Fissures
A fissure is a tear in the lining of the anus. Like external hemorrhoidal disease, it can be associated with a change in bowel habits. Normally, a fissure is associated with pain and bleeding. Most often, it is located towards your tailbone, but it can be located in the front, towards your scrotum/vagina. In other locations, a fissure may be a sign that there is another disease state, such as inflammatory bowel disease, an infectious disease, or a malignancy. When it is chronic, it can be associated with a skin tag in the area, and/or a papilla, or thickened white tag from inside the anus. While there may be pain from the fissure itself, associated discomfort may result from spasm of the rectum. This discomfort establishes a cycle in which the afflicted patient may avoid bowel movements, thus perpetuating constipation, which may worsen the symptoms.

Though the exact cause of fissures is unknown, most believe that they are caused by ischemia, or the relative lack of blood flow, to this area. Since greater that 80% of fissures will heal without an operation, it is of utmost importance to maximize these measures of good bowel habits and symptomatic care. Changes may include the addition of a high fiber diet, in which 20-30 grams of fiber per day is ingested, a fiber supplement such as Metamucil, Konsyl, Citrucel, or Per diem, drinking plenty of fluids, sitz baths, and moderate exercise. Prescriptions for medications which may increase the blood flow to this area, such as nitrates or calcium channel blockers, as used for chest pain due to heart disease may be helpful. Recent studies have used injection of botulinum toxin into the sphincter muscles to paralyze them and allow healing to take place. Unfortunately, it is not yet clear how much to use, and exactly where the injection should take place. Additionally, temporary fecal incontinence may ensue.

Sphinterotomy, or the division of the internal sphincter, for fissure disease is highly effective. During this procedure, your surgeon will identify the internal sphincter and cut a portion of it. However, the internal sphincter is largely responsible for your continence, and short-term and long-term incontinence has been identified in some patients. The technique of the sphincterotomy is important, and preoperative evaluation of your sphincter through symptom complex and perhaps measured sphincter pressures may be warranted. Your surgeon will discuss these possibilities with you.