ANAL FISSURE TREATMENT

ANAL FISSURE TREATMENT

How is anal fissure treated?

The aims of treatment are two-fold. The first aim is to heal the fissure and the second aim is to identify and treat the underlying cause.

Healing the fissure

A patient is usually prescribed a combination of stool softeners/ laxative, oral painkillers and anal ointment to facilitate easier bowel movement and avoid aggravating the fissure. A topical medication, such as glycerin trinitrate, can be used to aid healing. If the anal fissure persists despite the prescribed treatment, a course of Botox® (botulinum toxin) may be used to relax the anal sphincter muscles temporarily to aid healing.

If a fissure has become chronic, surgery may be necessary. It is important to remember that more than 90% of anal fissures will heal without requiring surgery.

Treating the underlying cause

Once a specific underlying cause is identified, it must be addressed otherwise the anal fissure will recur. The treatment of each cause is individualized.

If the patient suffers from constipation, this must be treated concurrently with the prescribed treatment to heal the fissure. Dietary advice and good toilet habits are essential. This is to prevent recurrence of the anal fissure. Similarly, if the patient is suffering from diarrhoea, it must be controlled. Patients suffering from inflammatory bowel diseases must have treatment to control their condition otherwise the anal fissure will not heal.

Do I need any tests before surgery?

Your doctor may request for some tests before surgery if there is a suspicion that there is an underlying medical problem. This may involve gastrointestinal endoscopy and anorectal physiology studies. Endoscopy is used to rule out medical conditions affecting various parts of the bowel including the stomach, small intestine and colon. Anorectal physiology studies are warranted if there is a dis-coordinated bowel movement pattern which can be corrected by physiotherapy.

Surgery for anal fissure

If an anal fissure persists despite medication, surgery is aimed at reducing the anal muscle pressure to improve blood circulation to the fissure. Very often, there is persistently raised anal muscle pressure due to muscle spasm. This procedure is termed “lateral internal anal sphincterotomy”.

The procedure is performed under light general anaesthesia or lower body anaesthesia as a day surgery procedure. The surgeon cuts a small portion of the lower internal anal sphincter (without risking anal incontinence) and that should allow the anal fissure to heal spontaneously.Recurrence of anal fissure after surgery is rare (less than 10%).

In cases of recurrent anal fissure after previous surgery, a surgeon may have to perform an “advancement flap” surgery to cover the affected fissure with healthy tissue.

What do I need to look out for after surgery?

The patient will have minimal pain even on passing motion. There is a small wound at the edge of the anus after surgery. There may be a small amount of blood stained discharge from the wound for a few days and the wound heals over in 1-2 weeks. Any stitches used are non-permanent and dissolve spontaneously.

Some potential complications to watch out for include wound infection, wound bleeding and anal incontinence. The likelihood of any complication is low.

A wound infection can occur if blood collects under the stitches in the wound and get infected during bowel movement. If that happens, you will need drainage of the infection and antibiotics. Rarely, a small blood vessel that had sealed during surgery re-opens a few days later and bleeds. You may need to have stitching of the vessel if the bleeding does not stop with pressure dressing. Neither of these complications are life-threatening.

Losing control of bowel movement is a nightmare to both patient and surgeon. Even though the risk is very small, it is difficult to treat once it occurs. That is why surgery is only offered if medical treatment fails.

How do I prevent recurrence of anal fissures?

If an underlying medical condition is identified, it is important to get it treated to prevent recurrence of anal fissure. For patients who develop anal fissures due to chemotherapy, it is unlikely to recur after chemotherapy is completed.

If there is an abnormal bowel movement pattern diagnosed, this should be corrected to prevent recurrence of anal fissure as well as other related problems. This can be done through a combionation of medication, dietary advice and pelvic floor physiotherapy (if needed).