Progress in the understanding and treatment of chronic anal fissure

Abstract

Background-Chronic anal fissure is a common and painful condition associated with internal anal sphincter hypertonia. Reduction of this hypertonia improves the local blood supply, encouraging fissure healing. Surgical sphincterotomy is very successful at healing these fissures but requires an operation with associated morbidity. Temporary reduction in sphincter tone can be achieved on an outpatient basis by applying a topical nitric oxide donor (for example, glyceryl trinitrate) or injecting botulinum toxin into the anal sphincter. Methods-A Medline database was used to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure. Results-Review of the literature shows botulinum toxin injection to be more eVective at healing chronic anal fissures than topical glyceryl trinitrate. Topical isosorbide dinitrate has not been directly compared with either of these two agents but has a healing rate approaching that of botulinum toxin injection. The main side eVect of botulinum toxin injection is temporary faecal incontinence in approximately 2% of cases, whereas topical nitrates cause headaches in 20%-100% of cases. No long term side eVects were identified with any of the medical treatments. Conclusion-Chemical sphincterotomy is an eVective treatment for chronic anal fissure and has the advantages over surgical treatment of avoiding long term complications (notably incontinence) and not requiring hospitalisation. (Postgrad Med J 2001;77:753-758)

Prevalence of Fissure-in-Ano among the Patients of Anorectal Complaints Visiting Nium Hospital

“…bleeding, pain, prolapse and/or discharge per rectum were included, so the high prevalence of anal fissure was expected. According to a study carried out in proctology clinic 10% patients were found to be affected with anal fissure [11] which is somewhat closer to our data.…”

“…Included patients were also asked about their bowel habits as trauma due to the passage of hard stool, as in constipation, is thought to be and mentioned in many texts as an important initiating factor for the development of anal fissure [1,3,5,[7][8][9]11]. In our study out of 65 anal fissure patients, 48 were found to be with constipation and 17 were not.…”

Clinical and manometric evaluation of women with chronic anal fissure before and after internal subcutaneous lateral sphincterotomy

“…This pressure would not be great enough to overcome the high resting anal pressure (90 mmHg) observed in anal fissure patients. As a result, the blood flow to fistula area would be decreased, preventing its healing 15 . Schouten et al 16 defined an inverted correlation between irrigation of the posterior midline and maximum resting anal pressure in both health and anal fissure patients.…”

Anal fissures: Open lateral internal sphincterotomy results

“…Since its introduction by Eisenhammer in 1951, lateral internal sphincterotomy has been used with increasing frequency and it is now considered the treatment of choice for chronic anal fissures. [19][20][21][22][23][24][25] The administration of pharmacological preparations that relaxes the internal anal sphincter effectively reducing anal pressure, can lead to healing of chronic fissures. However, this effect on the muscle is reversible and resting pressures appear to return to original values once treatment is discontinued, even after the fissure has healed.…”