Long-Term Results of Lateral Internal

Sphincterotomy for Chronic Anal

Fissure with Particular Reference to
Incidence of Fecal Incontinence
D e n i s C. N. K. Nyam, M.D. John H. Pemberton, M.D.
From the Division of Colon and Rectal Sz~rge,y, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
PURPOSE: Lateral internal sphincterotomy is the procedure
of choice for chronic anal fissure because it relieves symptoms and heals the fissure in nearly all patients. However,
there is evidence that fecal incontinence complicates lateral
internal sphincterotomy. The aim of this study was to examine the outcome of lateral internal sphincterotomy in
terms of fissure healing and incidence of fecal incontinence.
METHODS: Between 1984 and 1996, 585 patients underwent lateral internal sphincterotomy and were surveyed by
questionnaire. Eighty-three percent (487/585) responded.
The mean follow-up was 72 (range, 6-145) months. RESULTS: Fissures had healed by a median of three weeks after
surgery in 96 percent of patients. Recurrent fissures occurred in 8 percent. Two thirds of the recurrent fissures
healed on conservative management alone. Ninety-eight
percent of patients were satisfied with the outcome of
surgery, but some degree of fecal incontinence occurred in
fully 45 percent of patients at some time in the postoperative period. Incontinence occurred in 53.4 percent of
women and 33.3 percent of men (P < 0.05). Incontinence
to flatus, mild soiling, and gross incontinence occurred in
31, 39, and 23 percent of patients, respectively. However,
by the time of survey (a mean of >5 years after lateral
internal sphincterotomy) 6 percent reported incontinence
to flatus, 8 percent had minor fecal soiling, and 1 percent
experienced loss of solid stool. Importantly, only 3 percent
of patients stated that incontinence had ever affected their
quality of life. CONCLUSION: Although lateral internal
sphincterotomy heals and relieves symptoms of chronic
anal fissure in nearly all patients (96 percent), incontinence
occurs frequently. Most episodes of incontinence are indeed minor and transient, but in a small subgroup, incontinence seems to be permanent. [Key words: fecal incontinence; Lateral internal sphincterotomy; Anal fissure]
Nyam DCNK, Pemberton JH. Long-term results of lateral
internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis
Colon Rectum 1999;42:1306-1310.
h r o n i c anal fissures are often a s s o c i a t e d w i t h
h i g h resting anal p r e s s u r e s at m a n o m e t r y , suggesting u n d e r l y i n g h y p e r t o n i a o f the internal anal
sphincter. 1-3 A lateral internal s p h i n c t e r o t o m y , w h i c h

Read at the meeting of The American Society of Colon and Rectal

Surgeons, Philadelphia, Pennsylvania, June 22 to 26, 1997.
Address reprint requests to Dr. Pemberton: Division of Colon and
Rectal Surgery, Mayo Clinic, East 6-A, 200 First Street SW, Rochester.
Minnesota 55905.
1306

r e d u c e s this anal resting p r e s s u r e , e results in h e a l i n g

in m o r e t h a n 95 p e r c e n t o f patients w i t h c h r o n i c anal
fissures.< 5 The p r o c e d u r e is s i m p l e a n d c a n b e d o n e
in the o u t p a t i e n t setting w i t h r e p r o d u c i b l e results.
C o m p l i c a t i o n s o f the p r o c e d u r e s u c h as infection a n d
b l e e d i n g are relatively u n c o m m o n a n d self-limiting.
H o w e v e r , fecal i n c o n t i n e n c e has b e e n r e p o r t e d
since the initial d e s c r i p t i o n o f the p r o c e d u r e b y Eisenh a m m e r . 6 Most of t h e s e r e p o r t s d e a l w i t h the i m m e diate p o s t o p e r a t i v e p e r i o d a n d d o c u m e n t o n l y gross
incontinence.5.7-11 O u r a i m w a s to d e t e r m i n e the inc i d e n c e a n d the l o n g - t e r m s e q u e l a e o f a n y form o f
fecal i n c o n t i n e n c e after lateral s p h i n c t e r o t o m y for
c h r o n i c anal fissure.

PATIENTS

AND

METHODS

A total o f 585 patients w h o u n d e r w e n t lateral internal s p h i n c t e r o t o m y b e t w e e n 1984 a n d 1996 for

c h r o n i c anal fissure at the M a y o Clinic w e r e identified
a n d sent q u e s t i o n n a i r e s . Q u e s t i o n s w e r e d e s i g n e d to
d e t e r m i n e the o u t c o m e o f s u r g e r y w i t h r e f e r e n c e to
healing, r e c u r r e n c e o f the fissure, a n d fecal incontin e n c e . Fecal i n c o n t i n e n c e w a s c a t e g o r i z e d into inc o n t i n e n c e to flatus, m i l d i n c o n t i n e n c e ( o c c a s i o n a l l y
soiling o f the u n d e r g a r m e n t ) , a n d gross i n c o n t i n e n c e
( a c c i d e n t a l b o w e l m o v e m e n t s ) . D u r a t i o n o f incontin e n c e after s u r g e r y w a s c a t e g o r i z e d into transient (if
the i n c o n t i n e n c e lasted less t h a n 1 w e e k p o s t o p e r a tively), p r o l o n g e d (if it lasted m o r e t h a n 1 w e e k b u t
less t h a n a m o n t h ) , a n d p e r s i s t e n t (ff the patients w e r e
still c o m p l a i n i n g o f i n c o n t i n e n c e o n e m o n t h after
their surgery).
Lateral internal s p h i n c t e r o t o m y w a s p e r f o r m e d und e r direct vision u s i n g a short radially o r i e n t e d incision in the lateral anal canal (either left o r righ0,
visualizing the internal s p h i n c t e r a n d incising it for 50
to 60 p e r c e n t o f its length. T h e incision w a s c l o s e d
w i t h a n a b s o r b a b l e suture. "Blind" lateral internal

Vol. 42, No. 10

INCONTINENCE AFTER LATERALSPHINCTEROTOMY

sphincterotomy was performed by inserting an Number 11 blade just lateral to the rolled edge of the
internal sphincter, turning the blade, and incising the
muscle under the operator's finger. This resulted in 50
to 60 percent of the muscle length being incised. More
than 95 percent of the patients underwent open lateral
internal sphincterotomy in this study.
The severity of incontinence was graded never, rare
(less than once per month), rarely (more than once
per month but less than once per week), occasionally
(more than once per week) and frequently (every
day). The impact upon quality of life was assessed by
documenting limitation of physical, social, and sexual
activity.
The quality-of-life questions asked of these patients
were "operation specific," meaning that the patients
responded quite simply to one question: "Was or is
your activity of daily living in the areas of work,
sports, family relationships, work around the house,
travel, and sexual activity affected by your operation
severely, a little, don't notice it, or not at all?" Similar
operation-specific quality-of-life queries have been
published for years from this institution :2, 13 being
validated in 1989. :4

RESULTS
There was an 83 percent (487/585; 251 males) response rate from the questionnaire survey. The cohort
had a median follow-up of 72 (range, 6-145) months.
The median age of this group was 38 (range, 17-68)
years. All patients had been diagnosed with the condition and treated with conservative medical therapy
for at least six weeks before surgery. Only patients
who underwent a lateral internal sphincterotomy in
the period of the study were included in the questionnaire mailing list. All these patients had a sphincterotomy that did not extend beyond the dentate line.
Ninety-six percent of the patients had symptoms of
the fissure relieved after lateral internal sphincterotomy. The median time for this to occur was three

1307

weeks. Most patients reported almost immediate improvement of anal pain. Overall, 98 percent of the
patients were satisfied with the outcome of the surgery.
The fissure persisted or recurred in 8 percent (36/
487) of patients at a median of 22 months from the
index surgery. Two-thirds of these healed after a further period of conservative treatment consisting of
fiber and fluids. In 13 patients further surgery was
necessary. Ten patients underwent repeat sphincterotomies; one had an anal dilation, and two were
treated with anoplasties.

Fecal Incontinence
Fully 45 percent (219/487) of the patients reported
one or more episodes of fecal incontinence at some
time after lateral internal sphincterotomy. There was
no statistically significant difference w h e n the incidence of incontinence was analyzed by age.
Comparing males and females, there was no difference between genders in the ability to differentiate
gas from stool after lateral internal sphincterotomy.
Females seemed to have more flatus incontinence
( P < 0.05), and although more men complained of
soiling, this did not reach statistical significance.
When it came to gross incontinence or loss of solid
stools, there was no difference between the genders
(Table 1).

Early Postoperative Incontinence

The majority of these incontinent events occurred
in the early postoperative period. Thirty-one percent
of patients reported incontinence to gas, 39 percent
had soiling, and 13 percent had gross incontinence.
The problem of flatus incontinence, soiling, and gross
incontinence, respectively, was persistent b e y o n d
one month in only 6, 8, and 0.8 percent of patients
(Table 2). By one month after surgery, the incidence
of incontinence diminished such that 6 percent of pa-

Table 1.
Differences in Fecal Incontinence After Lateral Internal Sphincterotomy by Gender
Males

Females

(n = 236)

(n = 251)

Difficulty in differentiating gas from stools

80
Flatus control
85
Soiling
102
Gross incontinence
57
NS = not significant.
Figures are number of patients unless otherwise specified.

73
132

NS
<0.05

87

NS

56

NS

1308

NYAM AND PEMBERTON

Table 2.
Incontinence Early (1 Month) After Lateral
Internal Sphincterotomy
%
Flatus
Transient
Prolonged
Persistent
Soiling
Transient
Prolonged
Persistent
Gross
Transient
Prolonged
Persistent

6
19
6

Total (%)

31

19
12
8

39

11
2
1

13

Transient = less than a week postoperative; Prolonged = one week to one month postoperative; Persistent = more than one month postoperative.

tients were incontinent of flatus occasionally, 8 percent complained of occasional soiling, and 0.8 percent had gross fecal incontinence.
Seventy-nine percent of patients never used a pad
after surgery. Ten percent used pads only in the daytime, 4 percent used pads only at night, and 7 percent
used pads all the time. However, the majority of these
patients used pads for security rather than for protection from fecal incontinence.

I n c o n t h a e n c e Score
Patients were scored on an incontinence score as
outlined in Table 3. Two scores were calculated for
each patient, one in the immediate postoperative period and another at the time of the questionnaire. The
m a x i m u m score is 21 and the severity is classified as
none (score = 0), mild (score = 1-7), moderate
(score = 8-14), and severe (score = 15-21).
In the early postoperative period, 55 percent of
patients scored 0, 33 percent scored as mild incontinence, 9 percent had moderate incontinence, 7-~3 and
3 percent had severe incontinence. 1~-16 At the time of
last follow-up, however, the numbers had improved,
with 89 percent of patients being totally continent (0),
6.5 percent having mild incontinence, >6 3.7 percent
with mild incontinence, ~13 and only 0.8 percent having fecal incontinence that was scored as severe .4q7
(Table 4).
That the majority of incontinence episodes were
not severe was also reflected in the quality-of-life
assessment after lateral internal sphincterotomy. Although in the early postoperative period 3.3, 3.7, and

Dis Colon Rectum, October 1999

Table 3.
Incontinence Score Based on Persistence and Severity
Persistence

Score

Severity

Score

Flatus
None
Transient
Prolonged
Permanent

0
1
2
3

Never
Rarely
Occasionally
Frequently or all the
time

0
1
2
3

Soiling
None
Transient
Prolonged
Permanent

0
1
2
3

Never
Rarely
Occasionally
Frequently or all the
time

0
1
2
3

Gross
None
Transient
Prolonged
Permanent

0
1
2
3

Never
Rarely
Occasionally
Frequently or all the
time

0
1
2
3

Pads
Never
Nighttime only
Daytime only
All the time

0
1
2
3

Maximum score for fecal incontinence = 21.

Table 4.
Severity of Incontinence (Based on Incontinence Score)

None (0)
Mild (1-7)
Moderate (8-14)
Severe (15-21)

Early Postoperative

Last Follow-Up

55
33
9
3

89
6.5
4
1

1 percent of patients replied that their physical, social,

and sexual lives, respectively, were affected as a result
of fecal incontinence after their surgery, less than 1
percent of these patients had their lives affected by
incontinence at the time of answering the questionnaire.
DISCUSSION
Chronic anal fissures are associated with spasm of
the internal anal sphincter. Moreover, fibrosis
throughout the internal sphincter in patients with fissures has b e e n demonstrated. ~5 Manometric evidence
of internal sphincter spasm reflecting elevated resting
anal pressures has also b e e n shown, i The first lateral
internal sphincterotomy was reported by Eisenhammer 6 and Notaras ~v is credited with the first report of
the subcutaneous closed lateral sphincterotomy. The
procedure consistently heals and relieves the symp-

Vol. 42, No. 10

INCONTINENCE AFTER LATERALSPHINCTEROTOMY

toms of chronic anal fissures in more than 95 percent

of patients and has replaced both anal dilation and
posterior sphincterotomy as the treatment of choice
for anal fissures. It is a simple procedure, which facilitates controlled division of the internal sphincter
spasm related to chronic fissures with relatively minor
immediate complications. 18, 19 Recurrence or persistence of fissures after lateral internal sphincterotomy
is u n c o m m o n ; the literature is generally in agreement
that recurrence rates are less than 10 percent. 7, 18 In
this study only 4 percent of patients had a recurrence.
Furthermore, two-thirds of the recurrences healed
with medical m a n a g e m e n t that included pharmacologic manipulation of stool consistency and symptomatic treatment.
The actual incidence of fecal incontinence after
lateral internal sphincterotomy has b e e n poorly documented, the reported incidence varying b e t w e e n 1.3
and 66 percent. 5, 7-11 Earlier reports implied the problem was infrequent but this has b e e n disputed recently.
The results of this survey, which had a g o o d response rate of 83 percent and a median follow-up of
six years, documents the actual incidence of the problem and the long-term outcome in detail. Healing
rates and time to healing are similar to those reported
elsewhere. However, w e found that fully 45 percent
of respondents had experienced some form of fecal
incontinence at some time after their surgery. The
majority of these events occurred in the early postoperative period. Although some episodes may be
caused b y having a raw w o u n d in the perianal region,
a significant n u m b e r of events were delayed (Table
2).
Fecal incontinence is difficult to quantify and there
is no universally acceptable scoring system. We devised our scoring system to assess both the severity
and persistence of the problem. Patients were then
reclassified into I, no fecal incontinence; II, mild; III,
moderate; or IV, severe based on their scores (Tables
3 and 4). Although 45 percent of patients had early
postoperative incontinence, at the time of follow-up
only 11 percent complained of incontinence. The
proportion of patients w h o had full continence also
increased from 55 to 89 percent in the same period.
Importantly, although 3 percent of patients had severe fecal incontinence in the early postoperative
period, only 0.8 percent had the same severity at the
time of follow-up.
Even though some patients developed fecal incontinence, severe incontinence enough to cause lifestyle

1309

disturbance was fortunately u n c o m m o n . Furthermore, it is reassuring that in the long term, quality of
life was s o m e h o w affected in less than one percent of
patients. This finding is supported by the observation
that the majority were satisfied with the outcome of
surgery. However, the incidence of fecal incontinence
in the early postoperative is very high and is a problem that cannot be ignored. It seems propitious,
therefore, that nitric oxide has b e e n identified recently as the chemical messenger mediating relaxation of the internal anal sphincter. It has b e e n shown
that local application of exogenous nitric oxide donors such as nitroglycerine and isosorbide dinitrate
reduces anal pressures and improves anodermal
blood flow. This dual effect has b e e n reported to
result in healing of anal fissures and in more than 80
percent of patients, z-22 Manometry m a y supplement
the physical examination and history in an attempt to
differentiate patients w h o may benefit from nonsurgical or sphincter-saving procedures. 23

CONCLUSION
The incidence of fecal incontinence in the early
postoperative period after lateral internal sphincteroto m y is very high, but the severity is mild. Gross fecal
incontinence is rare. Impot'tantly, incontinence after
lateral internal sphincterotomy is self-limiting, and the
incidence of severe permanent disability is less than 1
percent. When anal fissures b e c o m e chronic and unresponsive to aggressive medical m a n a g e m e n t including topical nitroglycerine, lateral internal sphincteroto m y remains the treatment of choice.

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1310

NYAM AND PEMBERTON

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