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ANAL FISSURES
At a glance
An anal fissure is a small tear in the thin, moist tissue that lines the anus. Anal fissures are commonly caused by straining during bowel movements, constipation, chronic diarrhoea and after childbirth. The majority of acute anal fissures generally resolve through non-operative management, which includes topical ointment, stool softeners and dietary modifications. Those that do not respond can develop into chronic anal fissures.
The pathophysiology of chronic anal fissures involves spasms of the internal anal sphincter as a response to pain. This results in reduced blood flow and oxygenation of tissues and, therefore, non-healing.
In this case, the surgical options include:
- Tailored lateral internal sphincterotomy (LIS): This involves cutting the internal anal sphincter fibres to the length of the fissure. This type of sphincter surgery is done to relieve the spasm in the sphincter muscle, alleviating the pain and promoting healing of the anal fissure.
- Alternatively, an injection of Botox has become popular as it is safe, quick and easy to perform with a lower incidence of post-operative faecal incontinence. Dr Maraj commonly performs the injection of Botox for the treatment of chronic anal fissures.
How to prepare for the procedure
Diagnosing an anal fissure is generally simple as the tear is usually visible. It requires only a gentle inspection of the anal region to notice.
If it is too painful to examine the perineum during your consultation, you will require an examination under anaesthesia in theatre. If surgery is deemed appropriate, you will be instructed how to prepare for your surgery, which may be either lateral internal sphincterotomy or injection of Botox. Dr Maraj will advise that you stop eating and drinking 6 hours before your procedure. To ensure your bowels are empty, she will also ask that you empty your colon with an enema or laxative. Both procedures are performed in theatre under general anaesthesia, and you may need to stay in the hospital overnight for observation.
What does a tailored lateral internal sphincterotomy involve
The goal of anal fissure surgery is to relieve symptoms of pain and discomfort by healing the torn lining. Under general anaesthesia, Dr Maraj will make a small incision in the internal anal sphincter; the cut is tailored to the length of the anal fissure. This will release tension and allow the fissure to heal. The incision may be left open to heal naturally. Dressings may be applied.
What does injections of botox involve?
This involves the injection of Botox into the sphincter to relieve this spasm. This will release tension and allow the anal fissure to heal. The reported success rate is 70%, and repeat injections may be indicated.
What to expect post-procedure
You may need to stay in the hospital overnight for observation after the surgery. It is normal to notice some blood on the toilet paper after a bowel movement for the first few weeks. While patients may report that bowel movement after surgery may be painful, and this may be the case, the pain is usually less than it was before the surgery. Symptoms of the anal fissure should disappear within a few days to weeks after the procedure.
You will be discharged on a regimen of stool softeners, analgesia, sitz baths and dietary modifications. After surgery, you can expect a temporary inability to control gas and mild faecal leakage, but recovery can be expected in about six weeks. You should be able to resume your normal lifestyle within two weeks.
As this is merely a guide providing a basic understanding of the surgery, Dr Maraj will be able to answer any further questions should you have any.
Risks & complications
Guidelines and protocols are followed to prevent complications; however, there are risks to any surgery. The complications involved with anal fissure surgery include bleeding, pain, urinary retention, constipation, fistula development, incontinence and infection. To prevent this, you will be monitored closely for signs of these complications, and if need be, you may require hospitalisation for treatment thereof.
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