Treatment of chronic anal fissure

Chronic anal fissure is a common benign anorectal problem in Western countries that substantially impairs the patient's life. Consequently, a rapid and effective solution is required. We reviewed the various treatments for chronic anal fissure described in the literature, with the aim of establishing a therapeutic protocol. We recommend surgical sphincterotomy (preferably open or closed lateral sphincterotomy) as the first therapeutic approach in patients with chronic anal fissure. However, we prefer the use of chemical sphincterotomy (preferably botulinum toxin) in patients aged more than 50 years old and in those with previous incontinence, risk factors for incontinence (previous anal surgery, multiple vaginal births, diabetes, inflammatory bowel disease, etc.), or without anal hypertonia, despite the higher recurrence rate with medical treatments, since this procedure avoids the greater risk of residual incontinence described in the literature with surgical sphincterotomy in this group of patients.     

Treatment of chronic anal fissure

Current treatment of chronic anal fissure continues to be based on conventional conservative measures in a high percentage of cases. What is known as chemical sphincterotomy aims to achieve a temporary decrease of anal pressures that allows fissures to heal. There are various alternatives such as nitroglycerine or diltiazem ointment and botulinum toxin injections. However, because of collateral effects and recurrences in the medium term, the definitive role of these treatments remains to be elucidated. Nevertheless, chemical sphincterotomy should be the first option in patients with a high risk of incontinence. "Open" or "closed" lateral internal sphincterotomy performed in the ambulatory setting with local anesthesia can currently be considered the ideal treatment of chronic anal fissure refractory to conservative measures so long as the patient is informed about the risk of minor incontinence. This procedure provides rapid and permanent recovery in more than 95% of patients. There is evidence demonstrating that the incontinence rate is related to the extent of the lateral internal sphincterotomy and consequently the extent of this procedure should be reduced to the length of the fissure.     

病理性肛裂组织切除治疗慢性肛裂疗效观察

目的 探讨病理性肛裂组织切除治疗慢性肛裂的疗效。方法 回顾分析2019年9月至2020年4月在我院接受病理性肛裂组织切除手术46例慢性肛裂患者的临床及随访资料,观察患者手术时间、术中出血量、术后并发症情况、术后疼痛评分、手术前后肛管静息压变化及临床疗效。结果 本组患者手术时间（35.91±12.35）min,术中出血量（7.33±3.48）mL。术后出现尿潴留4例（8.70%）,切口感染1例（2.17%）,未出现切口出血、肛门失禁等并发症。术后24 h疼痛评分（3.43±0.91）分,术后48 h疼痛评分（3.00±0.73分,术后72 h疼痛评分（2.22±0.76）分,术后1周疼痛评分（0.67±0.63）分。术前肛管静息压（19.86±2.24）kPa,术后3周肛管静息压（10.396±1.97）kPa,差异具有统计学意义（P=0.000）。创面愈合时间为（24.26±5.14）d。本组患者治愈42例（91.30%）,好转4例（8.70%）,有效率100%。中位随访时间8.2个月,无复发病例。结论 病理性肛裂组织切除术治疗慢性肛裂安全、有效。     

Oral nifedipine in the treatment of chronic anal fissure

BACKGROUND: The purpose of this study was to demonstrate the effect of oral nifedipine on maximal resting anal pressure (MRAP) in healthy volunteers and to evaluate its role in the treatment of chronic anal fissure (CAF). METHODS: MRAP was measured in 10 healthy volunteers and 10 patients with CAF before and after oral nifedipine (20 mg b.i.d.). Patients were assessed on the first visit and every fortnight for measurement of MRAP, pain scores, blood pressure, pulse rate, healing of the fissure and adverse effects. Treatments were continued until healing had occurred or for up to 8 weeks. RESULTS: MRAP values before and after nifedipine were 73.2 and 49.3 cm H2O, respectively, in healthy volunteers (p < 0.001). Nifedipine caused a reduction in mean MRAP from 105.2 to 74.0 cm H2O (p < 0.001) in patients with CAF. Pain scores were significantly reduced after 2 weeks of treatment with nifedipine (p < 0.001) and continued throughout the treatment period. At the end of the study 6 of the 10 patients treated with nifedipine were deemed to be healed (n = 5) or improved (n = 1). Headache occurred in 1 patient. CONCLUSION: We conclude that oral nifedipine is effective in reducing MRAP and should become the first-line treatment for CAF.     

Treatment of chronic anal fissure by gonyautoxin

OBJECTIVE: The use of gonyautoxin has been reported to be safe and effective in healing acute and chronic anal fissures. This study was designed to show better efficacy in healing patients with chronic anal fissure by increasing the frequency of toxin injection. METHOD: Twenty-three chronic anal fissure patients were treated with doses of 100 units of gonyautoxin, which was intrasphincteric, infiltrated. The frequency of injection was every 4 days. Anorectal manometries were performed before and 4 min after infiltration. RESULTS: Total remissions were achieved within 7-14 days. The patients healed with a mean time of 8.2 +/- 2.4 days. No relapsed were observed during the 10-month follow up. Neither faecal incontinence nor other side effects were observed. All patients showed immediate sphincter relaxation detected by clinical examination. The maximum anal resting pressures, recorded 4 min after injections decreased to 62.9 +/- 27.7 mmHg, being 65.3 +/- 29.6% of baseline. Immediately after infiltration, patients reported anaesthetic effect with a fall down of the postdefecatory pain. CONCLUSION: Although, gonyautoxin anal fissures treatment recently published proved to be safe and effective, this study shows a better protocol for anal fissure treatment, showing better efficacy by shorting the healing time with better perception of healing by patients. Gonyautoxin anal sphincter infiltration proves to be safe and effective, reducing discomfort and healing time, advantageously comparing with alternative therapeutic approaches for chronic anal fissure.     

Innovations in chronic anal fissure treatment: A systematic review

A chronic anal fissure is a common perianal condition. This review aims to evaluate both existing and new therapies in the treatment of chronic fissures. Pharmacological therapies such as glyceryl trinitrate (GTN), Diltiazem ointment and Botulinum toxin provide a relatively non-invasive option, but with higher recurrence rates. Lateral sphincterotomy remains the gold standard for treatment. Anal dilatation has no role in treatment. New therapies include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Further research is required comparing these new therapies with existing established therapies. This paper recommends initial pharmacological therapy with GTN or Diltiazem ointment with Botulinum toxin as a possible second line pharmacological therapy. Perineal support may offer a new dimension in improving healing rates. Lateral sphincterotomy should be offered if pharmacological therapy fails. New therapies are not suitable as first line treatments, though they can be considered if conventional treatment fails.     

Sphincterolysis: a novel approach towards chronic anal fissure

BACKGROUND AND AIMS: The surgical approach in chronic anal fissure is often found associated with disturbed anal continence as well as recurrence. This report describes the author's approach of 'sphincterolysis' or fragmentation of the fibers of the internal sphincter on the left lateral anal wall. PATIENTS AND METHODS: 132 patients with chronic anal fissures were treated with this technique. Pre- and postoperative anal manometry was recorded. The postoperative course and early and 1-year follow-up results were recorded. RESULTS: Early complications included ecchymosis, hematoma, and pain. Fissure healing and relief of symptoms observed in 97% of patients. A transient, variable degree of incontinence occurred in 23 patients and persistent incontinence to flatus and soiling in 5. CONCLUSION: Internal anal sphincterolysis is a safe, effective procedure for the treatment of chronic anal fissure.     

Topical diltiazem ointment in the treatment of chronic anal fissure

BACKGROUND: Chronic anal fissure has traditionally been treated surgically. Initial enthusiasm for chemical sphincterotomy has waned because of poor outcomes with glyceryl trinitrate ointment. In this study the use of topical 2 per cent diltiazem ointment has been investigated as an alternative method of chemical sphincterotomy. METHODS: A prospective assessment of 71 consecutive patients with a chronic anal fissure treated with 2 per cent topical diltiazem ointment for a median duration of 9 (range 2--16) weeks was performed. RESULTS: Fifty-one patients (75 per cent) experienced healing of the fissure after 2--3 months of treatment with topical diltiazem. Seventeen patients who did not heal were treated for a further 8 weeks with topical diltiazem. Eight of these patients subsequently healed with diltiazem. Fifty-nine of 67 patients who completed follow-up therefore healed on diltiazem ointment. Four patients experienced perianal dermatitis and one patient experienced headaches. No other side-effects were recorded. After a median of 32 (range 14--67) weeks' follow-up following completion of treatment, 27 of 41 patients available remain symptom free. Six of seven patients with recurrent fissure were treated successfully by repeat chemical sphincterotomy. CONCLUSION: Topical 2 per cent diltiazem ointment used as an agent for chemical sphincterotomy for chronic anal fissure offers significant healing rates but does not have a significant side-effect profile, which may aid compliance to treatment. Early recurrences are common but usually amenable to further chemical sphincterotomy.     

裁剪式内括约肌侧切术治疗陈旧性肛裂的临床疗效观察

目的探讨裁剪式内括约肌侧切术的临床疗效。方法对170例陈旧性肛裂患者采取裁剪式内括约肌侧切术,观察手术疗效、手术时间、愈合时间、手术并发症等指标。结果 170例患者全部治愈,术后随访3个月至2年,无肛裂复发。7例患者出现术后并发症（1例肛周脓肿、3例切口感染、2例急便感、1例术中血肿）。结论裁剪式内括约肌侧切术临床疗效较好,治愈率高,同时术后并发症少,并较好的保护了肛门功能,提高患者术后的生活质量。     

Internal sphincterotomy for chronic anal fissure: long term effects on anal pressure

In 28 patients with chronic anal fissure the median anal canal pressure was 98 cmH2O, significantly higher than in control subjects (P less than 0.001). After lateral internal sphincterotomy the pressure dropped by 50 per cent to normal levels and the fissures healed with no change in pressure over 12 months. Ten patients also had normal anal pressures and were asymptomatic 4-6 years after internal sphincterotomy. Adequate internal sphincterotomy appears to reduce permanently anal canal pressure, suggesting that abnormal activity in the sphincter contributes to the development of a fissure.     

Quality of life in patients with chronic anal fissure

Objective Little is known about the quality of life in patients with the distressing symptoms of chronic anal fissure. This was a prospective study assessing the physical and mental health of fissure patients before and after topical treatment. Patients and methods New patients attending the fissure clinic were recruited prospectively into the study over a 2‐month period. On first appointment, patients were given 2 questionnaires to complete: the Short‐Form 36 Health Survey (SF‐36) and a general questionnaire recording patients' demographic details, previous treatment, site and duration of fissure and symptoms on a visual analogue scale (VAS). Following an 8‐week course of topical treatment, patients repeated the SF‐36 and symptoms were again recorded on a VAS. Healing of fissure was noted. Results Fifty‐four patients entered the study, of which 39 returned for follow‐up; 16 male, 23 female; mean age 38.6 years (range 17–80 years). Median duration of fissure was 6 months (3 months – 10 years). Higher VAS ratings for fissure pain were associated with worse scores for all aspects of health‐related quality of life, including mental health (P < 0.001), bodily pain (P < 0.001), vitality (P < 0.006) and social functioning (P < 0.001). Compared to age and gender matched norms for the SF‐36, fissure patients had more bodily pain (P < 0.001, Wilcoxon) and poorer health perceptions (P < 0.02, Wilcoxon). Gender did not affect any of the SF‐36 subscales. However, females did report significantly more bleeding (P = 0.05). On follow‐up, healing was complete in 27 patients (69%). Symptoms of pain, bleeding and irritation were all significantly reduced in this group. Repeating the SF‐36 showed an improvement in bodily pain, role‐physical functioning and vitality (P < 0.05). Conclusion Successful nonsurgical treatment of chronic anal fissure leads to symptomatic improvement and beneficially affects health‐related quality of life.     

Advancement flap in the management of chronic anal fissure: a prospective study

Lateral internal sphincterotomy is the surgical treatment of choice of chronic anal fissure after failure of conservative measures. Several randomized trials identified an overall risk of incontinence of 10 % mostly for flatus. Fissurectomy is the most commonly used procedure to preserve the integrity of the anal sphincters. However, a possible complication is keyhole defect that may lead to faecal soiling. In this study, chronic anal fissure (CAF) was treated by fissurectomy and anal advancement flap to preserve the anatomo-functional integrity of sphincters and to reduce healing time and the risk of anal stenosis. In patients with hypertonia, surgical treatment was combined with chemical sphincterotomy by injection of botulinum toxin to enhance tissue perfusion. Forty eight patients with CAF underwent fissurectomy and anal advancement flap. In 22 subjects with hypertonia of the internal anal sphincter, intrasphincter injection of 30 UI of botulinum toxin at the completion of the surgical operation was used. All patients were followed up to 24 months. Since the first defecation, the intensity and duration of pain were significantly reduced. Two patients had urinary retention, five had infections and three had partial breakdowns. No anal stenosis, keyhole deformity or necrosis flap was recorded. At the 24 months follow-up visit, anal incontinence was similar to those detected preoperatively. Only four recurrences were detected at 18 and 20 months. After medical treatment failure, fissurectomy with advancement flap is a valid sphincter-conserving procedure for treatment of anterior or posterior CAF, regardless of hypertonia of the internal anal sphincter.     

Changing patterns of treatment for chronic anal fissure.

To assess changing patterns of treatment for chronic anal fissure, a retrospective analysis of treatment for chronic anal fissure within one hospital between January 1990 and December 1996 was undertaken. A total of 221 patients received treatment for a chronic anal fissure in this period, of whom 209 had a surgical procedure. Manual dilatation of the anus was performed in 21 patients (10%) and has not been performed since 1995. Lateral internal sphincterotomy was performed in 183 patients (88%) and continues to be the mainstay of treatment. Five female patients (2%) were identified as having a sphincter defect by anal manometry combined with endoanal ultrasound and were treated by an anal advancement flap. From 1996 onwards, 15 patients (7%) were treated by topical glyceryl trinitrate (GTN) paste as the first line of treatment. Of these patients, nine have experienced healing of their fissure, and three have had relief of pain without healing of the fissure. Three have gone on to have a lateral internal sphincterotomy. Lateral internal sphincterotomy remains the primary form of treatment for chronic anal fissure. GTN cream has increasingly been offered as preliminary treatment over the last 12 months. Perioperative use of endoanal ultrasound allowed identification of patients who may be at high risk of postoperative incontinence from a sphincterotomy. An anal advancement flap has been used as an alternative surgical approach for these patients.     

Oral nifedipine reduces resting anal pressure and heals chronic anal fissure.

BACKGROUND: Topical preparations have been used in the treatment of anal fissure. However, they are not universally successful and there is confusion over the site and dose of application. This study assessed the effectiveness of oral nifedipine in reducing resting anal pressure and on fissure healing. METHODS: Anal manometry was performed on eight healthy volunteers and 15 patients with chronic anal fissure before and after oral administration of nifedipine 20 mg. Nifedipine was taken twice daily. Fissure healing was assessed over an 8-week period and pain scores were monitored. RESULTS: Oral nifedipine produced an initial reduction in maximum resting anal pressure (MRP) of 35 per cent (P < 0.001) and of 28 per cent after 5 days (P < 0.001) in healthy volunteers. A reduction in MRP of 36 per cent (P < 0.001) was observed in patients with fissure. Pain scores were significantly reduced during the treatment period. Healing was complete in nine patients after 8 weeks and a further three were asymptomatic. Ten patients experience flushing and four had mild headaches. There were no episodes of postural hypotension or incontinence. CONCLUSION: Oral nifedipine reduces resting anal pressure. It is well tolerated and offers an alternative treatment for chronic anal fissure.