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1 CR08 Lateral Internal Sphincterotomy Further information You can get more information and share your experience at Local information You can get information locally from: Taunton and Somerset NHS Foundation Trust Musgrove Park Hospital Taunton Somerset TA1 5DA Switchboard: This leaflet can be supplied in large print, on audio cassette or can be translated. For more details contact the Communications Department on Tell us how useful you found this document at Issued January 2012

2 What is an anal fissure? An anal fissure is a tear in the skin around the back passage. It is a common problem that causes severe pain, especially after a bowel movement. It may also cause bleeding. Your surgeon has recommended an operation called a lateral internal sphincterotomy. However, it is your decision to go ahead with the operation or not. This document will give you information about the benefits and risks to help you make an informed decision. If you have any questions that this document does not answer, you should ask your surgeon or any member of the healthcare team. How does an anal fissure happen? The anus is the opening of the bowel at the back passage (anal canal). There are two rings of muscle, called the internal and external anal sphincters, around the anal canal. These muscular rings relax when you open your bowels. The internal sphincter remains contracted the rest of the time so that you do not pass faeces involuntarily (incontinence). The anal canal has a lining of skin. An anal fissure is a tear in the anal skin that may happen because of diarrhoea or constipation (see figure 1). This causes pain and bleeding when the anal skin is stretched during a bowel movement. Figure 1 Position of an anal fissure Internal anal sphincter External anal sphincter Anal fissure Anal canal The pain can continue for several hours and often discourages bowel movements. This leads to constipation, which makes the problem worse. The condition is associated with spasm of the internal anal sphincter. This reduces the blood supply to the area and prevents healing. The treatment is aimed at breaking this cycle to allow healing to take place. The sphincter muscles can be damaged after a difficult childbirth or episiotomy (a cut in the skin between the vagina and back passage). Let your surgeon known if this is the case with you because other treatment may be appropriate. What are the benefits of surgery? Surgery is effective at treating an anal fissure, but is usually recommended to people who fail to get better with non-surgical treatments. Are there any alternatives to surgery? Surgery is usually offered only if the following simple non-surgical treatments fail. Eating more fibre and drinking more fluid helps you to pass soft motions and reduces the pain. Laxatives help you to pass soft motions, preventing unnecessary stretching of the anal canal. Glyceryl trinitrate (GTN) or diltiazem are ointments that can be applied to the skin at the back passage, helping to reduce muscle spasm and improve the blood supply. Studies show that this treatment heals around 2 in 3 anal fissures if given for eight weeks. Once the treatment is stopped, symptoms will return in about 1 in 8 people. Up to 2 in 5 people suffer headaches with the GTN ointment. Paracetamol taken at the same time usually helps. A small percentage of these people have to stop the treatment. Botulinum toxin can be injected into the sphincter muscle. It works by paralysing the muscle and so reducing the spasm and increasing the blood supply enough to allow the fissure to heal. The effects of the botulinum toxin last for three months, which is enough time for 2 in 3 fissures to heal. Incontinence is rare. The muscle returns to normal after three months. Infection at the injection site may happen (risk: less than 1 in 100). Copyright 2011 CR08 Page 1 of 4

3 Local anaesthetic ointments can also be given to help the pain. These do not treat the underlying cause. What will happen if I decide not to have the operation? Non-surgical treatments can be continued. However, they are less likely to cure the problem. What does the operation involve? Sphincterotomy simply means dividing the sphincter. The operation reduces the strength of muscle spasm, allowing increased blood supply and helping the fissure to heal. The healthcare team will carry out a number of checks to make sure you have the operation you came in for. You can help by confirming to your surgeon and the healthcare team your name and the operation you are having. The operation is usually performed under a general anaesthetic and takes about a quarter of an hour. You may also have injections of local anaesthetic to help with the pain after surgery. You may be given antibiotics during the operation to reduce the risk of infection. Your surgeon will make a small cut in the skin near your back passage. They will then cut the lower part of the internal sphincter muscle. This will relieve the spasm in the sphincter, allowing a better blood supply to heal the fissure. Your surgeon will either leave the wound open or close the cut with stitches. What should I do about my medication? You should let your doctor know about all the medication you are on and follow their advice. This includes herbal remedies and medication to control diabetes and blood pressure. If you are on beta-blockers, you should continue to take them as normal. You may need to stop taking warfarin or clopidogrel before your operation. What can I do to help make the operation a success? If you smoke, stopping smoking several weeks or more before an operation may reduce your chances of getting complications and will improve your long-term health. Improving your diet will help to speed up your recovery and will reduce your chances of the problem coming back. Drink plenty of fluid and increase the amount of fibre in your diet to avoid constipation. Try to maintain a healthy weight. You have a higher chance of developing complications if you are overweight. Regular exercise should help prepare you for the operation, help you recover and improve your long-term health. Before you start exercising, ask a member of the healthcare team or your GP for advice. You can reduce your risk of infection in a surgical wound. In the week before your operation, do not shave or wax the area where a cut is likely to be made. Try to have a bath or shower either the day before or on the day of your operation. Keep warm around the time of your operation. Let a member of the healthcare team know if you are cold. What complications can happen? The healthcare team will try to make your operation as safe as possible. However, complications can happen. Some of these can be serious and can even cause death. You should ask your doctor if there is anything you do not understand. Any numbers which relate to risk are from studies of people who have had this operation. Your doctor may be able to tell you if the risk of a complication is higher or lower for you. 1 Complications of anaesthesia Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic. Copyright 2011 CR08 Page 2 of 4

4 2 General complications of any operation Pain, which happens with every operation. There is usually little pain after a sphincterotomy. As the spasm in the sphincter is reduced by the operation and the fissure begins to heal you will notice much less pain during and after a bowel action. This improvement is often noticed within just a few days. Pain after the operation can normally be successfully treated with a mild painkiller such as paracetamol. Bleeding during or after surgery. This rarely needs a blood transfusion or another operation but can lead to bruising (risk of bruising: less than 1 in 100). Infection of the surgical site (wound) (risk: less than 1 in 100). It is usually safe to shower after 48 hours. However, you should check with a member of the healthcare team. Let your surgeon know if you get a temperature, notice pus in your wound, or if your wound becomes red, sore or painful. An infection usually settles with antibiotics but you may need another operation. 3 Specific complications of this operation Involuntarily passing wind or loose faeces (incontinence), which is usually temporary and settles after about two or three months (risk: 6 to 30 in 100). Difficulty passing urine, which can happen in elderly people. You may need a catheter (tube) in your bladder for a day or two (risk: 1 in 200). Permanent incontinence from the bowel. This is rare. How soon will I recover? In hospital After the operation you will be transferred to the recovery area and then to the ward. You should be able to go home the same day. However, your doctor may recommend that you stay a little longer. If you do go home the same day, a responsible adult should take you home in a car or taxi and stay with you for at least 24 hours. You should be near a telephone in case of an emergency. Drink plenty of fluid and increase the amount of fibre in your diet to avoid constipation. You may need to take mild bulking laxatives for a few weeks. If you are worried about anything, in hospital or at home, contact a member of the healthcare team. They should be able to reassure you or identify and treat any complications. Returning to normal activities You should not drive, operate machinery (this includes cooking) or do any potentially dangerous activities for at least 24 hours and not until you have fully recovered feeling, movement and co-ordination. If you had a general anaesthetic or sedation, you should also not sign legal documents or drink alcohol for at least 24 hours. It is normal to get some spotting of blood for the first couple of days after your operation. Keep the area around the wound clean by bathing or showering often. The pain from the fissure should improve rapidly. It is usually possible to return to work after a few days depending on your type of work. Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, you should ask a member of the healthcare team or your GP for advice. Do not drive until you are confident about controlling your vehicle and always check your insurance policy and with your doctor. The future Most people make a full recovery and can return to normal activities. The fissure can come back, so you may need further treatment (risk: less than 1 in 20). Summary An anal fissure is a common condition that causes a lot of pain. At first, it may be treated with ointments, creams or botulinum toxin. If this fails, surgery is the best option for a cure. Copyright 2011 CR08 Page 3 of 4

5 Surgery is usually safe and effective. However, complications can happen. You need to know about them to help you make an informed decision about surgery. Knowing about them will also help to detect and treat any problems early. Keep this information leaflet. Use it to help you if you need to talk to a healthcare professional. Acknowledgements Author: Mr Jonathan Lund DM FRCS (Gen. Surg.) Illustrations: Medical Illustration Copyright 2011 Nucleus Medical Art. All rights reserved. This document is intended for information purposes only and should not replace advice that your relevant health professional would give you. Copyright 2011 CR08 Page 4 of 4