An anal fissure is a linear ulcer or tear in the anoderm, usually located just distal to the dentate line. It is a common and painful anorectal condition encountered in both surgical and obstetric practice, especially in postnatal women. Anal fissures may be primary (idiopathic), which are more prevalent, or secondary to underlying diseases like tuberculosis1, Crohn’s disease, ulcerative colitis, AIDS, or malignancy. Among the idiopathic cases, contributing factors include constipation, repeated trauma from hard stools, anal sphincter hypertonia, and sometimes childbirth or diarrhea. Most fissures (about 80%) are found in the posterior midline, while the remaining (20%) are located anteriorly, with atypical fissures often being multiple or lateral, raising suspicion for a secondary cause. Anal fissures are categorized as acute if present for less than six weeks, and chronic when symptoms persist beyond six weeks2. Chronic fissures typically present with exposed internal sphincter fibers, a sentinel pile at the distal edge, and a hypertrophied anal papilla proximally. The pathophysiology revolves around a vicious cycle of pain, internal sphincter spasm, reduced blood supply (ischemia), and delayed healing. Pain leads to sphincter contraction, further reducing blood flow to the fissure site and perpetuating the non-healing wound. Clinical presentation includes sharp, severe pain during and after defecation, rectal bleeding in streaks or drops, and voluntary stool withholding, resulting in worsened constipation and further trauma to the anoderm. Diagnosis is primarily clinical3. Digital rectal examination (DRE) is often not feasible due to severe pain and sphincter spasm. Inspection reveals a longitudinal tear, often with a sentinel tag, and a tightly puckered sphincter. Management strategies range from conservative to surgical interventions. First-line therapy includes stool softeners, bulk laxatives, warm Sitz baths, and dietary modification. In cases unresponsive to conservative therapy or those with recurrent fissures, second-line options include topical agents (e.g., glyceryl trinitrate, diltiazem, nifedipine) and botulinum toxin injections. Surgical options are reserved for chronic or refractory cases. The two main procedures include Lord’s Anal Dilatation4 (LAD) and Lateral Internal Sphincterotomy (LIS). LAD is a simpler, older technique, involving controlled manual dilatation of the anal canal to relieve sphincter spasm, but is associated with higher chances of incontinence and recurrence. LIS, now more commonly practiced, involves partial division of the internal anal sphincter, providing better long-term healing but also carries a risk of permanent anal incontinence. However, criticisms of LAD—primarily regarding incontinence—are not conclusively substantiated, as many complications go unreported or patients consult other surgeons postoperatively.5 Moreover, LAD is also performed during haemorrhoidectomy, a more common procedure, yet post-procedure incontinence is rarely encountered in practice, indirectly supporting the safety of LAD6. Given these controversies and lack of consistent documentation, the objective of the present study is to evaluate LAD in the management of anal fissures, with particular attention to recurrence and incontinence rates, and to compare the findings with available literature to assess its current relevance7.

AIM

A Clinical Study to Evaluate the Outcome of Lord’s Anal Dilatation in the Treatment of Chronic Anal Fissure.

This prospective observational study was conducted in the Department of General Surgery at Government R.D.B.P. Jaipuria Hospital, which is affiliated with RUHS-CMS, Jaipur. The study was carried out over a period of six months, from August 2023 to March 2024. The study population consisted of patients who were clinically diagnosed with chronic anal fissure and scheduled for surgical intervention using Lord’s Anal Dilatation. On average, 1 to 3 out of every 100 patients attending the outpatient department per day were diagnosed with chronic anal fissure, forming the study universe. Inclusion criteria for the study included patients aged between 18 and 60 years of either sex who were undergoing LAD  at the hospital and provided informed written consent for participation in the study. Exclusion criteria included patients below 18 years or above 60 years of age, known cases of gastrointestinal tuberculosis, Crohn’s disease, ulcerative colitis, HIV-positive individuals, patients with haemorrhoids, and those who refused surgery or were managed conservatively. The study focused on observing outcomes related to symptom relief, recurrence, and postoperative complications, particularly anal incontinence, following LAD. By employing a structured observational design in a real-world clinical setting, this study aimed to contribute meaningful data to the ongoing debate regarding the efficacy and safety of LAD in the management of chronic anal fissure.

Table 1: Age range:

Out of 40 patients, 25% were aged 18–30 years, 35% were 31–40 years, 25% were 41–50 years, and 15% were 51–60 years; 70% of the patients were male.

Table 2: presenting complaints

Among the 40 patients, 97.5% had pain during defecation, 80% experienced bleeding per rectum, 75% had constipation, 65% reported post-defecation pain, and 50% had fear of passing stools.

Table 3: Position of fissure

In the study, 80% of fissures were located in the posterior midline and 20% in the anterior midline.

Table 4: Duration of symptoms

In this study, 20% of patients had symptoms for less than 2 months, 35% for 2–4 months, 30% for 4–6 months, and 15% for more than 6 months.

Table 5: Operative time and hospital stay

In this study, operative time was ≤5 minutes in 15% of patients, 6–10 minutes in 70%, and >10 minutes in 15%, while hospital stay was day-care in 65% of cases, 1 day in 25%, and ≥2 days in 10%.

Table 6: POST OPERATIVE COMPLICATIONS

In terms of complications, 15% of patients had flatus incontinence, 7.5% experienced pain, 5% had bleeding, 2.5% developed urinary retention, none had fecal incontinence, and 87.5% had no complications.

The present study was conducted to analyze the complication risks and clinical outcomes of Lord’s Anal Dilatation (LAD) in the treatment of chronic anal fissure. Our findings demonstrate that LAD is a simple, effective, and reliable procedure with minimal postoperative complications. Most patients experienced rapid symptom relief and short hospital stay, with no reported cases of fecal incontinence or recurrence during follow-up. Minor complications like transient flatus incontinence and mucous discharge were self-limiting. These results strongly support the continued use of LAD, particularly in low-resource settings. However, compared to other published studies, our complication rates were slightly lower. This variation may be attributed to differences in surgical technique, patient selection, and follow-up duration. Thus, LAD proves to be a dependable and safe therapeutic option in our clinical context.

In this study comprising 40 patients who underwent Lord’s Anal Dilatation, the majority belonged to the age group of 31–40 years, accounting for 35% (14 patients). This was followed by the 18–30 years and 41–50 years age groups, each contributing 25% (10 patients each). The smallest group was patients aged 51–60 years, comprising 15% (6 patients). The gender distribution revealed a male predominance, with 70% (28 patients) being male and the remaining 30% (12 patients) female. This reflects the higher prevalence of chronic anal fissure and surgical intervention among middle-aged males in the general population. Male to female ratio in our study was 2.3:1, which is comparable with the Male to female ratio of 1.7:1 recorded by Kumar et al8, 1.5:1 by Velani et al9.

The age range was 18 to 60 years which is comparable to the study by Velani et al9 having an age range of 18-50 years, Uttam et al10 having an age range of 18-50 years & Razzaq et al11 having an age range of  20-65 years.

The most common presenting symptom among patients undergoing Lord’s Anal Dilatation was pain during defecation, reported by 97.5% (39 out of 40 patients), indicating its hallmark presence in chronic anal fissure. Bleeding per rectum was the second most frequent complaint, observed in 80% (32 patients). Constipation was reported by 75% (30 patients), reflecting its contributory role in the pathogenesis of fissure. Post-defecation pain was experienced by 65% (26 patients), suggesting prolonged sphincter spasm after bowel movements. Fear of passing stools was reported by 50% (20 patients), highlighting the psychological distress associated with the condition. These findings reinforce that chronic anal fissure severely impacts both physical and mental well-being. The predominance of multiple symptoms also supports the need for prompt and effective surgical intervention. Kumar et al8 recorded painful defecation in 96%, fresh Bleeding PR in 83%, Velani et al07 recorded painful defecation in 97%, fresh bleeding PR in 80%, Uttam et al10 recorded painful defecation in 96% while Razzaq et al11 recorded painful defecation in 100% patients.

In this study, the duration of symptoms among patients undergoing Lord’s Anal Dilatation varied significantly. A majority of patients, 35% (14 out of 40), had symptoms lasting between 2 to 4 months, indicating a subacute course before surgical intervention. This was followed by 30% (12 patients) who experienced symptoms for 4 to 6 months, suggesting progression toward chronicity. Only 20% (8 patients) had symptoms for less than 2 months, indicating early cases that likely failed conservative management. Meanwhile, 15% (6 patients) had symptoms persisting for more than 6 months, reflecting long-standing disease. These findings emphasize that most patients present between 2 to 6 months after symptom onset. Early surgical intervention in such cases can help prevent further deterioration and improve quality of life. The data also shows a trend toward timely referral and surgical management in the majority. The duration of symptoms before presentation in our patients ranged from 15 days to 6 months, with a majority presenting between 2 to 4 months (35%), which is comparable to the ≥8 weeks reported by Kumar et al8., Velani et al.,9 and Uttam et al.10, though shorter than the 11 months reported by Kader et al.12

In this study, the most common position of the fissure was the posterior midline, observed in 32 patients (80%).Anterior midline fissures were found in 8 patients, accounting for 20%.No patients had fissures in both positions simultaneously. This distribution is consistent with the known anatomical predisposition of posterior fissures. The total number of patients analyzed for fissure position was 40.Hence, posterior midline remains the predominant site in chronic anal fissure cases. Our study aligning closely with findings from other studies—Kumar et al. (93%)8, Velani et al. (93%)9, Uttam et al. (92%)10, and Razzaq et al. (80%).11 Anteriorly located fissures were seen in 20% of our patients, which is slightly higher than the 5% reported by Kumar et al8. and Velani et al.9, 6% by Uttam et al.10, and 15% by Razzaq et al11. This slight variation may be attributed to anatomical or demographic factors specific to our study population.

In this study, the operative time for Lord’s Anal Dilatation was ≤ 5 minutes in 15% of patients, 6–10 minutes in 70%, and >10 minutes in 15%. The majority of patients (65%) were managed as day-care cases and discharged the same day. About 25% of patients stayed for 1 day postoperatively, while 10% required a hospital stay of 2 or more days. The mean hospital stay in our study was approximately 1–2 days, significantly shorter than the mean stays reported by Kumar et al. (3.4 days)8, Velani et al. (3 days)9, Uttam et al. (3.4 days)10, and Razzaq et al. (2.5 days)11, likely reflecting a shift toward shorter hospitalization with improved perioperative care and emphasis on early discharge.

In this study, the most common complication observed was flatus incontinence in 15% of patients. Pain was reported in 7.5% of cases, while bleeding occurred in 5%. Urinary retention was seen in 2.5% of patients. Notably, there were no cases of fecal incontinence. Overall, 87.5% of patients experienced no complications post-procedure.

This study supports Lord’s Anal Dilatation (LAD) as a simple, safe, and effective surgical option for managing chronic anal fissur

The majority of patients were middle-aged males, with pain during defecation being the most common presenting symptom. Most patients had symptoms for 2–6 months and posterior midline fissure was the predominant location. Operative time was short, and most patients were managed on a day-care basis. Complication rates were low, with no cases of fecal incontinence or recurrence reported. The results demonstrate shorter hospital stays and fewer complications compared to similar studies. Thus, LAD remains a reliable technique with favorable outcomes in appropriately selected patients.

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