How does treating a rectal fissure affect erectile dysfunction (ED) treatment?

Treatment of Anal Fissure and Its Impact on Erectile Dysfunction

Treating anal fissures with conservative management first, followed by surgical sphincterotomy if needed after 8 weeks, can resolve associated erectile dysfunction in the majority of patients, as the ED appears directly related to the fissure pathology and anal pain. 1, 2

The Connection Between Anal Fissure and Erectile Dysfunction

A specific relationship exists between anal fissure and erectile dysfunction through the bulbocavernosus muscle (BCM), which is anatomically part of the external anal sphincter. 2

• All men with acute anal fissure (32/32 patients) experienced erectile dysfunction that had not been present before fissure occurrence, with anal pain radiating to the penis and exacerbating during erection and penile thrusting. 2
• In chronic anal fissure patients, 76% (16/21) experienced erectile dysfunction. 2
• Cure of the fissure resulted in resolution of ED in 94% of acute cases (30/32) and 90% of chronic cases (19/21), with ED persisting only in the four patients whose fissures failed to heal. 2

First-Line Treatment Approach for Acute Anal Fissure

Non-operative management is the strongly recommended first-line treatment for acute anal fissure and should be maintained for at least 8 weeks before considering surgery. 1

Conservative Management Components:

• Dietary and lifestyle modifications with increased fiber and water intake (strong recommendation, moderate quality evidence). 1
• Topical anesthetics (lidocaine) and oral analgesics (paracetamol or ibuprofen) for pain control, which relieves anal sphincter spasm and reduces local ischemia to enhance healing. 1
• Sitz baths to promote comfort and healing. 3, 4

Medical Therapy Options:

• Topical calcium channel blockers (nifedipine 0.2% gel) achieve 95% total remission after 21 days, compared to 50% with conventional therapy, by reducing maximum resting anal pressure by 30%. 5
• Topical antibiotics (metronidazole) may be added in cases of poor genital hygiene or reduced therapeutic compliance, showing improved healing rates (86% vs 56%). 1
• Manual dilatation is strongly recommended against due to poor outcomes. 1

Surgical Treatment Timing and Approach

Surgery should be avoided in acute anal fissure but is strongly recommended for chronic fissures that fail to respond after 8 weeks of non-operative management. 1

• Lateral internal sphincterotomy is the preferred surgical technique with healing rates exceeding 90% and lower recurrence rates compared to other procedures. 1
• Open and closed lateral internal sphincterotomy have similar results, though open technique may cause higher post-operative pain and delayed wound healing. 1
• Important caveat: Sphincterotomy carries a risk of fecal incontinence in a small but significant number of patients, making conservative management preferable when possible. 6

Clinical Examination Essentials

For typical acute anal fissure, no specific biochemical or imaging investigations are needed. 1

For atypical fissures (not posterior midline, multiple fissures, or non-healing), perform:

• Focused medical history and complete physical examination. 1
• Endoscopy, CT scan, MRI, or endoanal ultrasound only if suspecting inflammatory bowel disease, colorectal cancer, or occult perianal sepsis. 1

Treatment Algorithm for ED Associated with Anal Fissure

1. Initiate conservative fissure management immediately with dietary changes, increased fiber/water, sitz baths, and topical anesthetics. 1

2. Add topical calcium channel blocker (nifedipine 0.2% gel every 12 hours) for superior healing rates. 5

3. Reassess at 2-3 weeks: Most acute fissures and associated ED should show significant improvement. 2, 5

4. If no improvement by 8 weeks, proceed to lateral internal sphincterotomy, which should resolve both the fissure and ED in approximately 90% of cases. 1, 2

5. ED investigations are typically unnecessary as the dysfunction is mechanical/pain-related rather than vascular or neurologic, and resolves with fissure healing. 2

Key Clinical Pitfalls

• Do not perform routine ED workup in patients with anal fissure and new-onset ED, as the ED is secondary to the fissure pathology and will resolve with fissure treatment. 2
• Avoid premature surgical intervention in acute fissures, as 95% can heal with topical calcium channel blockers alone. 5
• Do not use manual dilatation, which has poor outcomes and strong evidence against its use. 1
• Warn patients about sphincterotomy risks including potential incontinence, making medical management the preferred long-term approach when effective. 6