29 years
Is there a solution to an unsuccessful anal fissure surgery? I did it 6 years ago and now sometimes when I am out of the toilet I am in pain and my sciatic nerve hurts..Will i ever go back to normal?
Oct 13, 2014
If a patient develops a recurrence after a sphincterotomy, it could be from recurrent disease or from an improperly or incompletely performed initial sphincterotomy.
Fissures can recur easily, and it is quite common for a fully healed fissure to recur after a hard bowel movement or other trauma. Even when the pain and bleeding have subsided, it is very important to continue good bowel habits and a diet high in fiber as a lifestyle change. If the problem returns without an obvious cause, further assessment is warranted.
In the event of a recurrence, medical therapy should be attempted again. If no relief is obtained, the surgeon must evaluate whether the original sphincterotomy was adequate. Evaluation is done by means of palpation during examination under anesthesia or through endoanal ultrasound. If the sphincterotomy was incomplete, it can be completed on the initial side or redone on the opposite side. If the first sphincterotomy was complete, a second sphincterotomy can be completed on the opposite side.
Medical therapy for an anal fissure aims at the relief of constipation and breaking the cycle of hard bowel movement, associated pain, and worsening constipation. Softer bowel movements are easier and less painful for the patient to pass.
First-line medical therapy consists of therapy with stool-bulking agents, such as fiber supplementation and stool softeners. Laxatives are used when necessary in order to maintain regular bowel movements. Mineral oil may be added to make the passage of stool easier without as much stretching or abrasion of the anal mucosa, but it is not recommended for indefinite use. Sitz baths (baths of warm water with iodine solution) after bowel movements and as needed provide significant symptomatic relief because they relieve some of the painful internal sphincter muscle spasm.
Recurrence rates are in the range of 30-70% if the high-fiber diet is abandoned after the fissure is healed. This range can be reduced to 15-20% if patients remain on a high-fiber diet.
Second-line medical therapy consists of intra-anal application of 0.4% nitroglycerin (NTG; also called glycerol trinitrate) ointment directly to the internal sphincter. This cream may be considered when conservative therapies have failed.
Unfortunately, many people cannot tolerate the adverse effects of NTG, which include headache and dizziness; therefore, the use of this drug is limited.
Botulinum toxin (BOTOX®) has been used to treat acute (less than 3 months) and chronic (more than 3 months) anal fissures. It is injected directly into the internal anal sphincter, which has the effect of a chemical sphincterotomy. The effect lasts about 3 months, until nerve endings regenerate. This 3-month period may allow acute fissures (and sometimes chronic fissures) to heal and symptoms to resolve. If botulinum toxin injection provides initial relief of symptoms but there is a recurrence after 3 months, surgical sphincterotomy should be considered.
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