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Anal fissure: Surgical management

Author
C Neal Ellis, MD, FACS, FASCRS, FACG
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

An anal fissure is a tear or ulceration in the lining of the anal canal below the mucocutaneous junction (dentate line) (figure 1). Most commonly caused by local trauma, anal fissures cause pain during defecation that persists for one to two hours. Persistence of an anal fissure is typically associated with anal spasm or high anal pressure. Medical management is typically used as the initial treatment for an anal fissure [1,2]. Surgery is reserved for patients who fail medical therapy [3-6].

Surgical modalities of anal fissure treatment, including lateral internal sphincterotomy and botulinum toxin injection, are discussed in this topic. The clinical presentation, diagnosis, prevention, and medical management of anal fissure are discussed elsewhere. (See "Anal fissure: Clinical manifestations, diagnosis, prevention" and "Anal fissure: Medical management".)

TYPICAL ANAL FISSURE REFRACTORY TO MEDICAL THERAPY

Medical treatment heals a typical anal fissure in most patients. (See "Anal fissure: Medical management", section on 'Initial management of typical fissures'.)

Surgical treatment may be offered to patients whose fissure does not heal with medical therapy. Patients who are willing to undergo surgical treatment are further triaged based upon their risk of fecal incontinence. Women who have had multiple vaginal deliveries and older patients may have a weak anal sphincter complex, which puts them at a high risk of developing fecal incontinence after surgical treatment of anal fissure. Such patients should undergo one of the procedures that do not require division of the anal sphincter muscle (eg, botulinum toxin injection, fissurectomy, or anal advancement flap). Other patients who are not at risk of developing fecal incontinence may undergo lateral internal sphincterotomy, which is considered the most effective treatment for anal fissure (algorithm 1) [7-9].

Patients with low risk of incontinence: Sphincterotomy — A lateral internal sphincterotomy provides prompt symptomatic relief and heals anal fissures in over 95 percent of patients within three weeks [10-18]. In patients who are at a low risk of developing fecal incontinence, the lateral internal sphincterotomy is the gold standard for the operative management of an anal fissure secondary to hypertonicity or hypertrophy of the internal anal sphincter [7-9]. As the gold standard, lateral internal sphincterotomy has been compared with all other therapies for anal fissure, including topical nitroglycerin [3,19], botulinum toxin A injection [6,20], and oral nifedipine [21]. Lateral internal sphincterotomy remains superior in its efficacy to all other therapies, according to a 2012 systematic review [22].

                      

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Literature review current through: Nov 2016. | This topic last updated: Mon Apr 11 00:00:00 GMT+00:00 2016.
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