Continence Disturbances Research Articles

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Originally described in 1982, scalp somatosensory evoked potential responses can be recorded after stimulation of multiple different pudendal nerve- and sacral root-supplied structures. The resulting P40 response is usually the highest amplitude at Cz. Responses are generally easy to resolve and therefore should be of equivalent ease to follow for neurophysiologic intraoperative monitoring versus lower limb peripheral nerve somatosensory evoked potentials (e.g., tibial or fibular [peroneal] nerves), but sizeable reports of pudendal somatosensory evoked potential monitoring are few. Direct orthodromic sensory nerve action potential recording from the cauda equina in response to single such sacral stimuli has been reported of utility for preserving roots that participate in urinary control during dorsal rhizotomy procedures for spasticity. Technical application of both techniques is quite straightforward. As in most areas of neurophysiologic intraoperative monitoring, there are no well-constructed historical control series informing use of these techniques and, certainly, no clinical trials. Given the socially devastating consequences of urinary and anal continence disturbances and a fairly high rate of functional postoperative disturbances when sacral roots are manipulated, this field begs more active clinical investigation.

Immediate outcome, long‐term function and quality of life after extended colectomy with ileorectal or ileosigmoid anastomosis

Total/subtotal colectomy with ileorectal (IRA) or ileosigmoid (ISA) anastomosis is associated with various reported rates of morbidity, function and quality of life. Our object was to determine these end-points in a series of patients undergoing these operations in our institution. All patients who underwent IRA or ISA between 1994 and 2009 were retrospectively reviewed. A total of 320 patients (female 49%) with a median age of 54.2 (16.8-90.6) years underwent 338 IRA or ISA (in 18 patients the anastomosis was done twice) for inflammatory bowel disease (n=96), polyposis (n=95) and colorectal cancer (n=97). Mortality and morbidity rates were 1.2% (n=4) and 19.5% (n=66) and 47 surgical complications (13.9%) occurred, including 26 (7.7%) cases of anastomotic leakage, leading to 23 re-operations. After a median follow-up of 49 (0-196) months, 262 patients still had a functioning anastomosis; 45 patients had died and 13 had a proctectomy. Information on function was obtained in 51.4% (133/259) of the cohort after a median follow-up of 77 (10-196) months. The mean (± standard deviation) rates of 24h and nocturnal defaecation were 3.6±2.4 and 0.5±0.9. A disturbance of faecal or flatus continence occurred in 20% and 21% of patients. There was no case of faecal incontinence to solid stool. The mean SF-36 Physical and Mental Health Summary Scales were 46.3±9.3 and 51.9±9.3. Multivariate analysis showed that IRA and inflammatory bowel disease were both independently associated with poorer long-term function. Colectomy with IRA or ISA is safe with low postoperative morbidity and mortality. The employment of IRA and inflammatory bowel disease appear to be independent negative factors on function in multivariate analysis.

Complications and functional outcomes of restorative proctocolectomy for ulcerative colitis in the elderly

BackgroundRestorative proctocolectomy with ileopouch-anal anastomosis (IPAA) is the treatment of choice for intractable or complicated ulcerative colitis (UC). Debate exists concerning outcomes of IPAA in the elderly and literature data are scarce. We report our experience of IPAA in older population.MethodsWe gathered data on a prospective database of patients undergoing IPAA for UC over 70 years of age in our Unit from January 1990 through January 2010. Patients were compared with randomly selected younger controls on a 1:3 ratio. Patients underwent IPAA in 2 or 3 stages. Demographical data, disease characteristics, comorbidities, concomitant medications, peri-operative management, intra- and post-operative complications were analyzed. Function and quality of life were assessed by clinical visit and Inflammatory Bowel Disease Questionnaire 1 and 3 years after ileostomy takedown.ResultsTwenty-seven elderly patients underwent IPAA for UC in the study period; these were compared with 81 younger controls. The former had more comorbidities and higher ASA score. All patients underwent loop-ileostomy closure. There were no differences between groups concerning the rate of major complications, but elderly patients more frequently had nuisances due to stoma output. Younger patients experienced significantly more episodes of small bowel obstruction. No significant differences in bowel control and health-related quality of life was observed, except for an higher rate of elderly patients taking antidiarrhoeals at 1-year follow-up; this observation was not confirmed at 3-year follow-up. A minimal decrease in continence was observed, but this did not affect overall satisfaction.ConclusionsIPAA can be safely offered to selected elderly UC patients who are strongly motivated and with no clinical disturbances of continence. In experienced hands no differences are likely to be expected concerning complications, quality of life and function. Results are stable with time and comparable to those of younger patients.

Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure

Anal fissure is a common benign condition. An anorectal problem is defined as a split in the anal canal mucosa that extends from the dentate line to the anal verge. Chronic anal fissure is defined by a history of symptoms present for more than 2 months' duration and with a triad of external skin tags, namely, a hypertrophied anal papilla, an ulcer with rolled edges, and a base exposing the internal sphincter. Because complications such as incontinence are associated with surgical treatment, chemical sphincterotomy is currently favored. The objective of this study is to compare the difference in outcome between open partial lateral anal sphincterotomy and application of topical 0.2% nitroglycerin ointment for the treatment of chronic anal fissure. This was a quasi-experimental study carried out between January 16, 2007 and January 15, 2008 in the Surgical Department of Jinnah Hospital, Lahore, Pakistan. Sixty consecutive cases with a clinical diagnosis of chronic anal fissure were recruited in the study. All recruited patients met the study inclusion criteria and were randomly assigned to one of the two groups. Group A was managed conservatively using topical 0.2% nitroglycerin ointment, whereas Group B underwent open partial lateral anal sphincterotomy. Both groups were followed up at 1 week, 2 weeks, 4 weeks, and 6 weeks after the treatment. All the patients complained of pain. A total of 43 (71.7%) patients had pain with constipation, whereas 31 (51.7%) patients had bleeding per rectum. Upon clinically examining the anal area, tenderness was elicited in all 60 (100%) patients. Group A included 30 (11 females and 19 males) cases treated with topical 0.2% nitroglycerin ointment and Group B included 30 (11 females and 19 males) cases who underwent open partial lateral anal sphincterotomy. In Group A, only 15 patients with fissures were successfully treated (50%). By contrast, 28 (93%) patients with fissures in Group B were successfully treated, and only two (7%) remained uncured. These two patients (6.6%) in Group B suffered from incontinence due to flatus and feces as a complication of the procedure. This quasi-experimental study demonstrates that open partial lateral internal sphincterotomy is superior to topical 0.2% nitroglycerin application in the treatment of chronic anal fissure, with good symptomatic relief, high rate of healing, fewer side effects, and a very low rate of early continence disturbances.

Coring‐out fistulectomy with a newly designed ‘fistulectome’ for complicated perianal fistulae: a retrospective clinical analysis

Conventional surgery for complex anal fistula (AF) is associated with continence disturbance and recurrence. In the hope of reducing these we developed a new mechanical device, the 'fistulectome', to excise the entire fistula tract. Between March 2001 and April 2011, 136 patients underwent surgery for a complex AF using the fistulectome. All fistulae were cryptoglandular in origin. Five patients were lost to follow up and were excluded from the analysis. Of the 131 fistulae, 76 were trans-sphincteric, 14 were suprasphincteric and 16 were extrasphincteric. Seven had a horseshoe extension and 18 were unclassified. Of the 131, 108 had recurred after conventional fistulotomy performed at another centre and 23 were primary. The mean duration of follow up was 34.6months, the mean hospital stay was 5days and the healing time was 14days. Recurrence, flatus incontinence and soiling occurred in 17 (12.9%), four (3.5%) and two (1.52%) patients. The results of this series suggest that coring-out of a fistula using a fistulectome may be a valid treatment for complicated anal fistula.

Conservative versus surgical treatment for chronic anal idiopathic fissure: a prospective randomized trial

Anal fissure is a tear in the lining of the anal canal distal to the dentate line, which most commonly occurs in the posterior midline. Anal fissure was defined chronic if the patient presented with history of anal pain during defecation for at least 2 months with the observation of sphincter fibers at the base of the lesion. One hundred and forty-two consecutive patients with a chronic anal fissure with hypertonicity of internal sphincter on proctological examination were selected for this study from October 2008 to October 2010. Patients enrolled for the study were randomized to two groups by using a computer-generated list. Patients who underwent lateral internal sphincterotomy (LIS) were operated as day surgery procedures under local or epidural anesthesia. Patients randomized to conservative treatment were prescribed to use warm anal dilator with a nifedipine ointment 5 min twice daily for 4 weeks. Patients were clinically examined after 2, 4 and 8 weeks of treatment to evaluate if there was complete healing of the fissure. All patients were required to record pain after the first defecation, on 3rd and 7th postoperative day on a self-administered VAS scale in cm (0-10). Sixty-eight patients were randomly assigned to LIS, 74 to the conservative approach. Fifty-one patients of topical nifedipine group (68.9 %) and 60 patients of LIS group (88.2 %) presented an anal fissure healed at 8 weeks with a p value of 0.0077. As regards post-operative pain, 43 patients of LIS group (63.2 %) and 25 patients of topical nifedipine group (33.7 %) referred first defecation as painless. In the topical nifedipine group 43 (58.1 %) after 3 days since treatment and 35 (47.3 %) after 7 days had pain. In the LIS group 22 (32.3 %) after 3 days and 9 (13.2 %) after 7 days referred pain. There was no statistical difference between LIS and topical nifedipine group concerning side effects. Lateral internal sphincterotomy is an effective, less painful, fast recovery treatment for chronic anal fissure. Incontinence rate is overestimated and often the fear of a continence disturbance, albeit with a low incidence following surgery, may obscure the need to relieve symptoms which may be so severe as to make the patient's life intolerable.

Long‐term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta‐analysis

A systematic review was carried out to analyse continence at 2years or more after lateral internal sphincterotomy (LIS) for chronic anal fissure (CAF). PubMed, MEDLINE, Scopus, Embase, Ovid, SCI, Cochrane Central Register of Controlled Trials (CENTRAL) and Google Scholar were used to search the literature from 1969-2012 for studies reporting a follow-up of more than 2years after LIS for CAF. The primary outcome parameter analysed was continence. The secondary outcome parameters included success rate, recurrence, incidence of postoperative abscess and fistula formation and patient satisfaction. Of 324 studies screened, 22 (n=4512) were included. The mean follow-up period ranged from 24-124months. The overall continence disturbance rate was 14% (95% CI 0.09-0.2). Weighted analysis showed flatus incontinence in 9% (95% CI 0.04-0.16), soilage/seepage in 6% (95% CI 0.03-0.1), accidental defaecation in 0.91% (95% CI 0.003-0.02), incontinence to liquid stool in 0.67% (95% CI 0.001-0.02) and incontinence to solid stool in 0.83% (95% CI 0.003-0.02) of patients. The long-term risk of continence disturbance after lateral internal sphincterotomy is significant. Randomized controlled trials with a long follow-up are needed to substantiate these findings and to redefine its role in the treatment of chronic anal fissure.

Comparative study of local calcium channel blocker application and lateral internal sphincterotomy in the treatment of chronic anal fissure: study of 50 cases.

Background: The treatment of chronic anal fissure has changed greatly during the past two decades with ongoing research directed at lowering the internal anal sphincter tone and avoiding the risk of fecal continence disturbance. Glycerin trinitrate, topical calcium channel blockers and anal dilators and botulinum toxin injection alone are all known to be able to lower the internal anal sphincter tone but results have been disappointing in curing chronic anal fissure, often marginally better than to placebo. The surgical treatment in the form of lateral internal sphincterotomy is the gold standard for chronic anal fissure. Aims & Objective: The aim of this prospective study was to assess the efficacy of medical treatment in form of topical calcium channel blocker and surgery in the management of chronic anal fissure. The objective is to compare the efficacy with regard to complete healing, recurrence, incontinence and other complications after treatment with topical calcium channel blocker and lateral anal sphincterotomy. Material and Methods: From October 2010 to October 2012, 50 patients with typical chronic anal fissure completed the study. 25 patients were initially treated with topical calcium channel blocker for 8 weeks and rests 25 were treated with lateral anal sphincterotomy. During the follow-up healing rates, symptoms, incontinence scores, and therapy adverse effects were recorded. Results: Overall healing rates were 60% after 8 weeks therapy with topical calcium channel blocker. Whereas overall healing after lateral internal sphincterotomy group was 88% with no recurrence. Conclusion: Lateral internal sphincterotomy is far more effective than medical treatment, with significantly increased healing rates while avoiding risk of incontinence.

Five‐year results of fissurectomy for chronic anal fissure : low recurrence rate and minimal effect on continence

The aim of the study was to determine the long-term outcome, recurrence rate and faecal incontinence score after fissurectomy for chronic anal fissure (CAF) not responding to conservative treatment. Fifty-three consecutive patients (29 women) who underwent fissurectomy for a medically resistant CAF between 1998 and 2005 were included in the study. At a minimum follow-up of 5 years a standardized questionnaire was sent to all patients, assessing recurrence, satisfaction with the operation (on a scale of 0-10) and faecal continence (Vaizey score, 0-24). The patients were compared with a control group of 50 healthy volunteers, matched for sex and age, who had never undergone anal surgery. Forty-three (81%) patients (25 women) returned the questionnaire. The mean age was 40 (SD 12.1) years and median follow up was 8.2 (5.5-12.2) years. Five patients had a recurrent CAF (11.6%). Ninety per cent of patients would have consented to the operation again if necessary. The mean Vaizey score at follow-up was 2.5 (SD ± 4.2). The mean Vaizey score of the four patients who had had a previous lateral sphincterotomy was 3.8 and for the eight patients who had reported a continence disturbance before fissurectomy it was 8.3. The mean Vaizey score of the 31 patients who were continent before fissurectomy was 0.8 compared with 0.4 in the control group (P = 0.9). At 5 years or more fissurectomy for medically resistant CAF is effective with a low recurrence rate and minimal influence on continence.

Long‐term results of stapled haemorrhoidopexy in a prospective single centre study of 153 patients with 1–6 years’ follow‐up

The long-term results of stapled haemorrhoidopexy for prolapsed haemorrhoids were assessed using uniform methods to acquire data and pre-set definitions of failure, recurrence, residual symptoms and impaired continence. From October 1999 to May 2005, 153 patients underwent a stapled haemorrhoidopexy and were enrolled prospectively. They were assessed preoperatively, postoperatively and at the end of the study from replies to a questionnaire about symptoms and continence. Preoperatively, manual reduction of prolapse was required in 103 patients, skin tags were found in 115 patients (circumferential in 22) and impaired continence in 63. In all, 145 patients completed preoperative and long-term protocols and were analysed as paired data, at a mean follow-up of 32 months. Failure to control the prolapse or recurrence was seen in 19 (13%) patients including nine reoperations for prolapse. Symptoms improved from 8.1 to 2.5 points on a 15-point scale (P = 0.001). Symptoms were not controlled in 25 (17%) patients. Continence improved from 4.7 to 2.9 points on a 15-point scale (P = 0.001). Twenty-five (17%) patients still had a continence disturbance. Altogether 51 (35%) patients had a deficient outcome with respect to prolapse, symptoms or continence. There were no major adverse events. Restoration of the anal anatomy by stapled haemorrhoidopexy resulted in a significant improvement in haemorrhoid-associated symptoms and continence but a third of patients had poor symptom control including 13% with persisting prolapse.

Should We Care About the Internal Anal Sphincter?

The internal anal sphincter is currently regarded as a significant contributor to continence function. Four physiological and morphological aspects of the internal anal sphincter are presented as part of the current evidence base for its preservation in anal surgery. 1) The incidence of continence disturbance following deliberate internal anal sphincterotomy is underestimated, although there is presently no prospective imaging or physiologic data supporting the selective use of sphincter-sparing surgical alternatives. 2) Given that the resting pressure is a measure of internal anal sphincter function, its physiologic representation (the rectoanal inhibitory reflex) shows inherent differences between incontinent and normal cohorts which suggest that internal anal sphincter properties act as a continence defense mechanism. 3) Anatomical differences in distal external anal sphincter overlap at the point of internal anal sphincter termination may preclude internal anal sphincter division in some patients where the distal anal canal will be unsupported following deliberate internal anal sphincterotomy. 4) internal anal sphincter-preservation techniques in fistula surgery may potentially safeguard postoperative function. Prospective, randomized trials using preoperative sphincter imaging and physiologic parameters of the rectoanal inhibitory reflex are required to shape surgical decision making in minor anorectal surgery in an effort to define whether alternatives to internal anal sphincter division lead to better functional outcomes.

Management of idiopathic anal fistula using cross‐linked collagen: a prospective phase 1 study

Fibrin glue and porcine intestinal submucosa are used in novel sphincter-preserving techniques to heal anal fistulae. However, their success is highly variable and decreases with the length of follow up. The aim of this study was to assess the safety, feasibility and potential efficacy of another novel agent, cross-linked collagen, in two different physical formats, to heal anal fistulae. Prospectively recruited patients underwent symptom, continence and anal physiology assessments and magnetic resonance imaging. Patients with secondary tracts or acute sepsis were excluded. At operation, participants were randomized to receiving a solid collagen implant or collagen fibres suspended in fibrin glue. Follow up included repeat symptom, continence and physiological assessments at 3 months, and regular clinical review thereafter. Twenty-nine of 43 entrants were eligible for inclusion. Thirteen patients received the collagen implant, and 16 collagen-fibrin glue. Three months postoperation, no patient experienced acute sepsis or continence disturbance, and sphincter function and integrity were unchanged. At 29 months, 12 of 15 (one lost to follow up) patients treated with collagen-fibrin glue were healed, compared with seven of 13 who received the implant. In the short-to-medium term, both techniques are safe and equally effective. The results justify continued research into the use of biomaterials to heal anal fistulae.

The Treatment of Stress Incontinence in Men

Stress incontinence in men is a rare, usually iatrogenic condition. Its prevalence can be expected to rise in the future because of the increasingly common performance of radical prostatectomy. Most men who have undergone prostatectomy experience a transient disturbance of urinary continence. Such disturbances are only rarely due to structural damage to the sphincter apparatus and therefore have a good prognosis for spontaneous recovery. Selective literature review. Pelvic floor training and/or pharmacotherapy can be used for more rapid restoration of subjectively satisfactory urinary continence. If the sphincter is intact, continence can also be regained in the early postoperative period through the submucosal injection of bulking agents. Incontinent patients whose urinary sphincter is dysfunctional because of denervation or direct injury to striated muscle can now be treated with a variety of surgical techniques. The implantation of an artificial sphincter is the gold standard of therapy. Properly selected and informed patients can also be treated with minimally invasive procedures, such as the creation of a male suburethral sling, although the experience with such procedures to date has not been extensive. Post-prostatectomy incontinence has a good prognosis and should thus be treated conservatively at first. If it nonetheless persists, surgical treatment is indicated for patients who choose it after being fully informed about their options.

Fistulectomy and sphincteric reconstruction for complex cryptoglandular fistulas

Complex anal fistulas (CFs) are difficult to treat. Endoanal advancement flap (EAF) is one of the standard treatment options for such clinical conditions. Immediate sphincter repair after fistulectomy (ISR) is not commonly performed because of the fear of causing postoperative incontinence. The objective of this study was to compare the results of both techniques. We retrospectively analysed a prospectively entered database composed of 146 patients (112 M; 34 F), undergoing operations for CF of cryptoglandular origin. The patients were divided in two groups: Group A: (EAF); n = 71 patients; Group B: (ISR); n = 75 patients. Forty-two fistulas (28.7%) were recurrent, 98 trans-sphincteric (TS) and 37 suprasphincteric (SS). Twenty-six (17.7%) patients had some degree of preoperative continence disturbances, 11 in Group A vs 15 in Group B (P = 0.47). After a mean follow up of 13 months (12-60), fistula persisted or recurred in 13 (18.3%) patients in Group A vs eight (10.6%) in Group B (P = 0.19) irrespective of the fistula type (TS or SS). Thirty-one (43.6%) patients in Group A vs 16 (21.3%) in Group B presented postoperative continence disturbances (P < 0.001). No changes were observed with the Faecal Incontinence Quality of Life Scale (FIQLS). Group A patients had a significant reduction of maximal rest pressure after surgery. After ISR, no significant changes in pressures were observed. Immediate sphincter repair can be a therapeutic option in selected cases of CF, mainly when associated with incontinence or increased risk factors.

Current problems and countermeasures in treatment of complex anal fistula

The high recurrent rate and insufficient protection of anal function in treatment of anal fistula were reviewed in this article. To solve the problems in the treatment of complex fistula-in-ano including ignorance of preoperative assessment and lack of consciousness of preserving anal function, the authors raised the countermeasures to carry out the "gold standard" of preoperative assessment and the system of medical delivery, form the new principle of incision of anal sphincters, collect the high-level evidence-based medicine proof, improve the healing rate and significantly reduce the postoperative continence disturbance, so as to develop a new guideline for the treatment of fistula-in-ano.

Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females

Lateral internal sphincterotomy is considered the surgical treatment of choice for chronic anal fissure after failure of medical therapy but it risks continence. The aim of the study was to evaluate fissurectomy with advancement flap for anterior chronic anal fissure (CAAF) resistant to medical therapy. Sixteen women with CAAF without hypertonia of the internal anal sphincter, unresponsive to previous medical treatment, were included in the study. Absence of hypertonia was defined as a maximum anal resting pressure (MRP) of less than 85 mmHg. All patients underwent fissurectomy with an advancement skin flap. Complete healing occurred in all patients within 30 days. The intensity and the duration of pain after defecation reduced from the first postoperative defecation. MRP before surgery and at 6 months showed no significant difference. At 1 month, four patients experienced a continence disturbance, two of whom had it preoperatively. At 12 months, two (12.5%) patients continued to experience a continence disturbance. Fissurectomy with skin advancement flap resulted in complete healing and full relief of symptoms in all patients. There was a low incidence of continence disturbance.

Delorme's operation for severe rectal outlet obstruction

BACKGROUND: The aim of this study was to evaluate the long-term outcome of Delorme's operation for severe symptomatic rectal outlet obstruction. METHODS: In a retrospective cohort analysis, we have evaluated 15 patients operated between 1996 and 2004. Telephone interviews or mailed questionnaires assessed constipation and fecal incontinence preoperatively and at the time of follow-up and overall satisfaction with the outcome of the operation. RESULTS: Nine patients (60%) were available for assessment by questionnaire after a median follow-up of 63 months. Two reported no improvement and seven reported an improvement in their defecation problems. Of the latter, six were satisfied with the outcome of the operation, and one was not. The median constipation score decreased significantly from preoperatively 16 (range 0–21) to 10 (range 0–14). However, 5/9 patients (55%) also reported a new continence disturbance after the operation. CONCLUSIONS: Delorme's operation provides relief of symptoms and an acceptable level of satisfaction in patients with rectal outlet obstruction due to intussusception. However, some patients can develop a variable degree of fecal incontinence following the procedure, and this fact might affect postoperative quality of life.

Anal Fissure; surgery is the most effective treatment

Anal Fissure; surgery is the most effective treatment

Anal fistulotomy using radiowaves - long-term outcome

The aim of this paper was to analyze the results of treatment of anal fistulas using a radiowave device retrospectively. Between 2000 and 2008, 976 patients were operated on for perianal fistula. A Ellman radiowave generator was used to carry out the complete surgical procedure. In the follow-up period 155 patients were lost, remaining 821 patients were analyzed in the study. The mean follow-up time was 6.8 years. Analyzed parameters included: postoperative complications, wound healing time, off work duration, recurrence rate and incidence of anal sphincter dysfunction. Severity of gas and stool incontinence was assessed. In our study, subcutaneous fistula was diagnosed in 28.1%, inter-sphincteric in 39.1%, and trans-sphincteric in 32.8%; supra-sphincteric and extra-sphincteric fistulae were not included in the study. Single-tract fistulas were present in 85.4% and multi-tract fistulas were present in 14.6%. Postoperative complications were noticed in 1.4% of patients, which included postoperative bleeding, abscess formation, premature approximation of skin edges, prolapse of hemorrhoids and local skin allergic reactions. Postoperative gas and/or stool incontinence was noticed in 3.8%. The recurrence rate was 1.7%. Radiowave fistulotomy offers short operation time, less postoperative pain, early return to normal activity, and faster healing of the wound. The recurrence rate and continence disturbances are comparable to conventional fistulotomy procedures.

Fine-tuning of the Extent of Lateral Internal Sphincterotomy: Spasm-controlled vs. up to the Fissure Apex

This study was designed to compare the results of controlled lateral internal sphincterotomy by using anal calibrators with those of sphincterotomy up to the fissure apex in a randomized, prospective fashion. In the fissure apex group, sphincterotomy was extended to the level of the fissure apex, and in the spasm-controlled group, serial small sphincterotomies and anal caliber measurements followed until an anal caliber of 30 mm was obtained. The preoperative anal caliber was 24 +/- 1.9 (range, 20-28) mm and 24.9 +/- 2.44 (range, 19-28) mm in the spasm-controlled and fissure apex groups, respectively (P = 0.127). Postoperatively, the spasm-controlled group had a mean anal caliber of 31.5 +/- 1.28 (range, 30-32) mm, and the fissure apex group had 32.5 +/- 2.33 (range, 25-37) mm (P = 0.035). In the fissure apex group, a significant negative correlation was determined between the postoperative anal caliber and time of relief of pain (r = -0.568, P = 0.001). The early (7 and 28 days) postoperative anal incontinence scores were significantly higher in the fissure apex group (P = 0.002, P < 0.0001, respectively). A significant positive correlation between the anal caliber measurements and anal incontinence scores at 28 days and 2 months also was noted in the fissure apex group (r = 0.406, P = 0.023; and r = 0.364, P = 0.044). Controlled sphincterotomy provided a faster relief of pain, and it was associated with a lower rate of early postoperative disturbance of continence and an insignificantly lower rate of treatment failure compared with sphincterotomy up to the fissure apex.