Anal fissure surgery

Procedures to help a long-standing tear in the lining of the anus heal when creams and self-care have not worked, by relaxing or carefully dividing the tight muscle, or covering the tear with healthy tissue.

✓ Medically reviewed by a GMC-registered consultant · last reviewed September 2026 · next review September 2027 · how we review

In short

Surgery is for a chronic anal fissure that has not healed with creams, fibre and fluids — it is not usually a first step.
There is a trade-off: cutting the muscle (sphincterotomy) heals most fissures but carries a small risk of reduced control of wind or stool. A Botox injection avoids cutting but works less reliably.
Pain often settles within days to a few weeks, but keeping stools soft afterwards is essential or the fissure can come back.
Ask which procedure your surgeon recommends for you and why, and what it means for bowel control — this is the key safety conversation.

A plain-English summary. The detail — including risks and recovery — is below.

At a glance

TypeSurgical or injection procedure for a chronic anal fissure

AnaestheticUsually a general anaesthetic; sometimes a spinal or local anaesthetic with sedation

How long it takesUsually around 15–30 minutes

Hospital stayUsually a day case — home the same day

Time off workOften a few days to about 1–2 weeks, depending on the procedure and your job

When you'll see resultsPain often eases within days to a few weeks as the fissure heals

On the NHS?Commonly available on the NHS when creams have not worked; also offered privately for speed or choice

A general guide. Your surgeon will give you advice for your situation.

Best fit

Can relieve the sharp pain of a chronic fissure that creams have not healed

Pause if

People who already have poor control of stool or wind, in whom cutting muscle (sphincterotomy) may not be advisable.

Main recovery point

Expect some soreness, a little bleeding and possibly discharge. Use prescribed pain relief, take stool softeners or laxatives as advised, and have warm...

Good aftercare

A clear written plan for keeping stools soft with fibre, fluids and laxatives.

First few days

Expect some soreness, a little bleeding and possibly discharge. Use prescribed pain relief, take stool softeners...

First 1–2 weeks

Many people return to desk-based work within a few days to a couple of weeks. Fissure pain on passing stool...

2–6 weeks

The fissure continues to heal. After a botulinum toxin injection, the muscle gradually returns to normal over a...

From 6 weeks

Most fissures are healed or much improved. Any early trouble controlling wind has usually settled. Tell your...

Medical line illustration of lower rectum and anal canal treatment anatomy for Anal fissure surgery. — Illustration only - not a diagnosis, medical advice or a promise of result. Your anatomy and treatment plan may differ. Vuemedics does not publish before-and-after photos.

What is anal fissure surgery?

An anal fissure is a small tear in the skin-like lining of the anus (back passage). It can cause a sharp pain when you poo and bright red bleeding. Many fissures heal with self-care, more fibre and fluid, and creams. A fissure is usually called 'chronic' once it has lasted more than about six to eight weeks.

Surgery is considered when a chronic fissure has not healed despite creams such as glyceryl trinitrate (GTN) or diltiazem. The aim of most procedures is to relax the tight ring of muscle around the anus (the internal sphincter), which is often in spasm and reduces the blood supply the tear needs to heal.

There is more than one option. A botulinum toxin (Botox) injection relaxes the muscle temporarily. A lateral internal sphincterotomy permanently divides a small part of the muscle. An advancement flap brings healthy tissue over the fissure without cutting muscle, and is sometimes chosen when the risk of affecting control of wind and stool is a particular concern.

These procedures treat the fissure. They do not treat the underlying tendency to constipation or hard stools, so keeping stools soft afterwards matters as much as the procedure itself.

Types & techniques

There isn't one single operation. The right approach depends on you — which is something to discuss with your surgeon.

Botulinum toxin (Botox) injection

A small amount of botulinum toxin is injected into the sphincter muscle to relax it for a few months, giving the fissure a chance to heal. It avoids cutting the muscle, so there is little risk of lasting effect on control, but healing is less reliable than sphincterotomy and the fissure can return. Using botulinum toxin this way is an established but unlicensed (off-label) use.

Lateral internal sphincterotomy

A small, deliberate cut is made in part of the internal sphincter muscle to release the spasm. It heals the large majority of chronic fissures and is often described as the most effective surgical option, but carries a small risk of reduced control of wind or stool.

Fissurectomy

The edges of the chronic fissure are trimmed to encourage fresh healing. It is sometimes combined with a botulinum toxin injection rather than cutting muscle, particularly when avoiding any effect on continence is a priority.

Anal advancement flap

A small flap of healthy nearby tissue is moved to cover the fissure, improving its blood supply without dividing the sphincter. It is an option when the muscle pressure is not high, or when the risk of incontinence from a sphincterotomy needs to be avoided.

Botulinum toxin injection vs lateral sphincterotomy

Point	Botox injection	Sphincterotomy
Cuts muscle?	No	Yes, a small part
How well it heals	Works for many, less reliable	Heals the large majority
Risk to bowel control	Very low	Small but real
Can the fissure return?	More likely	Less likely
Often tried	Before, or instead of, cutting	When injection fails or for a firm result

There is no single right answer. The best choice depends on your symptoms, muscle pressure and how much any risk to continence matters to you.

Preparing for your surgery

See the operating surgeon, who should examine you and confirm the diagnosis; an examination under anaesthetic is sometimes part of the procedure.
Make sure creams (such as GTN or diltiazem), fibre and fluids have been given a fair trial first, as surgery is not usually the first step.
Tell your surgeon if you have any problems controlling wind or stool already, as this strongly affects which procedure is safest for you.
Mention inflammatory bowel disease, previous anal surgery, childbirth tears, or any fissure that is not in the usual position, as these change the plan.
List all medicines, including blood thinners, and follow advice on fasting if you are having a general or spinal anaesthetic.
Plan to keep stools soft afterwards: arrange laxatives or fibre as advised before you come in.
Arrange a lift home and, if you have a general anaesthetic, someone with you for the first 24 hours.

What happens

Most procedures are done as a day case, often under a general anaesthetic, though a spinal or local anaesthetic with sedation is sometimes used. You will usually be asleep or numb and will not feel the procedure.

The surgeon examines the anus, confirms the fissure and decides on the approach. For a botulinum toxin injection, a small amount is injected into the muscle through the lining. For a sphincterotomy, a tiny cut is made in part of the internal muscle, usually through a very small opening that is left to heal on its own. For an advancement flap, healthy tissue is moved over the fissure and stitched.

The operation itself usually takes around 15 to 30 minutes. Afterwards you recover in the unit and most people go home the same day with advice on pain relief, keeping stools soft and looking after the area.

Is this operation right for me?

A good consultation should explore whether it's the right choice for you now — including reasons to wait or consider something else.

May not be suitable if…

People who already have poor control of stool or wind, in whom cutting muscle (sphincterotomy) may not be advisable.
Fissures in an unusual position (for example to the side, or multiple fissures), which need investigation for another cause such as Crohn's disease before surgery.
An acute fissure that has not yet had a fair trial of fibre, fluids, softer stools and creams.
Someone whose pain is actually from another condition, such as an abscess, fistula, haemorrhoids or infection, that needs different treatment.

Delay surgery if…

There is an active infection, abscess or undiagnosed swelling near the anus.
Creams (such as GTN or diltiazem), fibre and fluids have not yet been properly tried.
Inflammatory bowel disease is suspected and not yet assessed.
There are unexplained changes in bowel habit, weight loss or bleeding that need investigation first.
Bowel control is already impaired and has not been assessed.

Alternatives to discuss

Continued conservative care: more fibre and fluids, softer stools and warm baths.
Topical creams such as glyceryl trinitrate (GTN) or diltiazem, often tried for several weeks.
A botulinum toxin injection instead of cutting muscle.
An advancement flap to protect continence where sphincterotomy risk is a concern.
Treating an underlying cause, such as managing inflammatory bowel disease.

Before you decide

Use this as a shared-decision checklist. The aim is not just “can this be done?”, but whether it is right for you, now, with the risks and alternatives clearly understood.

What matters most to me?

Think about symptoms, daily life, work, caring responsibilities, sport, fertility, travel, appearance and anxiety — the right choice depends on your priorities, not just the medical facts.

What are all my options?

Ask about waiting, monitoring, medicines, rehabilitation, a smaller or larger procedure, a different test, NHS referral, or a second opinion where that would help.

What would make me pause?

Active infection, pregnancy, unstable medical problems, smoking, medicines that increase bleeding, poor support at home, or feeling pressured are all reasons to slow down and get tailored advice.

What happens if I do nothing today?

For some problems, waiting is safe; for others, delay can make treatment harder. A good consultation should explain the trade-off in plain English.

Anaesthetic choices

The safest option depends on the operation, your health, the facility and your surgeon/anaesthetist. Ask what is planned and why.

General anaesthetic

Commonly used; you are fully asleep for the short procedure.

Spinal anaesthetic

Numbs the lower body; sometimes used instead of a general anaesthetic.

Local anaesthetic with sedation

May be used for a botulinum toxin injection or a brief examination in selected people.

Benefits

Can relieve the sharp pain of a chronic fissure that creams have not healed
Sphincterotomy heals the large majority of chronic fissures
A botulinum toxin injection can heal a fissure without any cutting of muscle
Advancement flap can treat a fissure while protecting bowel control
Stopping the pain often makes it easier to keep stools soft and avoid a relapse

Risks & complications

More common

Soreness, mild bleeding or discharge for a few days afterwards
Temporary, mild trouble controlling wind in the early weeks (more common after sphincterotomy)
The fissure not fully healing, or coming back, particularly after a botulinum toxin injection
Needing stool softeners or further creams for a while

Less common

Infection or a small abscess near the wound
Bleeding that needs medical attention
Longer-lasting difficulty controlling wind or loose stool
Needing a second procedure or a different operation if the first does not work

Rare but serious

Lasting incontinence of solid stool — uncommon but the most important risk to understand, mainly after sphincterotomy
A small tunnel forming between the anus and skin (fistula)
Risks related to anaesthetic

The most important risk to weigh up is the effect on bowel control. After a lateral internal sphincterotomy, many people notice minor, temporary trouble controlling wind, while lasting incontinence of solid stool is uncommon. The risk is higher in women, in older people, and in anyone who already has weak control or has had childbirth-related injury — for these groups a botulinum toxin injection or advancement flap may be safer. Ask your surgeon to set out your personal risk and which option they recommend for you.

Published figures to discuss

Reported outcomes vary with the procedure, how 'incontinence' is defined and measured, and how long people are followed. Minor, temporary trouble controlling wind is common after sphincterotomy, while lasting incontinence of solid stool is uncommon. Healing and recurrence figures come mainly from research series and meta-analyses, so treat them as a guide to magnitude rather than your exact personal risk.

Figure	Reported range	How to interpret it	Source / confidence
Fissure healing after lateral sphincterotomy	Around 90% or more in pooled studies	Often described as the most effective surgical option for chronic fissure.	StatPearls (NCBI) — Internal Anal Sphincterotomyncbi.nlm.nih.govPublished figure
Fissure recurrence after sphincterotomy	Low single figures (around 3–4% in some meta-analyses)	Recurrence is more likely if constipation and straining continue.	StatPearls (NCBI) — Internal Anal Sphincterotomyncbi.nlm.nih.govPublished figure
Any disturbance of continence after sphincterotomy	Reported around 8–14% across studies (mostly minor, e.g. wind)	Definitions vary widely; much of this is temporary.	StatPearls (NCBI) — Internal Anal Sphincterotomyncbi.nlm.nih.govPublished figure
Major incontinence (involuntary loss of solid stool) after sphincterotomy	Uncommon — reported under about 2% in long-term pooled data	Higher risk in women, older people and those with prior weakness or childbirth injury.	StatPearls (NCBI) — Internal Anal Sphincterotomyncbi.nlm.nih.govPublished figure

These are literature figures, not a personalised prediction. Your own risks and likely benefits depend on your circumstances, your health, and how your care is carried out and followed up.

Recovery — what to expect, and when

Recovery from anal fissure procedures is usually quick. The fissure pain often improves within days to a few weeks as it heals, although the area can be sore at first and keeping stools soft is essential throughout.

First few days

Expect some soreness, a little bleeding and possibly discharge. Use prescribed pain relief, take stool softeners or laxatives as advised, and have warm shallow baths to ease discomfort.

First 1–2 weeks

Many people return to desk-based work within a few days to a couple of weeks. Fissure pain on passing stool usually starts to settle. Keep stools soft so you are not straining.

2–6 weeks

The fissure continues to heal. After a botulinum toxin injection, the muscle gradually returns to normal over a few months, by which time the fissure has often healed.

From 6 weeks

Most fissures are healed or much improved. Any early trouble controlling wind has usually settled. Tell your surgeon if pain persists or the fissure returns, as a further or different procedure may be discussed.

What's normal — and not a worry

Soreness and a little bright bleeding when you poo in the first days
Some clear or blood-stained discharge from the area while it heals
Mild, temporary trouble holding wind, especially after a sphincterotomy
Gradual easing of the sharp fissure pain over days to weeks

Aftercare

Take stool softeners, laxatives or extra fibre as advised so stools stay soft and you do not strain.
Drink plenty of fluids and eat a higher-fibre diet to keep bowel movements comfortable.
Have warm, shallow baths, particularly after passing stool, to ease discomfort and keep the area clean.
Use any prescribed creams or pain relief as directed.
Keep the area clean and dry, and pat rather than rub after washing.
Avoid heavy lifting and strenuous activity in the first week or two if advised.
Contact the clinic if you have increasing pain, fever, heavy bleeding or signs of infection.
Keep any follow-up appointment so healing and bowel control can be checked.

Before-surgery checklist

Stool softeners or laxatives obtained as advised
Higher-fibre foods and plenty of fluids planned
Pain relief and any prescribed cream ready
Time off work arranged (a few days to about 2 weeks)
Lift home arranged if you have a general anaesthetic
Clinic's contact number saved for problems

Scars and how they heal

These procedures usually leave little or no visible scarring. A lateral sphincterotomy is done through a very small opening that is often left to heal naturally. An advancement flap involves stitches inside the anal area that are not externally visible. Some soreness, a small lump or a little firmness at the site can be normal while healing.

⚠ Get urgent help if…

Heavy or persistent bleeding from the back passage
Severe or worsening pain that is not controlled by your pain relief
A high temperature, feeling unwell, or spreading redness and swelling (signs of infection)
Pus or a painful swelling near the anus (possible abscess)
New or worsening inability to control stool or wind
Being unable to pass urine or open your bowels with significant pain or bloating

Who to contact: your surgeon or clinic first (keep their number to hand). For urgent advice when you can't reach them, call NHS 111. In an emergency, call 999.

General guidance — it doesn't replace the specific advice your surgeon gives you.

Results & realistic expectations

A good result is a fissure that heals and pain that settles, letting you open your bowels comfortably. Sphincterotomy heals the large majority of chronic fissures; botulinum toxin injection works for many people but less reliably, and may need repeating or be followed by surgery if the fissure returns.

No procedure removes the underlying tendency to constipation or hard stools. Keeping stools soft and avoiding straining is what protects against the fissure coming back, so this is a long-term habit rather than a one-off fix.

How long it lasts

When a chronic fissure heals after surgery, it often stays healed, especially after a sphincterotomy. Fissures are more likely to return after a botulinum toxin injection, or if constipation and straining continue. Looking after your bowel habit with fibre, fluids and not straining is the main thing that keeps the result lasting.

Combining with other procedures

A fissurectomy is sometimes combined with a botulinum toxin injection in the same procedure. An examination under anaesthetic may be done at the same time to confirm the diagnosis and rule out other causes, particularly if the fissure is in an unusual position or has not behaved typically.

Follow-up & long-term care

You will usually be reviewed after a few weeks to check that the fissure is healing and that bowel control is normal. If the fissure has not healed, or if it returns, your surgeon will discuss whether to repeat treatment, switch approach, or investigate further for another cause.

Keep stools soft long term with enough fibre and fluid to avoid straining.
Treat constipation early if it returns, as this is the main trigger for a new fissure.
Seek advice promptly if pain or bleeding comes back rather than waiting.

Revision and secondary surgery reality

A fissure that does not heal after a botulinum toxin injection may be treated with a repeat injection or a sphincterotomy.
A fissure that returns may need a different operation, such as an advancement flap.
If the fissure is atypical or persistent, further investigation for another cause may be needed before more surgery.

Ask your surgeon for their own revision rate, what counts as a revision, and what is included in the written aftercare policy.

What good aftercare looks like

A clear written plan for keeping stools soft with fibre, fluids and laxatives.
A named contact route for problems such as bleeding, severe pain or signs of infection.
Review after a few weeks to confirm healing and check bowel control.
A clear plan for what happens if the fissure does not heal or comes back.

What affects the cost

Costs vary a great deal between people and providers, and we don't publish prices. What matters is understanding what drives the cost and making sure your quote is complete. The main things that affect it:

Which procedure is done (injection, sphincterotomy or flap) and how long it takes
Surgeon's fee and the anaesthetist's fee if a general or spinal anaesthetic is used
Theatre or facility fee for a day-case procedure
Whether an examination under anaesthetic or biopsy is needed at the same time
Follow-up appointments and any further treatment if the fissure does not heal
Medicines such as stool softeners, laxatives or creams afterwards

Make sure your written quote includes

The surgeon's fee and the anaesthetist's fee
The theatre or facility fee for the procedure
Which procedure is included, and what happens if a different one is needed once inside
Follow-up appointments to check healing and bowel control
What happens, and what it costs, if the fissure does not heal or comes back
The cancellation policy and what is covered if a complication occurs

On the NHS? Treatment for a chronic anal fissure that has not healed with creams is commonly available on the NHS; private care may be used for faster access or choice of surgeon.

You're entitled to your total cost in writing — including aftercare and any revision — before you decide.

Choosing a surgeon safely

Check your surgeon is on the GMC Specialist Register for this area.
Make sure they practise at a CQC-registered location, and look for membership of bodies like BAAPS or BAPRAS.
You're entitled to a two-stage consent process with time to reflect (a cooling-off period). The surgeon who will operate must consent you — not a salesperson.
Be wary of pressure: time-limited offers, discounts or deposits taken before you've had time to think are red flags, not bargains.
You're entitled to your total cost in writing — including aftercare and any revision — before you decide.

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Questions to ask your medical professional

Take this to your consultation. A good surgeon will welcome every one of these.

Which procedure do you recommend for me, and why that one rather than the others?
What is my personal risk of trouble controlling wind or stool afterwards?
Have my creams, fibre and fluids been given a proper trial first?
What is the chance the fissure heals, and the chance it comes back?
What will you do if this procedure does not work?
How should I manage my bowels afterwards to stop it returning?
Are you on the GMC Specialist Register for this area, and which Royal College or professional body are you a member of?
Will you be the surgeon who carries out my operation, and who looks after me afterwards?
What are the risks for someone like me, and how often do your own patients have a problem or need it repeated or redone?
What does a realistic result look like — and what can this operation not achieve?
What are my options, including waiting, doing nothing for now, or choosing a different approach?
Can I have written information, results and aftercare instructions in a format I can use, including any accessibility or communication support I need?
What is the total cost in writing, including any follow-ups, and how much time do I have to decide?

Frequently asked questions

Do I need surgery for an anal fissure?

Often not. Most fissures heal with more fibre and fluid, softer stools and creams such as GTN or diltiazem. Surgery is usually only considered once a fissure has become chronic and has not healed despite these measures.

Will surgery affect my ability to control my bowels?

It can. After a lateral sphincterotomy, minor, temporary trouble controlling wind is common, and lasting incontinence of solid stool is uncommon but possible. A botulinum toxin injection or advancement flap avoids cutting muscle and carries much less risk to control. This trade-off is the key thing to discuss.

Which is better, Botox or sphincterotomy?

Neither is simply 'better'. Sphincterotomy heals more fissures and is less likely to let them return, but cuts muscle. A botulinum toxin injection avoids cutting and is often tried first, but works less reliably. The right choice depends on you.

Is the procedure painful?

The procedure itself is done under anaesthetic, so you should not feel it. Afterwards the area can be sore for a few days, but for many people the constant fissure pain actually improves quite quickly as it heals.

How soon will the pain go?

Many people notice the sharp pain easing within days to a few weeks as the fissure heals. Keeping stools soft helps a great deal.

Can the fissure come back?

Yes, particularly after a botulinum toxin injection or if constipation and straining continue. Looking after your bowel habit is the best way to reduce the chance of it returning.

Can I get this on the NHS?

Yes, treatment for a chronic fissure that has not healed with creams is commonly available on the NHS. Some people choose to be seen privately for speed or choice of surgeon.

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How we made this page

Medically reviewed by a GMC-registered consultant. Written in plain English, checked against NHS, NICE, GMC and relevant Royal College / specialist-society guidance, and kept under review. No clinic paid to appear on this page, and we publish no pricing. This is general information to help you prepare — it is not a substitute for advice from your own clinician. How we review our guides →

Source hierarchy: UK regulator and NHS/NICE guidance first, then relevant Royal College or specialist-society guidance, then peer-reviewed evidence for procedure-specific figures where available.

Sources & standards: NHS — Anal fissure NICE — Chronic anal fissure: 2% topical diltiazem (information for the public) StatPearls (NCBI) — Internal Anal Sphincterotomy Guy's and St Thomas' NHS FT — Anal fissure treatment: surgery ACPGBI / Pescatori — Management of primary chronic anal fissure (position paper, PMC) Closed vs open lateral internal sphincterotomy: systematic review and meta-analysis (Scientific Reports)

Reviews reflect patients' experience of care, not clinical outcomes. For procedure volumes and outcome data see PHIN.

Last medically reviewed 2026-09-21. Spotted something wrong or out of date? Report an error in this guide.