It is postulated that an anterior anal fissure can result from mucosal trauma occurring during distention of a rectocele and that repair of the rectocele by anterior levatorplasty can lead to healing of these anal fissures. This study was designed to compare anterior levatorplasty with internal sphincterotomy for the management of anterior anal fissures in females with a rectocele. From June 2000 until May 2002, 54 consecutive females with an anterior anal fissure and a rectocele were randomized to be managed by internal sphincterotomy or anterior levatorplasty. Preoperatively, manometry was performed, continence was measured using the Cleveland Clinic scoring system, pain scores were obtained using a visual analog scale, and the symptoms of bleeding and straining to defecate were assessed. Postoperatively, pain scores were obtained at Days 2, 7, and 21. Manometry, continence scores, and resolution of symptoms were measured between 8 and 12 weeks. Patient satisfaction and fissure healing also were assessed between 8 and 12 weeks. The average length of follow-up was 20 (range, 6-30) months. Postoperatively, lateral sphincterotomy caused a decrease in the resting pressures and anterior levatorplasty resulted in an increased length of the anal canal. Anterior levatorplasty also caused increased postoperative pain scores. There were no differences in fissure healing and patient satisfaction. These data suggest that anterior levatorplasty is an option for the management of patients with a rectocele, which may avoid the risk of incontinence with lateral internal sphincterotomy and better address the etiology of anterior anal fissures.