The symptoms of an anal fissure are evocative.

In general, the patient is constipated.

The patient complains about a very sharp pain immediately after a bowel movement.

Such pain can often last for an hour or two, and reoccur with each bowel movement.

Between bowel movements the patient feels no pain.

Diagnosis:

The examination is difficult because of sphincter spasms which contract the anal orifice.

The anus must be gently relaxed and smoothed out (after local anaesthetic if necessary).

Longitudinal ulcers one centimetre long, more or less deep, with a whitish base (sclerous),

usually located at the 6-o’clock position

Rectal examination: confirms the hypertonia of the sphincter.

Anoscopy: provides a better view of the fissure and clearly identifies its distinctive nature.

Its development comes in surges followed by temporary remissions.

Surgery for an anal fissure can be proposed for a chronic or complicated fissure, or when the pain is serious and persistent, or recurring even with classic medicinal treatment.

The medical treatment for a chronic anal fissure, currently comprises nitroglycerine ointment, injections of botulinum toxin, or calcium channel blockers nifedipine or diltiazem. 

For an acute or chronic fissure, and fissures in children, these medical treatments can be applied with a chance of healing slightly higher than a placebo.

For a chronic fissure in an adult, all medical treatments are far less efficient than surgery.

Certain very recent agents that have been studied seem promising based on unique individual studies (clove oil, sildenafil and « skincare cream »), but lack any comparison with established medicines.

Lateral internal sphincterotomy:

A lateral internal partial sphincterotomy is a partial and prudent section of the smooth muscle of the anus.

A partial section of the internal anal sphincter. 

It liberates the contracture of the sphincter, reduces the pain caused by bowel movement, and secondarily, allows the fissure to heal.

• Recurrence rate < 5%
• Rate of incontinence to flatus (+/- exuding liquids) 8%.

More than nine times out of ten, patients operated with this technique say they are satisfied with the result.

One of the risks of this method, is that signs of incontinence may occur in one in three cases immediately after the treatment, but normally disappear in the following weeks.

The sphincterotomy takes place either under a general anaesthetic or a local anaesthetic (usually a spinal anaesthesia which puts to sleep only the lower part of the body).

If a general anaesthetic is used, a pudendal nerve block might also be added. This involves a calming injection directly in the sensitive nerve of the anus, which eases the patient’s pain during the first 12 hours.

The causes of the pain reduce quite quickly over the first week.

Full healing, however, takes longer, over five weeks.