How should grade III internal hemorrhoids be managed in a patient with an anal fissure?

Management of Grade III Internal Hemorrhoids with Concurrent Anal Fissure

When managing grade III internal hemorrhoids alongside an anal fissure, you must first determine whether the fissure is acute (<8 weeks) or chronic (>8 weeks), then treat both conditions simultaneously using conservative measures initially, reserving combined surgical intervention (lateral internal sphincterotomy plus hemorrhoidectomy) only for chronic fissures that fail 6-8 weeks of medical therapy. 1, 2

Initial Assessment Framework

Verify the fissure location immediately. If the fissure is located off the posterior midline (lateral or anterior in a male patient), halt all treatment and urgently evaluate for Crohn's disease, HIV/AIDS, ulcerative colitis, tuberculosis, syphilis, or malignancy before proceeding with any therapy. 1

Determine fissure chronicity:

• Acute fissure: <8 weeks duration, appears as a fresh tear without surrounding changes 1
• Chronic fissure: >8 weeks duration, characterized by sentinel skin tag, hypertrophied papilla, fibrosis, and visible internal sphincter muscle fibers 1, 2

Perform anoscopy to visualize the grade III hemorrhoids (prolapse with defecation, require manual reduction) and confirm there is no active bleeding causing anemia. 2, 3

Conservative Management (First-Line for All Cases)

Initiate simultaneous treatment for both conditions:

Dietary and Lifestyle Modifications

• Increase dietary fiber to 25-30 grams daily using psyllium husk (5-6 teaspoons with 600 mL water daily) to soften stool and reduce straining 1, 2
• Ensure adequate hydration to prevent constipation 1
• Perform warm sitz baths 2-3 times daily to promote sphincter relaxation and reduce hemorrhoidal inflammation 1, 2

Topical Pharmacologic Therapy

• Apply compounded 0.3% nifedipine with 1.5% lidocaine ointment three times daily to the anal verge for the fissure, achieving 95% healing rates after 6 weeks while simultaneously providing pain relief for hemorrhoids 1, 2
• This combination relaxes internal anal sphincter tone, increases anodermal blood flow, and provides local anesthesia 1
• Alternative: 2% diltiazem cream twice daily for 8 weeks (48-75% healing rates, no headache side effects) 1

Pain Control

• Topical lidocaine 5% for local pain relief 1, 2
• Oral NSAIDs or acetaminophen for systemic pain control 2
• Avoid topical corticosteroids beyond 7 days due to risk of perianal skin thinning and atrophy 1, 2

Adjunctive Therapy

• Oral flavonoids (phlebotonics) to reduce hemorrhoidal bleeding, pain, and swelling, though 80% symptom recurrence occurs within 3-6 months after cessation 2

Re-evaluation at 6-8 Weeks

If the fissure heals and hemorrhoid symptoms improve: Continue conservative management indefinitely as maintenance therapy. 1

If the fissure persists beyond 8 weeks (now chronic) or hemorrhoids remain symptomatic: Proceed to the next treatment tier. 1, 2

Second-Line Options for Persistent Disease

For Chronic Fissure (Failed 6-8 Weeks Conservative Therapy)

Option A: Botulinum toxin injection into the internal anal sphincter, achieving 75-95% cure rates with sphincter-sparing benefits 1, 2

Option B: Lateral internal sphincterotomy (LIS) remains the gold standard for chronic fissures, with >95% healing rates and 1-3% recurrence 1, 4

For Grade III Hemorrhoids (Failed Conservative Therapy)

Rubber band ligation is the preferred office-based procedure for grade III internal hemorrhoids, with success rates of 70.5-89% 2, 3

• Place bands ≥2 cm proximal to the dentate line to avoid severe pain 2
• Can treat 1-3 hemorrhoidal columns per session 2
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic sepsis 2

Combined Surgical Approach (For Refractory Cases)

When both the chronic fissure and grade III hemorrhoids fail 6-8 weeks of comprehensive medical therapy, perform combined surgical intervention in a single operative setting. 2

Recommended Surgical Technique

Perform lateral internal sphincterotomy (at 3 or 9 o'clock position) PLUS conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique). 2, 4

Critical technical points:

• Execute a minimal, controlled sphincterotomy extending only to the dentate line to reduce incontinence risk 2
• Hemorrhoidectomy alone carries up to 12% risk of sphincter defects; adding aggressive sphincterotomy increases this risk 2
• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 2, 4
• Expected outcomes: 90-98% success rate, 2-10% recurrence rate 2, 4

Alternative Surgical Options

Stapled hemorrhoidopexy is contraindicated in this setting because it does not address external hemorrhoid components and was not designed for concurrent fissure treatment 2

Hemorrhoidal artery ligation (HAL/RAR) may be considered but has higher recurrence rates than conventional hemorrhoidectomy 5

Treatments That Are Absolutely Contraindicated

Never perform manual anal dilatation under any circumstances—it causes sphincter injuries and results in 52% incontinence rate at 17-year follow-up. 1, 2

Never perform simple incision and drainage of any thrombosed external hemorrhoid component—this leads to persistent bleeding and higher recurrence rates. 2

Never use cryotherapy—it causes prolonged pain, foul-smelling discharge, and requires more additional therapy. 2

Never proceed with sphincterotomy while ignoring symptomatic grade III hemorrhoids—this leaves the patient requiring a second procedure for ongoing bleeding and prolapse. 2

Critical Pitfalls to Avoid

• Do not attribute any rectal bleeding or anemia to hemorrhoids without colonoscopy to rule out inflammatory bowel disease or colorectal cancer, especially in patients ≥50 years or with risk factors 2
• Do not rush to surgery for acute fissures—50% heal with conservative management alone within 10-14 days 1
• Do not use topical corticosteroids beyond 7 days—prolonged use causes perianal mucosal thinning and increases injury risk 1, 2
• Do not perform rubber band ligation on acutely thrombosed or incarcerated hemorrhoids—this causes severe pain and complications 2

Postoperative Management Expectations

After combined surgery, patients should expect:

• Narcotic analgesics required for postoperative pain 2, 4
• 2-4 weeks before returning to work 2
• Potential complications: urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), minor incontinence (2-12%) 2
• Mandatory high-fiber diet and adequate hydration postoperatively to prevent constipation and straining that could compromise healing of both surgical sites 1, 2