I suppose the greatest satisfaction for a surgeon is taking on a big and challenging case, carrying it out perfectly even when encountering difficulties, and having it turn out well. Saving a life in the process -- understood. And yet it might be that the most grateful patients I've ever had are those on whom I performed an embarrassingly simple operation -- one that takes only a minute or two. These patients, often, came (or were helped) into my office crying, begging, "Doc, if you can't help me, could you please kill me?"
In my previous post I suggested the anus could stand a little re-design. How nice it would be to download (as it were) version 2.0. Maybe it could come with a user's guide, too; and not just for the owners (it could be brief: Fiber. And lube. But I digress). A shop manual would be nice, because it's actually surprisingly misunderstood by lots of primary docs. (Also brief: hemorrhoids protrude, and bleed. If there's lots of pain involved, it's something else.) (Oh, yeah: "thrombosed hemorrhoid" -- which can indeed hurt like hell -- is another of those misnomers. "Peri-anal hematoma" is more apt. But that's not what I'm talking about.)
I'd guess most people (maybe not vegetarians) have had one of those bowel movements that brings tears to the eyes. A small tear of the skin overlying the sphincter muscle (control muscle) may occur on such an occasion. When it does, then things go in one of two directions: with time and luck and perfection of stoolage, it heals. Or it doesn't. The tear deepens, exposing the muscle underneath. Which leads to a vicious cycle of pain, spasm, tearing, more pain, more spasm, more tearing. And then you have an anal fissure. Ouch. No, seriously: ouch! Grab the walls, yell and cry ouch.
Most fissures heal, one way or another, without surgery. Hot soaks, stool softeners, various ointments or suppositories, injections. But some resist all that, leaving that patient asking for cure or death, whichever can be accomplished the quickest. Such patients, I treated as an emergency, imploring the surgery center to find a spot in a hurry (I had one of the three or four best centers on the planet one floor below my office. I say three or four because I accept the possibility that others could be as good. But, really, I doubt it.)
The operation is totally simple (lateral sphincterotomy). The idea is to break that cycle of spasm; so you make a cut in the muscle, off to the side -- forced relaxation. Applying a little pull while doing it, you can feel it release, like a rubber band. (There are two sphincter muscles there: cutting the most superficial, and smaller one rarely leads to control issues.) You can also just stretch the muscle, without cutting it. Personally, I don't think it's as effective. That release is like a bugle call: ta da. In rides the rescuer, swooping up the patient into heroic arms and riding off in glory. "Oh my god, doc," says the patient when it's over. "I love you. You're my hero. My kingdom, my gold: it's all yours." "Happy to help," I say, humbly, while walking off with at least some of the gold.
IMPORTANT NOTE (added 12/09): I'm beginning to think this post must be linked to some sort of forum on anal problems, because I'm getting a steady diet of questions lately. I'm truly delighted that my blog continues to be a source of information for people; that was, most certainly, one of my goals. On the other hand, I hope it's evident from my posts in general, and from my responses here in particular, that I'm not comfortable making specific diagnoses or treatment recommendations. I'd like to, really. But the problem is there's no way I can ever know for sure what's going on, and the last thing I want to do is substitute for or supersede in any way the input of a physician actually able to assess the situation directly. My aim has been to provide general information. Because my recommendations, absent direct involvement, might be wrong, and because it might delay a person from contacting their own doctor, I simply don't feel right about doing it.
SECOND IMPORTANT NOTE (added 10/10): I'm closing comments in this thread. The last four or five comments will demonstrate why. It ended badly, and I'm sorry for that. I must be getting crotchety in my old age. On the other hand, I'm pretty confident that any information I'd have to pass on to future commenters is already available in the original post and in my many, many responses to questions I've received. And the point of the first update still applies.
THIRD IMPORTANT NOTE (added 4/13): I recently did a series of interviews for a website. Below is what I had to say, in the brief time allotted, about anal fissures: