Treatment
Most fissures will respond to non-operative treatment. This generally consists of topical medications agents that produce a soft stool to facilitate bowel movements, avoiding trauma to the fissure and improving the possibility of healing. These include stool softeners such as Colace (generic DSS, etc.) in a dose sufficient to produce stool softening. The dose generally varies from 2 to 6, 100 mg capsules a day. Occasionally up to 9 or 10 may be required.

Psyllium seed or related products such as Metamucil, Citrucel, Benefiber, or bran, when added to the diet can produce soft formed stools, thereby contributing to their beneficial effect on fissure healing. These products work very well alone or in conjunction with Colace to result in bowel movements that are not irritating to the fissure.

A non-hydrocortisone suppository is usually prescribed. There are several available on the market. We prefer an over-the-counter preparation, Calmol-4 . The purpose of the suppository is to melt and lubricate the lower rectum so that bowel movements are not irritating to the fissure and permit healing. In general, suppositories containing cortisone or derivatives of cortisone should be avoided because cortisone can interfere with wound healing.

Nitroglycerine or Diltiazem
For over 10 years 0.2% nitroglycerin ointment has been used attempt to facilitate fissure healing. Nitroglycerin has been found to be of very limited benefit for most patients with fissures. More recently Diltiazem or related compounds have been tried and appear to be more effective than nitroglycerin and has replaced nitroglycerin in treating fissures.

Botulinum Toxin
Botulinum toxin (Botox) has been recommended for anal fissures. We find the results with Botox to be unimpressive, temporary, and inconsistent. We can administer this treatment if you so desire; however, we feel an anal dilatation is usually preferable.

Surgery
Surgery is indicated in the following circumstances:

• The fissure fails to heal
• The fissure heals but recurs
• The fissure is causing severe, unremitting or otherwise intense pain
• The presence of a fistula or abscess with the fissure.

The presence of anal stenosis (narrowing or stricture), caused by recurrent fissures that tend to heal with scarring of the internal sphincter frequently results in a condition that requires operative intervention.

The surgical treatment of fissures is based on understanding the theoretical considerations involved in the perpetuation of an anal fissure. The internal sphincter forms the base of the anal fissure. The fissure causes the internal sphincter to go into spasm and this spasm interferes with blood supply to the fissure and thus interferes with its healing. Operative therapy is directed toward interrupting the cycle of sphincter irritation and sphincter spasm. There are two ways of accomplishing this.

The first is termed anal dilatation . In this (office) procedure, the patient is given intravenous sedation. Local anesthesia is then instituted by means of injections of a local anesthetic into the tissues around the rectum. Calibrated rectal dilators designed by Dr. Sohn are then placed in the rectum; gradually stretching the rectum to a calibrated diameter usually for 6 minutes. Occasionally an enlarged sentinel pile, a hemorrhoid forming external to the fissure or an enlarged anal papilla is present and these can be excised along with dilatation or sphincterotomy. There is usually little or no pain or bleeding following this procedure and normal activities can be resumed the day following the procedure.

Compared to the internal anal sphincterotomy, the dilatation is much less likely to interfere with continence. We have performed Precise, Calibrated Anal Sphincter Dilatations in well over 2,000 patients and in only 0.33% has there been some minor loss of flatus control and none in the last 1000 cases. Problems with flatus control usually respond to a program of sphincter exercises over a period of approximately 3 weeks. Permanent loss of the ability to control flatus or stool is rare with dilatations performed in this manner. Where we judge this incontinence risk to be increased (patients over age 60, particularly women, or the presence of anal narrowing), we use narrower dilators, virtually eliminating these risks.

Another operation for fissures is the internal anal sphincterotomy. In this procedure after the patient is sedated and local anesthesia is administered, the internal sphincter is incised (cut). Sphincterotomy results in disruption of the cycle of internal sphincter spasm and permits the fissure to heal.

Which procedure should be selected? Until approximately 1970, the standard operation for an anal fissure was anal dilatation. At that time the internal anal sphincterotomy was introduced and gained acceptance. This was felt to be less traumatic than the dilatations as they were customarily performed. In 1988 we were dissatisfied with the complications associated with sphincterotomy. When we studied this topic and the techniques for dilatation, we were amazed to find so many varied techniques. We learned that the term, dilatation , included at least 20 varieties. The literature tended to view dilatation as too risky, without defining the technique of dilatation used.

In 1988 we introduced the concept of a reproducible, reliable, precise, and consistent dilatation.. Our precise, calibrated, dilatation overcame the objections to the older and outmoded techniques of dilatation. This resulted in comparable results and far fewer complications than the sphincterotomy. An obvious advantage of dilatation is that there is no cutting of tissue. The effect on the fissure is rapid, there is no need for healing of a surgical wound, and a more rapid and smoother postoperative course occurs. There is virtually no postoperative incontinence as will be described later. The dilatation results in approximately a 90-95% fissure cure rate.

The internal anal sphincterotomy results in a reported cure rate of approximately 95%. However there are significant complications associated with this procedure. In contrast with simple dilatation, which has a 0.33% or 1 in 300 risk of flatus incontinence, sphincterotomy is associated with a 5%-10% or up to a 1 in 10 risk. Sphincterotomy is associated with a potential for permanent loss of control of flatus or more severe incontinence is increased with impaired continence reported in up to 63%. Other possible complications include infection at the sphincterotomy site with the development of an abscess, fistula, or nonhealed wound. These latter complications are not present with dilatations. A sphincterotomy can always be performed if the dilatation fails to produce the desired result. Consequently our experience, as well as other groups, with our Precise, Calibrated, Anal Sphincter Dilatation has shown it to be nearly as effective as the internal anal sphincterotomy and associated with far fewer complications

Complications
The fundamental step in an operation for anal fissure consists of disruption of the function of the internal sphincter. The most feared complication of surgery for an anal fissure is incontinence. This is defined as loss of the ability to control one's bowel movements or gas. Our approach to managing an anal fissure is first to attempt to cure it with nonoperative therapy. If that fails, we perform a 6-minute anal dilation. If the fissure persists a repeat dilation for 12 mintues is advised. If that fails, an internal anal sphincterotomy can be performed. The major complications associated with the surgery are persistence of the fissure with failure to heal or impaired continence. We strongly feel that, with few exceptions, the Precise, Calibrated, Anal Sphincter Dilation is the operation of choice for patients with anal fissures in whom operation is indicated.

Summary
We have prepared this information brochure to provide you with details regarding anal fissures and to encourage a dialogue between you and your doctor. Many of the decisions made in the care of patients with fissures are based on subjective information and an evaluation, by the doctor and the patient, of the potential risks and benefits. You are encouraged to discuss these further with your doctor.