Anal fissure: when surgery is recommended and what recovery involves

An anal fissure (fissure-in-ano) is a small lengthwise tear in the skin at the entrance to the anal canal. It is most often at the back of the anal opening, towards the tailbone. It usually develops after passing a hard stool and straining hard, and sometimes after frequent diarrhoea or childbirth. The typical sign is a sharp pain when opening your bowels, which can last for hours afterwards. Alongside the pain, a small amount of bright red blood is often seen on the toilet paper.

Haemorrhoids are something different. They are cushions of blood vessels that everyone has in the anal canal, and they only cause symptoms when they become enlarged. The differences most often described:

• A fissure is a small wound in the skin, whereas a haemorrhoid is an enlarged cushion of blood vessels.
• With a fissure, the main sign is pain during and after a bowel movement.
• Haemorrhoids more often bleed without severe pain, can come out of the anus (prolapse) and can cause itching or a feeling of dampness. The exception is an external haemorrhoid in which a blood clot forms (thrombosis): this causes a painful lump and swelling next to the anal opening.
• Both conditions can cause bright red blood, and both can be present at the same time.

That is why the difference is reliably determined by a doctor at an examination. Blood in the stool can also have other causes, so it should not be put down to haemorrhoids or a fissure without an examination.

A new (acute) fissure usually heals without surgery within a few weeks. The aim of treatment is to keep the stool soft and to relax the muscle of the anal opening, because spasm of this muscle slows healing. The doctor usually recommends:

• More fibre in the diet (vegetables, fruit, pulses, wholegrain cereals) and enough fluids throughout the day.
• A stool softener, if the doctor recommends one.
• A warm sitz bath for 10 to 15 minutes, two to three times a day and after bowel movements.
• Gentle hygiene, rinsing with water instead of rough wiping.
• Going to the toilet as soon as you feel the urge, without sitting for long or straining.

When these measures are not enough, the doctor may prescribe an ointment that relaxes the muscle and improves blood flow to the area. For some patients, an injection into the muscle that relaxes it temporarily is also considered. Which medicine to use and for how long is decided by the doctor according to the findings. Over-the-counter ointments can ease symptoms, but they should not be used for a long time without an examination.

A fissure that does not heal for longer than about six to eight weeks is usually considered chronic. The edges of the sore then become harder, a small skin tag may form at the outer edge, and the inner muscle of the anal opening (the internal sphincter) remains in spasm. Such a fissure is less likely to heal with diet and ointments alone.

A surgeon usually considers surgery in the following situations:

• The fissure does not heal despite consistent treatment with diet, baths and medicines.
• The fissure heals and then opens up again.
• With a chronic fissure, pain when opening the bowels seriously disrupts sleep, work and daily life, despite treatment.

When an operation is already being planned, the surgeon may suggest removing a skin tag or troublesome haemorrhoids in the same procedure.

The decision is always made after an examination. The surgeon takes into account previous operations in the anal area, childbirth, inflammatory bowel disease and any existing problems with bowel control, because the choice of method depends on these. If the fissure is not in the typical place, if there is more than one, or if it does not hurt as expected, the doctor may suggest further tests, for example a colonoscopy or taking a tissue sample, to rule out other causes.

The most common procedure for a chronic fissure is dividing part of the inner muscle at the side (lateral internal sphincterotomy). Through a small incision, the surgeon cuts part of the inner muscle of the anal opening. The muscle then relaxes, spasm and pressure are reduced, and the sore gets a better blood supply and can heal. The outer muscle, which we tighten voluntarily, is not cut.

Depending on the findings, the surgeon may also remove the hardened edges of the fissure and the skin tag (fissurectomy). With inflammatory bowel disease, after previous operations in the anal area or after damage to the muscle during childbirth, cutting the muscle is usually avoided. In that case the surgeon may suggest a method that preserves the muscle, for example covering the sore with a flap of nearby skin. Which method the surgeon suggests, and why, is explained at the consultation.

The procedure is usually short. It can be done under local anaesthetic together with medicines given into a vein to calm the patient and relieve pain (sedation), under a spinal anaesthetic or under a general anaesthetic. The type of anaesthetic is decided by the surgeon and the anaesthetist. Before the procedure, depending on the type of anaesthetic, the necessary tests and an assessment by an anaesthetist are carried out. After procedures like this, the patient usually goes home the same day or the next day. Whether a hospital stay is needed is decided by the surgeon according to the procedure and the patient's general health.

Recovery is a little different for each patient. As a rough guide, it usually looks like this:

• The first few days: discomfort and pain around the wound, which are usually eased with painkillers recommended by the doctor. Pain when opening the bowels is still possible, but many patients notice that it is milder than before the operation.
• The first bowel movement: it often causes anxiety, but it should not be put off, because the stool then becomes harder and more painful to pass. Soft stools matter most, so the diet and the stool softener are continued as instructed.
• The first seven to ten days: a little blood on the toilet paper and a slight discharge are common. A thin pad and cotton underwear make this period easier.
• Returning to lighter duties: usually within a few days to two weeks, depending on your work.
• Healing of the fissure: usually within a few weeks, generally within six weeks. After removal of the fissure edges (fissurectomy), healing can take longer.

Care after the procedure is simple, but it should be followed consistently. After each bowel movement, rinse the area with lukewarm water or take a short sitz bath, then gently pat it dry. In the first few days it helps to avoid sitting for long periods on hard surfaces, heavy lifting and strenuous exercise. A follow-up appointment with the surgeon is booked as agreed, and the surgeon then assesses healing and gives further instructions.

As after any procedure, possible complications include bleeding, a collection of blood under the skin (haematoma), wound infection and, rarely, a pus-filled infection (abscess) next to the anal opening. In the first hours after the anaesthetic, passing urine may be difficult. Healing may be slower, and the fissure may also come back, but this is less common when stools are kept soft.

Patients often ask about control of wind and stools. After the inner muscle is cut, some patients may have reduced control of wind or, less often, slight leakage of stool. This is usually mild and temporary, but in a small number of patients it can be permanent, and very rarely further treatment is needed. That is why, before the operation, the surgeon asks about childbirth, previous operations and existing symptoms and chooses the method accordingly.

Contact your surgeon or GP without delay in the following situations:

• Bleeding is heavy or does not stop.
• You develop a high temperature or shivering.
• Pain is getting worse instead of better.
• Swelling, redness or a discharge of pus appears around the wound.
• You cannot pass urine, or you have not opened your bowels for more than two to three days despite taking a stool softener.

If bleeding is heavy or you feel very unwell, call an ambulance on 194.

Before deciding, many people read about other people's experiences on forums. These stories can help you prepare, but fissures, methods and the course of recovery differ from person to person. A more reliable guide is a conversation with a surgeon who has seen your findings. At the consultation it is useful to ask:

• Is the fissure new or chronic, and is treatment without surgery still worth trying?
• Which method do you suggest, and why that one?
• What kind of anaesthetic is used, and will I go home the same day?
• What is the risk to control of wind and stools in my case?
• How long will I be on sick leave, and when is the follow-up appointment?
• Which tests do I need before the procedure, and what should I bring to the hospital?

At Maja Hospital in Niš, proctology consultations are carried out by specialists in general surgery who practise colorectal surgery and proctology. A list of doctors and a description of the consultation can be found on the proctological surgery page.