Fissure in Ano

Our Approach In Managing Fissure in Ano

Break the spasm. Heal the tear. Restore comfort.

The vicious cycle of anal fissure is well understood in proctology: a hard bowel motion causes a small tear, the pain from this tear triggers spasm of the internal anal sphincter, and this spasm reduces blood flow to the area — impairing the very healing process needed to close the fissure. Without breaking this cycle, an acute fissure that should heal within weeks instead becomes chronic, with thickened edges and an associated skin tag or sentinel pile that perpetuates symptoms indefinitely.

At Shree Hospitals, our approach to chronic anal fissure diagnosis and pain management is centred on this physiological understanding. Our anal pain specialists focus first on relaxing the sphincter spasm - through medical, chemical, or surgical means depending on chronicity and severity - recognising that breaking the cycle, not simply treating the tear itself, is the key to lasting resolution.

1. Clinical Diagnosis & Assessment

• Careful history - pain pattern, duration, bleeding characteristics, and bowel habit assessment, conducted with sensitivity given the discomfort of examination
• Gentle external inspection - most fissures are visible without need for uncomfortable internal examination, particularly in the acute painful phase
• Identification of fissure location - posterior midline fissures are most common; atypical or multiple fissures warrant investigation for underlying conditions such as Crohn's disease
• Assessment for chronicity - presence of a sentinel pile, exposed internal sphincter fibres, or fissure edges indicating a chronic, non-healing tear
• Exclusion of secondary causes - particularly important for atypical fissures not in the classic posterior or anterior midline position

2. Conservative Medical Management
    
   First-line treatment for the majority of acute fissures:

• High-fibre diet and adequate fluid intake - softening stool to reduce trauma with each bowel movement, the foundation of anal fissure healing
• Stool softeners and bulking agents - ensuring consistently soft, easily passed stool during the healing period
• Topical nitroglycerin (GTN) ointment - relaxing the internal anal sphincter chemically, improving local blood flow to promote healing
• Topical calcium channel blockers - diltiazem or nifedipine cream as an alternative to GTN with a more favourable side effect profile
• Warm sitz baths - providing symptomatic relief and promoting relaxation of the sphincter muscle
• Adequate analgesia - managing pain to break the cycle of stool avoidance that worsens constipation and fissure persistence

3. Botulinum Toxin (Botox) Injection
    
   For fissures not responding to topical therapy:

• Botox injection for fissure - directly into the internal anal sphincter, providing temporary, reversible chemical relaxation of sphincter spasm
• Performed as a quick, minimally invasive office or day-care procedure under local anaesthesia
• Effect typically lasts 3 to 4 months - providing a sufficient window for the fissure to heal completely while spasm is controlled
• High success rates for chronic fissures resistant to topical treatment, avoiding the need for surgery in many patients
• Minimal risk of permanent continence issues compared to surgical sphincterotomy

4. Lateral Internal Sphincterotomy
    
   The definitive surgical treatment for fissures resistant to medical management:

• Lateral sphincterotomy in Mumbai - a small, precise surgical division of a portion of the internal anal sphincter, permanently breaking the spasm cycle
• Performed through a small incision lateral to the fissure itself, avoiding interference with the fissure's own healing process
• High success rates exceeding 90% for chronic fissure resolution with a single procedure
• Day-care procedure with most patients discharged the same day and returning to normal activity within days
• Careful technique calibration to minimise the small risk of flatus or minor continence disturbance associated with sphincter division

5. Fissurectomy & Advancement Flap
    
   For complex or recurrent chronic fissures:

• Fissurectomy - excision of the chronic fissure edges, sentinel pile, and any associated fibrous tissue to create a fresh healing surface
• Anal advancement flap - for fissures with significant tissue loss or in patients where sphincterotomy carries higher continence risk
• Combined approaches tailored individually by our anal pain specialist team based on fissure characteristics and patient sphincter function
• Particular consideration for patients with pre-existing continence concerns, where sphincter-sparing techniques are prioritised

6. Post-Treatment Care & Recurrence Prevention

• Continued high-fibre diet and stool softener use following any treatment - preventing recurrence through sustained soft stool consistency
• Sitz bath continuation during the healing period for symptomatic relief
• Clear guidance on avoiding excessive straining and prolonged toilet sitting - both contributing factors to fissure development
• Structured follow-up to confirm complete healing and address any recurrence promptly as part of Fissure in Ano treatment in Mumbai, India