Are There Risks to Anal Fissure Surgery?

This is a tear that occurs within the surrounding tissues of the anus. Normally, anal fissures do not result in severe health complications, although they cause discomfort and irritation and are very painful at times. If an anal fissure goes on for two months and beyond, it is termed as a chronic fissure.

While the general area is considered unclean, it is nevertheless susceptible to sudden infections post surgeries, but it is quite rare for a patient to develop an abscess immediately or after a certain period post operation. However, a small percentage of patients do develop an abscess in that area, which can then be treated by draining it and treating the same.

Since incontinence is one of the main reasons for anal fissures to form, naturally, a sphincterotomy can be used to effectively treat the same. However, surgery must be utilized as the last option after trying out other non-intrusive medical procedures in consultation with your doctor.

Chronic anal fissures are often the result of straining the inner muscles lining your anus; your doctor may recommend applying nitroglycerin based ointment to help relax those muscles and to increase the blood flow to the affected area, as this can help to treat the fissures effectively. It should also help to reduce the burning and itching sensation in the affected area, as well.

An individual with an anal fissure may experience a burning or sharp feeling during bowel movements. Bleeding is also expected, and a majority may have itchiness in their anus and rectal area.

While some may mistake this condition as hemorrhoids and take treatment for the same, it is always a good idea to consult your physician before opting for any over-the-counter medications. Anal fissures are treatable, and in case non-intrusive methods do not work, you can always opt for a sphincterotomy to treat such anal fissures that do not respond well to general treatment.

Causes

Anal fissures may occur due to various reasons. The leading cause is the passage of hard or large stools.

The following are some risk factors that make you prone to anal fissures:

• Infancy

Although the reason behind this is still unknown, a majority of infants have anal fissures in their earlier life. While some have theorized that this could be on account of the baby’s tissue being soft and tender, there is no conclusive proof yet to validate this claim. However, you may want to consult your child’s pediatrician to help treat your child.

• Advanced age

The circulation of blood slows down as people age. This can result in higher chances of anal fissures in their later lives. Since optimal blood flow is essential for tissues and muscles to function optimally, a loss of the same will impact them, resulting in anal fissures, dry skin, muscles that spasm out of control or do not function normally, ulcers, etc.

While anal fissures can be treated with applications of specific ointments, the process can be a little complicated with those well advanced in their age. Consult your physician, especially if you are of an advanced age, and ensure that your treatment does not cause you to suffer from any side effects or unnecessary complications.

• Recent childbirth

Normally, a woman has an increased risk of developing anal fissures after giving birth. Since you would be straining all your muscles from the lower back to your hips when giving birth, this process can cause the inner lining of your anus to tear up and even cause fissures.

Most anal fissures take about anywhere from two weeks to six weeks to heal completely, so do consult your doctor, and with the prescribed treatment, your body should be back to normal in no time at all.

• Constipation

Straining to have a bowel movement makes you prone to anal fissures. This explains why individuals have fissures mostly after passing large or hard stools. If you suffer from incontinence issues, then chances are that you would likely strain your muscles when voiding your bowels.

This, in turn, can tear the inner lining of your anus, cause bleeding, inflammation, and irritation, and cause anal fissures to open up. Do consult your physician to get the same treated immediately, and use doctor recommended ointments for seeking immediate relief.

• Inflammatory bowel disease and Crohn’s disease

These conditions together with other factors can result in bowel inflammation and cause several problems in the digestive tract. This increases the risk of anal fissures.

Again, it is always a good idea to consult a doctor before opting to medicate with over-the-counter medications and ointments. Schedule an appointment with your doctor and get your condition diagnosed correctly, since Crohn’s disease can hint at more serious health issues, such as cancer.

• Anal intercourse

There is an increased risk of anal fissures due to the trauma and strain the tissues of the rectum have to undergo during anal intercourse; anal intercourse is never considered to be healthy, given the various complications that arise out of frequent trauma to the inner linings of that specific area.

Moreover, this particular action could cause chronic anal fissures and frequent trauma to the affected area can make it hard, if not impossible, to treat it effectively.

At times (rarely) anal fissures may occur because of,

• Herpes

Anal herpes can cause anal fissures to occur as small cracks, which will cause you to experience severe pains each time you void your bowels. However, both the pain and the condition can be treated with specific ointments and medicines, so consult your doctor for some immediate relief.

• HIV

HIV can cause anal fissures and is harder to treat given the underlying cause, but the immediate symptoms of severe pain can be offset with specific medications, as recommended by your physician.

• Anal cancer

It is always a good idea to consult your physician to diagnose your condition, since anal fissures could be much more than a case of over strained muscles. It could also be an early indication of anal cancer, so do get a few tests done to rule it out and seek treatment for the condition from your doctor.

• Syphilis

Syphilis and anal fissures are two seemingly unrelated conditions, but it has been noted that patients who suffer from sexually transmitted diseases like Syphilis may also develop anal fissures. The treatment process for both are different, but do consult your doctor to run a few tests to eliminate other underlying conditions which could cause the same, such as cancer.

• Tuberculosis

Tuberculosis is a respiratory disease, caused by a bacterium, but it has also known to affect non-pulmonary zones of the body, including causing anal fissures to open up.

Complications

Surgery for anal fissures may result in the following complications:

• Development of fistula
• Infection
• Incontinence
• Bleeding

It is rare to have an infection after a sphincterotomy, and a little abscess may develop in about 2% of all patients. Draining the abscess is the treatment. Antibiotics are needed only if the individual is immunosuppressed or when significant cellulitis develops.

It is very rare to have bleeding, which requires therapy, although some ecchymosis may develop near the site of the sphincterotomy.

Less than one percent of individuals have an anal fistula at the sphincterotomy site. Usually this occurs due to the violation of mucosa during sphincterotomy. Mostly the fistula is superficial and requires fistulotomy to treat it.

The definition and occurrence of incontinence vary a lot from research to research and in various procedures. Between 12% and 27% of individuals undergoing the sphincter stretch develop incontinence after the operation. The reason for this could be an uncontrolled anal sphincter stretch or the stretching of internal and external sphincters.

If the internal sphincterotomy is performed properly, the rates of incontinence will be lower compared to sphincter stretch. For the majority of individuals, the incontinence that may develop immediately after the procedure clears with no long-term complications.

The rate of non-healing or recurrence of anal fissures is between 1% and 6%. According to several studies, approximately 50% of the patients who did not recover were suffering from undiagnosed underlying Crohn’s disease, being the cause of their fissure. 

Self-help

Your doctor may recommend some self-help measures to ease constipation and minimize the pain resulting from anal fissures.

Easing constipation enables anal fissures to recover and minimizes the risk of developing anal fissures in the future.

The following are some self-help measures:

• Include lots of fiber in your diet, such as whole grains, vegetables, and fruits.
• Drink a lot of water to prevent dehydration.
• Exercise more. Go for a daily run or walk.
• Use the toilet when you have the urge without delaying.
• When using wet wipes, avoid products that have alcohol or fragrance, since this may cause itching or discomfort. When using toilet paper, use a brand that is soft, and do not wipe too hard.
• Soak your bottom in warm water for a number of times each day, especially after a bowel movement, to relax your anal muscles.

Treatment

Several anal fissures do not require surgery. The leading treatment method for short-term anal fissures is the use of OTC fiber supplementation and making the stool bulky and more formed with a high fiber diet. The intake of lots of fluids and stool softeners may be necessary to enhance soft bowel movements to assist in the process of healing. To relieve anal pain, topical anesthetics, like lidocaine, could be used.

The use of Sitz baths (warm tub baths) for ten to twenty minutes each day is a soothing process that offers relaxation to the muscles of your anus, assisting in the process of healing. Non-operative measures such as these would assist in resolving bleeding and pain and possibly heal more than half of the short-term fissures with no side effects. 

Doctors do not recommend narcotic pain medications for the treatment of anal fissures, since they encourage constipation.

If an individual has a chronic fissure, doctors may recommend other medications to enhance relaxation of the muscles in the anal sphincter. Discuss the side effects and benefits of these medications with your surgeon. Since chronic fissures are hard to treat normally, your surgeon may recommend surgical treatment as the first option or after several attempts of medical management.

Anal fissure surgery

Lateral internal sphincterotomy (a surgical division of part of the internal anal sphincter) and Botox (Botulinum toxin) injection in the anal sphincter are the surgical options used in the treatment of anal fissures. Normally, these two are done as outpatient operations.

These surgical options aim to enhance anal sphincter relaxation and minimize anal pain to enable the recovery of your fissure. If there is a sentinel pile, it may be taken out to promote the recovery of your fissure. 

Side effects of the surgery

The side effects of the surgery are usually temporary, but you can consult your doctor. Usually after the surgery there are no complications, but you may experience some pain near the wound; that doesn’t need to be treated. You can also take some painkillers, like paracetamol and ibuprofen, but it is always better to consult your doctor.

Every surgical procedure has some risk. However, the sphincterotomy and Botox injection rarely interfere with your ability to control stool and gas. Discuss these risks with your surgeon to determine which treatment suits you the best.

Individuals with diarrheal conditions, like Crohn’s disease or anal sphincter muscle injury just after an obstetric injury, are given special consideration. Surgical sphincterotomy should be considered carefully for these particular individuals. Certain patients may find an alternative surgery known as anoplasty (an anal advancement flap) to be effective.

Recovery after the surgery

People should know that total healing with surgical and medical treatments can last up to six to ten weeks. However, acute pain after surgery clears within several days. The majority of individuals are able to resume daily activities and work in a few days after undergoing the surgery. You may also feel pain going to the toilet after the surgery, as the anal area will be sore due to the surgery.

You have to eat a healthy diet and drink a lot of fluids to avoid constipation, as eliminating stool can be excruciatingly painful, and some physicians have also advised taking laxatives to make your stool a lot smoother. The recovery time varies from person to person, so it is very important that you eat healthy and consume a lot of fluids and high fiber food. Your wound will also have to be left open to heal naturally.

Non-surgical treatments

The following may be recommended:

• Rectiv (externally applied nitroglycerin) to increase the flow of blood to your fissure and enhance healing to assist in the relaxation of the anal sphincter. When other options remain unsuccessful, nitroglycerin is mostly considered as the choice of medical treatment. The primary side effect may be a serious headache.
• Topical anesthetic creams, like xylocaine (lidocaine hydrochloride), may assist in relieving pain.
• Botox injection to relax spasms and paralyze the muscles of the anal sphincter.
• Blood pressure medications, like diltiazem or oral nifedipine, can assist in the relaxation of the anal sphincter. You may take these medications orally or apply them externally. You may also use them in cases where nitroglycerine proves ineffective or leads to great side effects.