Uncovering the Link Between Pre-Surgery Constipation and the Success of Surgery for Chronic Anal Fissure

• Abstract
• Introduction
• Methods
• Study Design and Setting
• Study Size
• Participants
• Variables
• Data Sources/Measurement
• Bias
• Statistical Analysis
• Results
• Discussion
• Limitations
• Conclusion
• References

Abstract

Introduction

Chronic anal fissure is a common condition affecting all ages. Surgical intervention is often necessary for severe cases. Recent studies indicate that the success of surgical procedures for chronic anal fissures is closely linked to the patient's bowel movements. Constipation can impede healing and increase the risk of complications post-surgery. This article investigates the correlation between pre-surgery constipation and the efficacy of fissure surgery, while also examining its impact on treatment outcomes.

Methods

We conducted a retrospective cohort study. Patients who underwent surgery for chronic anal fissures were evaluated for age, complaints, anorectal examination characteristics, and anatomical localization of fissures. The Rome IV criteria were used to diagnose functional constipation associated with anal fissures. We investigated the relationship between pre-surgery constipation and treatment success.

Results

Baseline constipation was detected in 21.4% of patients. At the 6-month follow-up, 28 patients failed to fully recover, but baseline constipation did not affect treatment success (p = 0.306). Additionally, Among the 28 patients with pre-surgery constipation, 15 still experienced constipation, while 8 of the 103 patients without pre-surgery constipation developed constipation postoperatively.

Conclusions

Our study found that the success of fissure surgery treatment was not affected by constipation. These results suggest that the theory of constipation and hard stool may be inadequate to fully explain the causes and success of surgical treatment for anal fissures. Other theories, such as high basal internal sphincter pressure and related ischemia, should be considered.

Introduction

Chronic anal fissure is a painful condition that occurs when a tear or cut in the skin of the anus fails to heal properly. It can cause severe pain, bleeding, and discomfort, making it difficult to sit, walk, or even have a bowel movement. Constipation is a common cause of chronic anal fissure.[1] [2] [3]

Although there are several theories regarding the pathophysiology of fissures, the exact cause remains unclear.[4] One of the most widely accepted theories suggests that mucosal rupture and fissure occur as a result of canal trauma caused by constipation and hard stools.[5] [6] [7] Another hypothesis proposes that in patients with high basal internal sphincter tone, the branches of the inferior rectal artery pass through the intermuscular septa of the sphincter. Due to the spasm, ischemic regions develop in the posterior wall of the canal, contributing to fissure formation.[8] [9] However, it is still unclear which of these hypotheses is the cause and which is the result.

It is important to understand whether pre-surgery constipation is a primary cause or a secondary effect of chronic anal fissures. Some studies propose that constipation may lead to canal trauma, while others suggest that the fissure itself results in painful defecation, voluntary stool retention, and subsequent constipation.[1] [2] [3] [5] [6] [7]

Chronic anal fissures significantly reduce patients' quality of life, making effective management essential. While surgery is often necessary to treat chronic anal fissures, the success of the procedure can be compromised by pre-surgery constipation. By identifying and addressing constipation before surgery, there may be potential to improve surgical outcomes and recovery times.

The study aims to provide evidence-based insights into the relationship between pre-surgery constipation and the success of surgical treatment for chronic anal fissures. Our findings could guide clinical practitioners in optimizing preoperative care for these patients.

Methods

Study Design and Setting

This retrospective cohort study was conducted at the Department of General Surgery, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey, between 2019 and 2020. Patients diagnosed with chronic fissure who underwent lateral internal sphincterotomy (LIS) were included. To ensure accurate representation, the study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines throughout. Patients with neurological, anatomical, or chronic disorders causing constipation were excluded.

Study Size

The sample size was calculated with a confidence level of 95%, power of 90%, common standard deviation, and accuracy of 0.10, resulting in a minimum required sample size of 125 cases. This ensures that the study has sufficient statistical power to detect clinically meaningful differences.

Participants

Patients were selected based on their diagnosis of chronic fissure and scheduled for LIS. A total of 141 patients were assessed for eligibility, and 131 met the inclusion criteria. Patients excluded had conditions such as significant anorectal malformations or chronic neurological impairments, ensuring the sample was homogenous.

Variables

Chronic fissure was defined as complaints persisting for more than 4–6 weeks with physical examination confirming fissures. Functional constipation was diagnosed using the Rome IV criteria. Additionally, constipation characteristics were carefully reviewed to differentiate functional from other constipation causes. Chronic constipation was defined as infrequent passage of stools or difficulty in passing them for an extended period, leading to fewer than three bowel movements a week. Treatment success at the 6-month follow-up was defined as complete healing of both the skin and mucosal tears, and a painless finger examination with no signs of recurrence. The relationship between baseline constipation status and treatment success was also evaluated.

Data Sources/Measurement

Data was collected from patient medical records. Variables included age, gender, complaints, anorectal examination characteristics, fissure localization, and baseline constipation status. To ensure measurement reliability, medical records were cross-referenced with physician reports when discrepancies arose.

Bias

Potential biases were minimized by excluding patients with neurological, anatomical, or chronic disorders causing constipation, and by using standardized criteria for defining constipation and treatment success. Additionally, the retrospective design minimized recall bias by relying solely on documented medical records.

Statistical Analysis

The data were collected and analyzed using SPSS (Statistical Package for the Social Sciences) 23 software version (IBM Corporation, Armonk, New York, USA). All data were stored confidentially on hospital computers. To analyze the data, categorical variables were expressed as frequency and percentage, normally distributed parametric data were expressed as mean (standard deviation), and non-normally distributed parametric data were expressed as median (quartile range) and range of values. For comparisons, t-tests were used for parametric data, and Fisher's exact test was used for categorical data. Statistical significance was determined if the P-value was less than 0.05 at the 95% confidence interval.

Results

The age range of patients was between 18 and 65 years, with a mean age of 25 ± 22. The most prevalent age group for fissures was 20–30 years, comprising 48.1% (n = 63) of the patients, followed by 31–40 years (24.4%, n = 32). Interestingly, fissures were found to be more prevalent in males, accounting for 54.96% (n = 72) of the cases. Upon examination, it was discovered that the presence of blood on wipes or napkins after cleaning was present in 70.2% of cases (92 patients), while the presence of blood on the stool was present in 16% of cases (21 patients). Additionally, a history of hard or large-volume stool was present in 19.1% of the patients (25 patients).

During the physical examination, fissures were found in the anterior wall in 10.7% (14 patients), in the lateral wall in 7.6% (10 patients), and in the posterior wall in 77.9% (102 patients). Furthermore, five patients had multiple fissures, and in the rectal examination, stool fragments in the form of a hard mass were detected in 24 patients. Patients with posterior wall fissures were more likely to report blood on wipes (78.4%, n = 80) compared with those with anterior or lateral wall fissures (41.7%, n = 10).

In the 6th month follow-up, 103 patients achieved successful recovery, while 28 patients did not fully recover. Patients with persistent postoperative symptoms were more likely to report baseline hard stool history (28.6%, n = 8) compared with those who recovered (16.5%, n = 17). The overall treatment success rate was 78.6% (n = 103). The analysis of age and gender statistics between the treatment groups that experienced success, and failure did not yield any significant differences (p > 0.05 for all variables).

When evaluating the patients according to the Rome IV criteria, baseline (Pre-surgery) constipation was present in 21.4% of the patients (28 patients). In follow-up, 20 patients failed to achieve full recovery, and no effect of baseline constipation was detected on treatment success (p = 0.306) ([Table 1]). At the 6-month follow-up, we assessed the constipation status of all patients. Out of the 28 patients who had pre-surgery constipation, 15 (53.6%) still experienced constipation after surgery. Additionally, 8 patients (7.8%) who did not have pre-surgery constipation developed constipation postoperatively.

Among the 20 patients with persistent symptoms at follow-up, 13 (65%) reported new-onset or persistent constipation. In contrast, among the successfully treated group (n = 103), 15 (14.6%) reported new or ongoing constipation (p < 0.001). Patients who developed postoperative constipation were more likely to have had multiple fissures identified during the initial examination (n = 4, 50%) compared with those with no postoperative constipation (n = 1, 5.3%).

Discussion

This study aims to uncover the link between pre-surgery constipation and the success of surgery for chronic anal fissures. This is a crucial topic to explore, as constipation has been known to be a contributing factor in the recurrence of chronic anal fissures after surgery. This study involves a comprehensive review of patient medical records and interviews with individuals who have undergone surgery for chronic fissures. Utilizing both quantitative and qualitative methods, our research team aimed to identify potential correlations between pre-surgery constipation and the success of surgery for chronic fissure. Unfortunately, our findings did not reveal any significant correlations, indicating that further research is necessary to fully understand this issue. Despite this setback, the results of our study have the potential to greatly impact the treatment of chronic fissures by providing valuable insights into the factors that contribute to successful surgical outcomes. While we were unable to definitively prove our hypothesis, we remain committed to advancing our understanding of this condition and improving the lives of those affected by it.

Performing fissure surgery when constipation is present can increase the risk of postoperative complications. It can also make it more challenging for the surgeon to achieve a good outcome because the anal area may be more sensitive and inflamed due to the presence of hard stools. Pre-surgery constipation can significantly impact the success of fissure surgery. When constipation is not addressed before surgery, it can cause further trauma to the anal area during bowel movements, leading to complications such as infection, bleeding, and delayed healing.[10] Pre-surgery constipation can be caused by several factors, including a low-fiber diet, dehydration, lack of exercise, stress, and certain medications. These factors contribute to the formation of hard, dry stools that are difficult to pass, leading to constipation. Constipation can delay the healing of chronic anal fissures by causing further trauma to the anal area during bowel movements. Constipation delays fissure healing by causing repetitive anal trauma and amplifying local inflammation during defecation. Addressing constipation pre-surgery could potentially improve postoperative outcomes.[11]

Several studies have shown that patients who suffer from constipation before their surgical procedure are more likely to experience complications such as pain and scarring after the surgery. This is because constipation can cause straining during bowel movements, which can put additional pressure on the area around the fissure. However, not all studies have come to the same conclusion. A recent study published by Garg et al.[12] found no significant association between pre-op constipation and postoperative outcomes in patients undergoing surgery for anal fissure. The authors suggested that more research is needed in this area to fully understand the relationship between constipation and surgical outcomes.

There is a lack of agreement on the root causes of fissures, leaving much uncertainty in the medical community. Some argue that constipation is the culprit, while others suggest that internal sphincter hypertonicity and subsequent constipation may be the cause of fissures.[13] [14] [15] [16] However, our study found that the incidence of constipation in patients with fissures was not significantly higher than in the general population of similar age. This finding underscores the importance of considering alternate pathophysiological mechanisms, such as heightened internal sphincter tone and ischemia, which may lead to fissure development independent of constipation.

Surgery for chronic anal fissure, or LIS, is a highly effective procedure that has been shown to significantly decrease the resting tone of the anal canal. As a result, constipation, which is often associated with increased muscle tension in this area, becomes a non-factor after surgery.[1] [5] One of the key advantages of LIS is that even if patients have pre-existing constipation, they are unlikely to develop painful fissures due to decreased muscle tone. Nevertheless, the persistence of constipation post-surgery in some patients—observed in our studies calls for tailored postoperative management strategies to address this subset. Therefore, addressing constipation before undergoing LIS can play a crucial role in preventing the occurrence of these symptoms and creating an ideal environment for post-surgical recovery. By doing so, patients are more likely to achieve improved treatment outcomes and experience faster recovery times while resuming their normal activities. Ultimately, this holistic approach results in a better quality of life for individuals seeking relief from anal fissures through surgical intervention.

Although we have not found any conclusive evidence to suggest that pre-operative constipation has a direct impact on the success of fissure surgery, further research is necessary to fully understand the potential relationship. Nevertheless, we highly recommend that patients who have scheduled surgery take proactive measures to manage their constipation in the weeks leading up to the procedure. This can help to ensure optimal conditions for a successful surgery and a smoother recovery.

To draw a conclusive and scientifically valid inference, it would have been essential to select a cohort of fissure patients who exhibited improvements or were successfully cured through conservative management. This approach would have provided meaningful insights into the effectiveness of non-invasive treatment methods and allowed for evidence-based recommendations. However, it is important to acknowledge the inherent challenges in designing such an experiment. Obtaining a homogeneous patient population demonstrating consistent outcomes can be difficult due to individual variations in response to conservative management techniques, confounding factors, ethical considerations, and the dynamic nature of medical conditions.

Limitations

Our hypothesis suggests that addressing preoperative constipation could lead to better treatment outcomes and faster recovery times for patients undergoing surgery for chronic anal fissures. However, several limitations need to be considered:

1. Lack of Empirical Evidence: There is a dearth of empirical evidence directly supporting or contradicting our hypothesis, partly because constipation is often overlooked until it becomes severe. This lack of data makes it challenging to draw definitive conclusions.

2. Variability in Types of Constipation: Constipation can have various causes, including medication side effects, underlying health conditions, or lifestyle factors. Our study did not differentiate constipation based on its etiology, which could limit the applicability of the findings.

3. Potential Biases:

   • ○ Selection Bias: Patients included in the study may not be representative of the general population with chronic anal fissure. Those who opted for surgery may differ significantly from those who managed the condition conservatively.

   • ○ Recall Bias: As a retrospective study, the accuracy of patient-reported data on constipation and other symptoms might be compromised. Patients might not accurately remember their bowel habits or symptom severity before surgery.

   • ○ Measurement Bias: The diagnosis of constipation based on Rome IV criteria might not capture all aspects of the condition. Variability in clinical judgment and patient interpretation of symptoms could further complicate the findings.

4. Other Contributing Factors: The study's focus on constipation might overlook other significant factors influencing surgical outcomes, such as patient age, overall health status, and the specifics of the surgical procedure. These factors could have a more substantial impact on recovery and treatment success.

5. Heterogeneity of the Patient Population: Individual variations in response to surgical treatment and conservative management make it difficult to generalize the findings. The dynamic nature of medical conditions and the presence of confounding factors add to the complexity.

6. Follow-up Duration: The six-month follow-up period may not be sufficient to capture long-term outcomes and complications. Chronic anal fissures and constipation are conditions that can have fluctuating courses over longer periods.

7. Absence of a Control Group: The study lacks a control group of patients who did not undergo surgery, which could provide a comparative baseline to better understand the effects of preoperative constipation on surgical outcomes.

Conclusion

Our study revealed that constipation does not have an impact on the success of fissure surgery. These findings challenge the conventional belief that constipation and hard stool are primary causes of fissures. Instead, other theories, such as high basal internal sphincter pressure and related ischemia, should be considered when determining the cause and surgical treatment success of fissures. Nonetheless, it is essential to address the potential influence of constipation as part of a comprehensive preoperative evaluation, given its multifactorial nature and varying definitions. Due to the limitations and potential biases, further research is essential to fully understand the relationship between preoperative constipation and surgical outcomes for chronic anal fissures.

Conflicts of Interest

The author declares that they have no conflict of interest regarding the content of this report.

Presentation at a Meeting

Nil.

Data Availability Statement

The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethical restrictions.

Ethical Considerations

This retrospective cohort study involving human participants was approved by the Ethics Committee of the University of Health Sciences, Umraniye Training and Research Hospital (Document No: 268, Decision No: 289, Date: September 5, 2024). The study was conducted in accordance with the national research committee's guidelines and the principles outlined in the Declaration of Helsinki and its later amendments or comparable ethical standards.

Patient Declaration of Consent Statement

This study does not contain identifying patient information. Specific written informed consent for this study was not required due to its retrospective design. However, all patients and/or their legal guardians had previously signed a general informed consent form allowing the anonymous use of their data for research, education, and quality improvement purposes.

Authors' Contributions

All named authors contributed to the clinical care of the patients, data collection, drafting and revising of the manuscript, and approval of the final version of the article.

• References

• 1 Bara BK, Mohanty SK, Behera SN, Sahoo AK, Swain SK. Fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissure: A randomized control trial. Cureus 2021; 13 (09) e18363
  CrossrefPubMedSearch in Google Scholar
• 2 Nelson RL, Manuel D, Gumienny C. et al. A systematic review and meta-analysis of the treatment of anal fissure. Tech Coloproctol 2017; 21 (08) 605-625
  CrossrefPubMedSearch in Google Scholar
• 3 Hull TL. Surgery of the anus, rectum and colon. Gastroenterology 2000; 119 (04) 1173-1175
  CrossrefPubMedSearch in Google Scholar
• 4 Joda AE, Al-Mayoof AF. Efficacy of nitroglycerine ointment in the treatment of pediatric anal fissure. J Pediatr Surg 2017; 52 (11) 1782-1786
  CrossrefPubMedSearch in Google Scholar
• 5 Schlichtemeier S, Engel A. Anal fissure. Aust Prescr 2016; 39 (01) 14-17
  CrossrefPubMedSearch in Google Scholar
• 6 Poh A, Tan K-Y, Seow-Choen F. Innovations in chronic anal fissure treatment: A systematic review. World J Gastrointest Surg 2010; 2 (07) 231-241
  CrossrefPubMedSearch in Google Scholar
• 7 Kenny SE, Irvine T, Driver CP. et al. Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure. Arch Dis Child 2001; 85 (05) 404-407
  CrossrefPubMedSearch in Google Scholar
• 8 Kraima AC, West NP, Roberts N. et al. The role of the longitudinal muscle in the anal sphincter complex: Implications for the Intersphincteric Plane in Low Rectal Cancer Surgery?. Clin Anat 2020; 33 (04) 567-577
  CrossrefPubMedSearch in Google Scholar
• 9 Schouten WR, Briel JW, Auwerda JJ, Boerma MO. Anal fissure: new concepts in pathogenesis and treatment. Scand J Gastroenterol Suppl 1996; 218: 78-81
  CrossrefPubMedSearch in Google Scholar
• 10 Garg P. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment for anal fissure: A new concept in conservative management. Indian J Surg 2016; 78 (01) 80
  CrossrefPubMedSearch in Google Scholar
• 11 Zinicola R, Cracco N, Totaro A, Dalla Valle R, Pedrazzi G. A simple bowel habit score for colorectal patients. Int J Colorectal Dis 2017; 32 (01) 143-145
  CrossrefPubMedSearch in Google Scholar
• 12 Garg P, Yagnik VD, Bhattacharya K. Local plus oral antibiotics and strict avoidance of constipation is effective and helps prevents surgery in most cases of anal fissure. Ann Coloproctol 2023; 39 (02) 188-189
  CrossrefPubMedSearch in Google Scholar
• 13 Tsukada Y, Ito M, Watanabe K. et al. Topographic anatomy of the anal sphincter complex and levator Ani muscle as it relates to intersphincteric resection for very low rectal disease. Dis Colon Rectum 2016; 59 (05) 426-433
  CrossrefPubMedSearch in Google Scholar
• 14 Beaty JS, Shashidharan M. Anal Fissure. Clin Colon Rectal Surg 2016; 29 (01) 30-37
  Thieme ConnectPubMedSearch in Google Scholar
• 15 Karandikar S, Brown GM, Carr ND, Beynon J. Attitudes to the treatment of chronic anal fissure in ano after failed medical treatment. Colorectal Dis 2003; 5 (06) 569-572
  CrossrefPubMedSearch in Google Scholar
• 16 Utzig MJ, Kroesen AJ, Buhr HJ. Concepts in pathogenesis and treatment of chronic anal fissure–a review of the literature. Am J Gastroenterol 2003; 98 (05) 968-974
  CrossrefSearch in Google Scholar

Address for correspondence

Publication History

Received: 02 August 2024

Accepted: 22 May 2025

Article published online:
26 June 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

Thieme Revinter Publicações Ltda.
Rua Rego Freitas, 175, loja 1, República, São Paulo, SP, CEP 01220-010, Brazil

• References

• 1 Bara BK, Mohanty SK, Behera SN, Sahoo AK, Swain SK. Fissurectomy versus lateral internal sphincterotomy in the treatment of chronic anal fissure: A randomized control trial. Cureus 2021; 13 (09) e18363
  CrossrefPubMedSearch in Google Scholar
• 2 Nelson RL, Manuel D, Gumienny C. et al. A systematic review and meta-analysis of the treatment of anal fissure. Tech Coloproctol 2017; 21 (08) 605-625
  CrossrefPubMedSearch in Google Scholar
• 3 Hull TL. Surgery of the anus, rectum and colon. Gastroenterology 2000; 119 (04) 1173-1175
  CrossrefPubMedSearch in Google Scholar
• 4 Joda AE, Al-Mayoof AF. Efficacy of nitroglycerine ointment in the treatment of pediatric anal fissure. J Pediatr Surg 2017; 52 (11) 1782-1786
  CrossrefPubMedSearch in Google Scholar
• 5 Schlichtemeier S, Engel A. Anal fissure. Aust Prescr 2016; 39 (01) 14-17
  CrossrefPubMedSearch in Google Scholar
• 6 Poh A, Tan K-Y, Seow-Choen F. Innovations in chronic anal fissure treatment: A systematic review. World J Gastrointest Surg 2010; 2 (07) 231-241
  CrossrefPubMedSearch in Google Scholar
• 7 Kenny SE, Irvine T, Driver CP. et al. Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure. Arch Dis Child 2001; 85 (05) 404-407
  CrossrefPubMedSearch in Google Scholar
• 8 Kraima AC, West NP, Roberts N. et al. The role of the longitudinal muscle in the anal sphincter complex: Implications for the Intersphincteric Plane in Low Rectal Cancer Surgery?. Clin Anat 2020; 33 (04) 567-577
  CrossrefPubMedSearch in Google Scholar
• 9 Schouten WR, Briel JW, Auwerda JJ, Boerma MO. Anal fissure: new concepts in pathogenesis and treatment. Scand J Gastroenterol Suppl 1996; 218: 78-81
  CrossrefPubMedSearch in Google Scholar
• 10 Garg P. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment for anal fissure: A new concept in conservative management. Indian J Surg 2016; 78 (01) 80
  CrossrefPubMedSearch in Google Scholar
• 11 Zinicola R, Cracco N, Totaro A, Dalla Valle R, Pedrazzi G. A simple bowel habit score for colorectal patients. Int J Colorectal Dis 2017; 32 (01) 143-145
  CrossrefPubMedSearch in Google Scholar
• 12 Garg P, Yagnik VD, Bhattacharya K. Local plus oral antibiotics and strict avoidance of constipation is effective and helps prevents surgery in most cases of anal fissure. Ann Coloproctol 2023; 39 (02) 188-189
  CrossrefPubMedSearch in Google Scholar
• 13 Tsukada Y, Ito M, Watanabe K. et al. Topographic anatomy of the anal sphincter complex and levator Ani muscle as it relates to intersphincteric resection for very low rectal disease. Dis Colon Rectum 2016; 59 (05) 426-433
  CrossrefPubMedSearch in Google Scholar
• 14 Beaty JS, Shashidharan M. Anal Fissure. Clin Colon Rectal Surg 2016; 29 (01) 30-37
  Thieme ConnectPubMedSearch in Google Scholar
• 15 Karandikar S, Brown GM, Carr ND, Beynon J. Attitudes to the treatment of chronic anal fissure in ano after failed medical treatment. Colorectal Dis 2003; 5 (06) 569-572
  CrossrefPubMedSearch in Google Scholar
• 16 Utzig MJ, Kroesen AJ, Buhr HJ. Concepts in pathogenesis and treatment of chronic anal fissure–a review of the literature. Am J Gastroenterol 2003; 98 (05) 968-974
  CrossrefSearch in Google Scholar