An anal fissure is a painful crack in the anal skin. This is usually caused by having a hard, constipated stool or a diarrheal stool. Patients with an anal fissure think they have "hemorrhoids" but actually hemorrhoids present with painless bleeding and a protruding mass. An anal fissure causes severe pain and spasm (a tight feeling) after a bowel movement. Occasionally spotting of blood is noted. If an anal fissure has been present for over 6 weeks or if symptoms have recurred frequently over a long time, it is considered to be a Chronic Anal Fissure. Such a fissure will never heal without surgery.

Treatment of Acute Anal Fissure - Most anal fissures occur because of a traumatic bowel movement (too hard or too loose/frequent). This acute fissure usually heals with a stool bulking agent (Metamucil or Citrucel), increasing water and fluid intake, hot baths (to relax the anal spasm), and local anal ointment (to anesthetize and sooth the raw area). If this acute anal fissure does not heal after 6 weeks, then surgery is usually necessary. Occasionally, using Nitroglycerine ointment (which relaxes the internal anal sphincter) will heal the fissure. However, this treatment may cause headaches and is successful in only about 20 to 30% of patients.

Other non-surgical treatments can be tried such as using BOTOX. Enthusiasts report good success rates but studies in the literature involve small numbers so making conclusion about effectiveness of BOTOX is difficult. The treatment is expensive and can cause transient incontinence.

Treatment of Chronic Anal Fissure- Lateral Internal Sphincterotomy and Fissurectomy (cut away fissure).
Internal sphincterotomy - partial cutting of the abnormal, spastic internal sphincter which allows the anus to relax and open up to accommodate the bowel movement. This allows the fissure to heal 95 to 99% of the time.

Preparation is done with a Fleet enema on the night before surgery and again 1-2 hours before coming to hospital.
Surgery is under local anesthetic with intravenous sedatives - which results in less nausea and faster recovery. A general anesthetic is not necessary.
Same day surgery - you do not have to be admitted to the hospital.
Time off work - 4 days to 1 week
95 to 99% success - 1% recurrence

Complications
1 % bleeding which may need more surgery to stop
1 % infection
5 % temporary urinary retention needing a bladder catheter
1 to 5 % minor seepage due to loss of control

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