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Anal Fissure


DEFINITION : Anal Fissure (Fissure in Ano) is a chronic ulcer meaning disintegration of the surface of thelining of the anal canal resulting in an “open sore” that resists healing. It is vertical, the long axis is five to ten millimetres and the width is two to three millimetres. The majority are situated on the posterior (back) side of the anal canal, just inside the anal verge. The minority are situated on the anterior (front) side of the anal canal. Anal fissures have been recognized for more than two centuries however the cause is unknown.These fissures cause the anal sphincter (muscles) to go into spasm and thus causes pain.SYMPTOMS : Anal fissure is a common but disturbing condition. The vast majority of patients are healthy youths and are commonly found in physically active young adults. It is far more common in males than in females. In females, it is worst after childbirth. The cardinal symptom is burning and a hot type of pain duringor shortly after a bowel movement. The patients describe the pain as a razor cut or like spreading chilli powder or lemon juice on a cut in the hand. Symptoms start between 20 and 30 years of age. Initially, the burning type of pain is recurrent, very mild and is not noticeable by the individual and may even have periods of complete remission.The pain worsens in time which could be between a few months and even several years. Frequently, the patients attribute the pain to constipation or eating spicy food. All ages experience constipation every now and thenand it does not cause much, if any pain. Constipation, even chronic, is not a cause of anal fissure. However, during defaecation the hard stool will touch and stroke the ulcer and triggers the pain. Usually, the patient is afraid to visit the lavatory to evacuate their bowels.I have seen several patients that have not used the lavatory for ten days! Ultimately, the pain becomes extreme causing intense and unbearable suffering. Over the tens of years of my surgical practice, I have seen young and middle-age patients, males and females, visiting my clinic with chronic anal fissure shouting and screaming from pain in such a way that it is not possible to inspect and examine the anal verge without giving a pain relieving injection of a potent synthetic opioid.Frequently, the patient observes a streak of fresh blood on the toilet paper when wiping after defaecation. Sometimes, patients pass a few drops of blood in the toilet during or after defaecation. Sometimes, fissures streak the stool with blood.

DIAGNOSIS is clinical

1) The above symptoms are pathognomonic (characteristic) of Chronic Anal Fissure.

2) The diagnosis is made by gently parting the buttocks in the left lateralSim’s position, using a very good light and goodnursing assistance and the fissure will be visible.

TREATMENT is either expectant or surgical.

1) EXPECTANT TREATMENT Stool softener, a high fibre diet, lubricant suppositories, the local applications of ointments, hot-sitz baths for 20 to 30 minutes, laser treatment etc. are all beneficial but temporary, there will be complete remission of pain for a few months, recurrence is certainly inevitable and the pain will be worse than before.

2) SURGICAL TREATMENT The very best and only certain treatment for a permanent cure and no recurrence of Chronic Anal Fissure symptoms is an elective surgical Anal Sphincterotomy, either of the Internal Anal Sphincter,the Subcutaneous External Anal Sphincter or both, depending on the tone and bulk of either sphincters at the time of the surgical operation. Sphincterotomy is an extremely effective procedure and has stood the test of time andrelieves pain immediately, completely and permanently if it is performed correctly and precisely. Sphincterotomy has been practiced since the mid-19th century (around 1850). However, there are some modifications of the procedure, this depends on the experience of the Surgeon. Over tens of years and according to my records, I have performed several hundreds of sphincterotomies in the operation theatre of my surgical clinic in Dubai under premedication and local anaesthesia (15ml of Lidociane 2% with Adrenaline 1/100,000) as an out-patient day care procedure. All cases are documented. All patients are followed-up post-operatively for many months up to a few years. All patients were completely cured from pain and there has never been a recurrence. The ano-rectal sphincters worked normally with full control of wind and faeces.

I would like to emphasize that the surgeon must have a very good and detailed knowledge of the surgical anatomy of the anal canal, rectum, the surrounding soft tissues and the highly specialized ano-rectal sphincters. Otherwise, there will be incontinence of wind and faeces, either partial or complete and this result is a disaster and it will not be possible to repair the damage which has been done. It is better for a surgeon to refrain from performing the surgical operation if they are not comprehensively familiar with the surgical procedure.                 


Ali Jafar’s personal experienceof nearly three hundred (300) surgical sphincterotomies for painful and tender Chronic Anal Fissures, just before the procedure of sphincterotomy while the patient is under anaesthesia, I palpate digitally the tones of both the Subcutaneous External Anal Sphincter and the Internal Anal Sphincter to determine the tone and bulkiness of both sphincters.



IN MALES, especially young adults, the muscle tone and power of both sphincters are normally high as well as bulkyTherefore in young adult males, I perform near full (not full) sphincterotomy of the Internal Anal Sphincter and limited sphincterotomy of the Subcutaneous External Anal Sphincter.

IN FEMALES, especially the multipara, the muscle tone and power of both sphincters are normally lower compared to males and in some very low. Also they are attenuatedThis is normally hormonal. Therefore, I perform either;

1) very limited sphincterorotmy of the Internal Anal Sphincter and full sphincterotomy of the Subcutaneous External Anal Sphincter or

2)full sphincterotomy of the Subcutaneous External Anal Sphincter only, especially in multipara.

Occasionally, the tone and power of sphincters of some males are the same as the females. In such cases, the surgical procedure will be the same as for the females.

The results of the above procedures are excellent i.e. immediate and permanent relief of pain during defaecation with full control of wind and faeces in both genders. These three methods  of sphincterotomies for males and females are different from the standard surgical practice which is full sphincterotomy of the Internal Anal Sphincter only for all patients of both genders. It is followed by a high percentage of incontinence of wind and frequently with faecesaccording to published reports; they are as high as thirty percent (30%).


The Anal Canal is four centimetres long (4 cm). It is a tube made of two types of muscular sphincters. Both are continuous with those of the Rectum and their fibres are all circular, consisting of two types of sphincters, the “Internal Anal Sphincter and the “External Anal Sphincters”. These sphincters hold the Anal Canal continually closed except for the temporary passage of flatus and faeces.

The junction of the Rectum and Anal Canal is at the pelvic floor, i.e. at the level where the “Pubo-Rectalis Muscle” clasps the gut and angles it forwards (see infra). From this right-angled junction with the Rectum, the Anal Canal passes downwards and somewhat backwards to the skin of the Perineum where it forms the Anal Verge.


As above, the Anal Canal is four centimetre (4 cm) long and divided into three parts. Upper (15 mm), middle (15mm) and lower (10mm).

The upper part (15mm) is lined with mucous membrane and contain crypts and glands. These glands are atypical Apocrine Mucous Glands and are called Anal Glands. The Anal Gland opens into a crypt. A mucous membrane is a membrane that lines cavities or passages and secretes mucus which is a protective slimy secretion. The nerve supply of this membrane is Autonomic and sensitive to pressure only, for example, digital examination of the ano-rectum and rectal tubeIt also can distinguish between constipated faeces, soft faeces, diarrhoea and flatus. It is relatively insensitive to touch and pain.

The lining of the middle part (15mm) is lined by none keratinized stratified squamous epithelium which is a transitional zone and called Pecten.The junction of the mucous membrane to the Pecten is called the Pectinate Line.

The lining of the lower part (10mm) of the Anal Canal is lined by a thin, hairless true skin and contains sebaceous and sweat glandsIts nerve supply is Somatic and therefore very sensitive to pain like a fissure and a cut from trauma.

The junction of the lower part of the Pecten to the upper part of the hairless skin lining of the lower part is abrupt and called Hilton’s White Line(Mr John Hilton, FRCS England, 1805-1878, English Anatomist and General Surgeon)This landmark is very important from the surgical point of view during surgical procedure of sphincterotomy for painful and tender Chronic Anal Fissure.

At this landmark, there is a “groove” or a “step” which is palpable. This groove separates the lower border of the Internal Anal Sphincter from the Subcutaneous External Anal Sphincter.

MUSCLE SPHINCTERS OF THE ANAL CANAL are Internal Anal Sphincter and External Anal Sphincters.

1) THE INTERNAL ANAL SPHINCTERS is a continuation of the muscles of the Rectum. It is a smooth muscle and encircles the upper two thirds of the Anal Canal down to Hilton’s White Line and it is under voluntary controlIts nerves supply are autonomic, Parasympathetic and Sympathetic.Parasympathetic stimulation relaxes the muscleSympathetic stimulation contracts the muscle, but this contraction is not competent when acting alone, it needs another three muscles to have complete continence of flatus and faeces (see infra).

2)THE EXTERNAL ANAL SPHINCTERS are striated muscles and encircles the lower two thirds of the Anal Canal. Therefore, the External Anal Sphincter overlaps the Internal Anal Sphincter at the middle third of the Anal CanalThe External Anal Sphincters consist of three separate parts.Each part is a ring of muscle lying adjacent to each other in a series. The lowest is called “Subcutaneous External Anal Sphincter”, the middle is called “Superficial External Anal Sphincter” and the uppermost which is the deepest is called “Profundus External Anal Sphincter”.

a) Subcutaneous External Anal Sphincter This is a thick ring of muscle like a ribbon band. It lies immediately beneath the skin and is easily palpable by the examining finger-tip (see infra)It is an important landmark during the surgical operation of sphincterotomy for Chronic Anal Fissures.

The lowest end of the Internal Anal Sphincter is thickened and by digital palpation during the surgical operation of sphincterotomy for Chronic Anal Fissure, it is felt as a tight flat band especially when stretched by a bivalved Alan Park’s anal retractor. It is bulky in young healthy adult males.

b) Superficial External Anal Sphincter This muscle contributes to the continence of wind and faeces.

c) Profundus External Anal Sphincter This is the uppermost and the deepest portion of the External Anal SphincterIt encircles the Internal Anal Sphincter in the highest part of the Anal Canal.

Corrugated Cutis of AniMuscle This small muscle consists of thin flat strip of smooth muscle fibres and is attached to the peri-anal skin. Its contraction expels the last drop(s) of faecal matter especially when the motion is loose and also, puckering of the peri-anal skin.                        

CONTINENCE OF FLATUS AND FAECES are essentiallyachieved by the four muscles which are the 1) “Pubo-Rectalis”, 2) “Profundus External Anal Sphincter”, 3) Superficial External Anal Sphincter and 4) part of the “Internal Anal Sphincter”.