Anal Fissure
20-Year Experience
Changyul Oh, M.D., Celia M. Divino, M.D., Randolph M. Steinhagen, M.D.
From the Department of Surgery, Mount Sinai Medical Center, New York, New York
PURPOSE: This study was designed to review a 20-year
experience of the treatment of patients with anal fissure to
identify possible etiologic factors and to explore effective
preventative measures and the ideal treatment for this dis-
ease. METHODS: From January 1972 to December 1991,
1,391 patients (700 males, 691 females; average age, 39
years) with chronic symptomatic anal fissures underwent
surgical treatment using either open or closed techniques.
The following procedures were perfonlmd: 1) internal
sphincterotomy for 1,313 idiopathic fissures; 2) C-anoplasty
for 36 cases of anal stricture; 3) debridement and sphinc-
terotomy for 25 patients with postsurgical nonhealing
wounds; 4) bilateral excision of the protruding internal
sphincter for 17 patients with "subluxation." Acute super-
ficial anal fissures were treated conservatively, with empha-
sis on anal hygiene. RESULTS:Acute superficial anal fissures
responded well to conservative management. Over 95 per-
cent of patients with chronic anal fissures treated by sur-
gery had satisfactory relief of symptoms. Early complica-
tions included urinary retention (1.4 percent), bleeding (1.1
percent), and abscess and fistula formation (0.7 percent).
Late complications manifested as flatus and liquid inconti-
nence (1.5 percent), delayed wound healing (1.4 percent),
recurrence of fissures (1.3 percent), and symptomatic itch-
ing and burning (1.1 percent). The complication rate was
higher in the group that underwent closed sphincterotomy
than in the group treated by open techniques. CONCLU-
SIONS: Proper anal hygiene is important in both prevention
and initial conservative management of symptomatic anal
fissures. For chronic intractable cases, open lateral internal
sphincterotomy is strongly recommended. C-anoplasty
should be done when strictures are present. Excision of the
protruding internal sphincter is recommended in patients
who present with an excessively elongated, tight anal canal
with a partially protruding internal sphincter. [Key words:
Anal fissure; Anus; Anal sphincter; Colon and rectal surgery]
Oh C, Divino CM, Steinhagen RM. Anal fissure: 20-year
experience. Dis Colon Rectum 1995;38:378-382.
nal fissure remains one of the most c o m m o n
A proctologic problems. Fissures are seen in all
age groups, although the majority of patients are rel-
atively y o u n g to middle-aged adults. Fissures cause
considerable pain, disproportionate to the size of the
lesion, resulting in significant morbidity and disability.
Therefore, it is worthwhile to explore effective pre-
ventive measures and attempt to identify the most
effective treatments for this disease.
No reprints are available.
378
METHODS
Records of 1,391 patients, o p e r a t e d o n at the Mount
Sinai Hospital for symptomatic chronic anal fissures
from January 1972 to D e c e m b e r 1991, w e r e reviewed
(700 males, 691 females; average age, 39 (range, 17-
80) years). Posterior fissures w e r e approximately
three times m o r e c o m m o n than anterior fissures, but
w o m e n were twice as likely to d e v e l o p anterior fis-
sures than men. About 10 percent of patients h a d both
anterior a n d posterior lesions, and a few cases were
seen elsewhere o n the circumference of the anus
(Table 1).
During the same period, w e o p e r a t e d o n 2,990
patients with symptomatic hemorrhoids. The age
range in this g r o u p was similar, but the average age
was 48 years. In general, patients with fissures t e n d e d
to be s o m e w h a t y o u n g e r than those with h e m o r -
rhoids (Fig. 1).
Treatment
Conservative nonoperative m a n a g e m e n t of acute,
superficial anal fissures consisted primarily of improv-
ing anal hygiene. Patients w e r e instructed to clean the
perianal area b y using w a r m water with detergent in
a squatting position at least two times a day. Some
patients used topical steroid preparations o n their
own. Chronic anal fissures that resisted healing were
subjected to surgical treatment u n d e r general or spi-
nal anesthesia. T w o h u n d r e d patients w e r e o p e r a t e d
o n using the closed technique. 1 For the remainder of
patients, the operation consisted of o p e n lateral inter-
nal sphincterotomy as previously described. 2
In addition to internal sphincterotomy, any s e c o n d -
ary changes present, such as sentinel pile or hyper-
trophied anal papilla, w e r e excised or coagulated
(Table 2). The majority of anal abscesses and fistulas
w e r e located at the posterior midline, limited to the
s u b c u t a n e o u s space, and w e r e simply drained with
excision of the overlying skin and curettage of the
tract. In the rare situation w h e n the fistula involved
the intersphincteric space, posterior sphincterotomy
was p e r f o r m e d b y incising the internal sphincter,
Vol. 38, No. 4
Location of Anal Fissure
Posterior
Male (%) 582 (83.2)
Female (%) 465 (67.3)
Subtotal (%) 1,047 (75.3)
along with the overlying subcutaneous external
sphincter.
Associated symptomatic hemorrhoids were treated
with surgical hemorrhoidectomy, and internal sphinc-
terotomy was performed in the base of the hemor-
rhoidectomy wound. In the group of 61 cases in
which the fissure was seen following previous anal
surgery, 36 patients who had severe anal stricture
were treated with C-anoplasty. 3 The remaining 25
cases of nonhealing surgical wounds were treated
with lateral sphincterotomy, in addition to curettage
of the granulation tissue or debridement of the
wound. Seventeen cases of protruding anus with an
excessively elongated tight anal canal were treated by
excision of the protruding portion of the internal
sphincter, as previously described. 4 Condyloma
acuminata, w h e n present, were excised or coagulated
at the time of sphincterotomy.
All patients were evaluated within two to three
weeks after surgery. Patient follow-up included an
average of two office visits, at three to five days
postoperatively, at two weeks postoperatively, and
then as necessary. Once w o u n d healing was satisfac-
tory, the patient was discharged and given specific
instructions to return to the office if they experienced
any problems or recurrent symptoms.
# of patients
800
600
400
200
<20 21-30 31-40 41-50 51-60 61-70
Age
Figure 1. Distribution of anal fissures and hemorrhoids by
age.
ANAL FISSURE 379
Table 1.
Anterior Both Other Total
51 (7.3) 57 (8.1) 10 (1.4) 700
129 (18.9) 89 (12.9) 8 (1.1) 691
180 (12.9) 146 (10.9) 18 (1.3) 1,391
RESULTS
Acute superficial anal fissures that were treated
nonoperatively responded favorably within two to
three weeks in approximately 90 percent of patients.
In those patients who underwent surgery, the over-
whelming majority (over 95 percen0 were satisfied
and had prompt relief of pain, even with the first
bowel movement. Complete w o u n d healing usually
took place within three weeks, except in 1.4 percent
of patients in w h o m healing was delayed.
Early and late surgical complications are detailed in
Table 3. Immediate postoperative complications in-
cluded urinary retention (19), Needing (15--of which
5 required surgical intervention), fistulas (3), and ab-
scesses (7), which required fistulotomy and simple
drainage, respectively.
Late complications included 21 cases of gas (flatus)
or liquid incontinence. These patients usually com-
plained of minor mucus seepage or difficulty control-
ling flatus. However, no patient was incapacitated
from social activities or required sphincteroplasty.
Within six months following surgery, they all recov-
ered completely. Twenty patients were found to have
nonhealing surgical wounds more than two months
postoperatively. Eighteen of these experienced com-
plete healing by six months. Two patients required
reoperation, with the w o u n d subsequently healing
within two weeks postoperatively. Recurrent fissures
occurred in 18 cases. Five of these were successfully
healed with repeat internal sphincterotomy, and one
was revised by C-anoplasty. Itching and burning were
experienced in 15 cases and were successfully treated
symptomatically.
Every effort was made to explore the possible
causes of anal fissure in this series. As Table 4 indi-
cates, the vast majority of cases (95 percent) were
idiopathic in nature, and many of theses were noted
to have some degree of inflammatory changes around
the anus. In 61 patients in w h o m fissures developed
>70
following hemorrhoidectomy, 36 were associated
with severe anal strictures. The remaining 25 cases
had nonhealing anal wounds. Seventeen cases of anal
380
Table 2.
Secondary Changes
No. (%)
Sentinel pile 658 (47.3)
Abscess or fistula 174 (12.5)
Papilloma 117 (8.4)
fissure were attributed to an excessively elongated,
tight anal canal, which predisposed to protrusion of a
portion of the internal sphincter.
Table 5 lists the most commonly observed clinical
conditions seen in associationwith anal fissure. Hem-
orrhoids are by far the most common, accounting for
approximately 25 percent of the cases.
DISCUSSION
Anal fissure (ulcer) remains one of the most com-
monly encountered proctologic problems. It affects
both men and w o m e n of all ages. Its appearance is
that of a relatively minor lesion, but anal fissure
causes considerable pain and discomfort, far dispro-
portionate to its size. Fissures are most commonly
found in the posterior midline, but anterior lesions are
not infrequent, especially in women, and may have a
considerable impact on marital life. Identification of
etiologic, as well as predisposing factors, may help
reduce the incidence of anal fissures. Much work has
gone into elucidating its etiology; however, a simple
unifying theory has not been established. 1' 5
The inciting factor appears to be variable. Trau-
matic injury to the anal canal, resulting from either
hardened stools as a result of constipation or stools of
normal consistency associated with frequent defeca-
tion, has been associated with the development of
anal fissure. The role of an infectious process predis-
posing to the formation of a fissure has long been
entertained. Surgical wounds may contribute to the
formation of scar tissue and subsequent stenosis of
the anal canal, which may predispose to ulcer forma-
tion. Different etiologies and the respective incidence
of anal fissures in our series of 1,391 patients are listed
in Table 4. There was no identifying cause in the
majority of patients, and only a few patients were able
to trace the cause of the fissure. Among the idiopathic
group, many were associated with some degree of
inflammation in the perianal area. When the anal
region is carefully observed, it is common to find
some stool trapped in perianal folds. We speculate
that ammonia, generated from the entrapped stool,
causes irritation of the skin. In concert with chloride
OH ETAI, Dis Colon Rectum, April 1995
ions from sweat, they act as potent irritants, leading to
inflammation around the anus.
It has been shown that inflammatory cells release
collagenolytic enzymes, which reduce tensile strength
of tissues. 6 If the inflammation persists, the tissue will
burst at the slightest stretch. It is, therefore, conceiv-
able that the passage of hard stool through the in-
flamed anal canal may lead to tearing of the anal skin.
This may occur even when a large caliber of normal-
consistency stool is evacuated. Once the fissure de-
velops, it becomes a source of significant pain and
discomfort with bowel movements. The patient then
typically resorts to the use of stool softeners to de-
crease the pain with defecation, leading to frequent
bowel movements, thereby setting up a cycle that
further enhances the inflammatory process. In prac-
tice, this scenario is not uncommon. Therefore, the
initial conservative approach begins with thorough
cleaning of the perianal area by using warm water
with detergent in a squatting position, along with
various conventional modalities. 7 The detergent helps
emulsify the fats and oils in stool, and the squatting
position facilitates exposure of the anal verge. For
persistent inflammation, the use of steroid or antifun-
gal cream has been advocated. Acute cases usually
resolve within two to three weeks. However, chronic
anal fissures with secondary changes, such as a sen-
tinel pile, require surgical intervention. Undue delay
of proper surgical treatment may lead to formation of
abscesses and fistulas.
Until the middle of this century, an accepted surgi-
cal treatment for chronic anal fissure was posterior
sphincterotomy. 8 However, minor postoperative
complications such as flatus incontinence or fecal
soiling (keyhole deformity) were observed in a high
proportion of patients (40-50 percent). 9-11 In 1969,
Notaras 12 described a simpler and more effective
method of lateral subcutaneous internal sphincterot-
omy. The advantage of this method over the posterior
open technique or stretching method was confirmed
by Hawley 13 and Hoffman and Goligher. 14 Ever since
this technique was widely adopted, it has proven to
be uniformly satisfactory. ~5 We have adopted the
closed procedure described by both Notaras 12 and
Hoffman and Goligher ~4 and found it to be easier than
the standard posterior open sphincterotomy. There
are disadvantages to this closed technique; there may
be uncertainty of completeness, inadvertent damage
to large vessels, and difficulty performing a selective
internal sphincterotomy because of its elasticity. To
overcome these problems, we have used a No. 11
Vol. 38, No. 4 ANAL FISSURE 381

Table 3.
Complications
Closed n = 200 Open n = 1191
Early complications
Urinary retention 19 (1.4)
Bleeding 15 (1.1) 8 (4) 7 (0.6)
Abscess and fistula 10 (0.7) 5 (2.5) 5 (0.4)
Late complications
Flatus or liquid incontinence 21 (1.5) 6 (3) 15 (1.2)
Delayed healing (over 2 too) 20 (1.4)
Recurrence 18 (1.3)
Itching and burning 15 (1.1)
Numbers in parentheses are percentages.

Table 4. that developed following anal surgical procedures.

Etiology Surgical excision of the anoderm results in tissue loss,
Idiopathic (inflammation) 1,313 which is not amenable to simple internal sphincterot-
Stricture (posttrauma) 36 omy. The rational approach to this problem is to
latrogenic (postsurgicat) 25 supplement the defect with an adequate amount of
Subluxation (protrusion) 17
anal tissue. A number of surgical procedures have
Total 1,391
been described to move tissue into the anal canal.
These consist primarily of the use of skin flaps, with
Table 5.
Associated Diseases either a triangular (Y-V) 18 or square-shaped sliding
graft. 19 However, sloughing of the terminal portion of
Hemorrhoids 347 AIDS 3
the skin flap because of tension or ischemia has been
Previous 53 Prostate cancer 2
hemorrhoidectomy observed. The use of C-anoplasty 3 is advantageous
Previous laser 8 Hepatitis 2 because it extends the pedicle without compromising
hemorrhoidectomy the vascular supply. Tension at the suture line can be
Anal stricture 36 Lung cancer 1 avoided by extending the incision. It also has the
Subluxation of anus 17 Heart disease 2
advantage of being able to easily adjust the graft size
Condyloma acuminata 12 Carcinoid 1
Hemodialysis 6 Pilonidal cyst 1 to the size of anal defect. Twenty-five of 26 cases with
Colon cancer 4 Parkinson's disease 1 nonhealing wounds responded well to this treatment.
Breast cancer 3 Rectal prolapse 1 Seventeen cases of anal fissures were associated
Sarcoma 3 Ileitis 1 with an excessively tight, elongated anal canal, in
AIDS = acquired immunodeficiency syndrome. which there was excessive protrusion of a hypertro-
phied internal sphincter muscle. We have termed this
blade to divide the internal sphincter fibers after the situation "subluxation." This group of patients can be
creation of the submucosal plane. 1 This modified identified by observing the hypertrophied internal
technique has previously been described in detail, a sphincter, which is elongated to such a degree that it
and we have found it to be quite satisfactory. projects beneath the skin at the anal verge. These
Early results were somewhat better with the group patients complain of severe constipation and pro-
of patients w h o underwent the modified Oh 16 open longed time of defecation because of the elongated,
technique than with those w h o were operated on tight anal canal. Therefore, the rational approach to
using the closed technique, particularly with regard to this condition is to excise the protruding portion of
postoperative bleeding and abscess formation. The the internal sphincter bilaterally, as has previously
open technique is not only convenient but also af- been described. 4 A simple internal sphincterotomy
fords the surgeon more technical control. 17 Because alone would not have sufficient treatment in this sit-
of these technical advantages, as well as a lower uation.
complication rate, we strongly recommend the open
technique w h e n performing a lateral internal sphinc- CONCLUSIONS
terotomy. Although we find ourselves in agreement with the
In our series, there were 36 cases of anal fissures majority of previous authors who found that the eti-
382 OH E T AL
ology of anal fissures is multffactorial, we stress the
importance of proper anal hygiene as the initial ap-
proach to conservative management. Surgical inter-
vention, in the form of open lateral internal sphinc-
terotomy, is recommended for chronic intractable
cases. Anal strictures should be treated by C-ano-
plasty, and a protruding anus should be managed by
excision of the involved hypertrophied internal
sphincter.
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