Anal sphincterotomy, also known as a lateral internal sphincterotomy is a surgical procedure that is used to cut or stretch the hypertrophied internal sphincter (anal sphincter).
The anal sphincter is the group of muscles connected to the rectum at the end of the digestive tract. This circular muscle group is responsible for controlling bowel movements. When an anal fissure, causing bleeding, and in some cases pain occurs, surgery is recommended once all other treatment options have been exhausted.
What is an Anal Fissure?
An anal fissure is a break or tear in the delicate tissue lining of the anus. The tear can expose the muscle around the anus, called the anal sphincter, and damage can cause muscle spasms, further pulling apart the ends of the fissure. As fissures are superficial, they can heal fairly quickly without treatment if they are considered to be acute. However, fissures are considered chronic if they are deeper and not healing after 6 weeks, or have returned following treatment. Bowel movements can prevent fissures from healing.
Causes of Anal Fissures
Anal fissures are common and have similar symptoms to haemorrhoids. Both men and women can get them, and they are most common in adults between 20-40 years of age. However, they can develop at any age, including in babies. Common causes include:
- Constipation or passing large or hard stools
- Explosive or chronic diarrhoea
- Anal sex
- Tight anal sphincter muscles
- Poor blood supply to the anus
Certain medical conditions can also cause anal fissures. These include:
- STDs and HIV
- Anal cancer
- Ulcerative colitis
- Inflammatory bowel disease such as Crohn’s
Symptoms of Anal Fissures
If you suspect you may have an anal fissure, you may feel a tearing or ripping sensation when passing stools. You may also experience some of the following symptoms:
- Burning or itching in the anal area
- Blood on the surface of stools or on toilet paper after wiping the area
- A skin tag or small lump of skin next to the tear
- Bad smelling discharge
- Sharp pain in the anal area when passing stools
- A visible tear in the anus
Diagnosing Anal Fissures
Anal fissures can usually be diagnosed with a simple physical examination of the area around the anus, although your doctor may want to perform a rectal exam to confirm the diagnosis. This involves a small thin tube (anoscope) inserted into the rectum to make it easier to see the tear. It also allows the doctor to inspect the anal canal and detect other causes of anal or rectal pain such as haemorrhoids. If your doctor feels he cannot make an exact diagnosis after performing a rectal examination, you may require a colonoscopy to better evaluation your symptoms.
Treatment for Anal Fissures
If anal fissures are not causing too much pain, then they can often be treated with conservative measures such as home remedies. It is important to keep your stools soft and easy to pass, so eating a healthy diet rich in fibre, staying well hydrated and taking regular exercise will help to avoid constipation. If stools can be passed without straining, this will help the fissure to heal and reduce pain during bowel movements.
Taking a sitz bath (sitting in a small amount of water) may help ease any pain in the anal area and promote healing. Stool softeners are also recommended, along with a prescribed local anaesthetic ointment to reduce pain during bowel movements.
Botox injections are another option if home remedies do not provide enough pain relief. Botox blocks the nerves that cause the anal sphincter to spasm which assists in helping the tear in the tissue to heal.
Your doctor may recommend an anal spincterotomy if anal fissures do not respond to conservative treatments.
Preparing for Surgery
You will be required to attend a pre-assessment appointment before your procedure to check you are healthy enough to undergo surgery. A clinician will take a medical history and ask about any medications or supplements you are currently taking. If you have any allergies, it is important you let them know as this could determine the type of anaesthetic you are given. If you are taking blood thinners, you will need to stop taking them several days before your procedure as they have the effect of thinning the blood which could cause internal bleeding during surgery.
Anal Sphincterotomy Surgery
You will be given either a general or local anaesthetic before your procedure. If you have a general anaesthetic, you will be asleep throughout the procedure. A local anaesthetic numbs the rectal area and you will be awake during surgery. You will not feel any pain regardless of what anaesthetic you are prescribed.
Surgery can be performed as an ‘open’ or ‘closed’ procedure, depending on a number of factors. During an open surgery, an anoscope is inserted into the anal sphincter to view the muscles and the fissure; an incision is then made. In a closed procedure, a small incision is made between the inner and outer anal sphincter muscle, the scalpel is inserted inside and an incision is made in the internal muscle.
The incision allows the sphincter to relax and stretch, taking pressure off the fissure. If any skin tags are near the fissure, they will be removed at the time of surgery.
Once the procedure is complete, the surgeon will put a dressing on the incision to stop any bleeding. You will be monitored for a few hours following surgery to ensure everything has gone well.
The operation generally takes less than 1 hour and is usually carried out as a day care procedure, meaning you can go home on the same day, provided you do not experience any complications. You will need someone to drive you home as you will likely find it uncomfortable to drive.
Recovery from anal sphincterotomy takes roughly 6 weeks to fully heal. Upon discharge from hospital, you will probably need to stay at home and take some time off work and regular activities for about 1-2 weeks. You may be prescribed painkillers or other medications to help ease any pain you experience after your procedure.
Pain experienced from their anal fissure usually disappears within a few days following surgery, although some patients worry about having bowel movements after their procedure as it can initially cause some pain, along with rectal bleeding. This is completely normal in the first few weeks of your recovery and will lessen in time. Ensure you eat a high fibre diet and drink plenty of water to keep stools soft.
Risks and Complications
Anal sphincterotomy is considered a safe procedure and most patients are satisfied with the results. However, as with any type of invasive surgery, there are certain risks and complications that can occur. They include:
Bleeding can sometimes occur after surgery and some stitches may be required to stop the bleeding.
A collection of pus can develop along with an anal fistula following surgery (more common with the closed technique). If this happens, the abscess may need to be drained and another surgery performed to remove the fistula (fistulotomy).
Some patients may experience incontinence following their surgery; this can include leakage of stools and gas. It is generally a temporary case and occurs in the first 1-2 weeks following surgery. If this continues after the recovery period, you should consult your doctor.
Outlook after Anal Sphincterotomy
An anal sphincterotomy is a simple procedure that is proven to be very successful in the treatment of anal fissures. Recovery is relative quick and side-effects are rare.
It is important that you follow measures to prevent anal fissures as they can return, even after surgery. Ensure you keep the anal area clean using a gentle mild soap and water, and fully dry at all times. Drink plenty of fluids, eat a high fibre diet and exercise regularly to avoid constipation. If you experience any diarrhoea, ensure it is treated immediately.
At One Healthcare we can book you in to see a specialist General Surgeon, usually within 48 hours, for an initial consultation. Anti-Reflux surgery is available at One Ashford Hospital in Kent and One Hatfield Hospital in Hertfordshire.
You can use your private medical insurance or pay for your Anal Sphincterotomy treatment. We offer competitive, fixed price packages as well as the ability to spread your cost with the option of 0% finance. If you are using your health insurance, please contact your insurer first for approval and let them know you’d like to be treated at One Hatfield Hospital.
Why One Hatfield
- Modern purpose-built hospital opened in December 2017
- Fast access to diagnostics including MRI, Xray and Ultrasound
- Private, spacious, en-suite rooms
- Specialist physiotherapy and nursing teams
- Little or no waiting time
- ‘Ultra clean air’ theatres
- Freshly prepared food
- Calm, dignified experience
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