Update on the management of anal fissure

Abstract

Anal fissure is an ulceration of the anoderm in the anal canal. Its pathogenesis is due to multiple factors: mechanical trauma, sphincter spasm, and ischemia. Treatment must address these causative factors. While American and British scientific societies have published recommendations, there is no formal treatment consensus in France. Medical treatment is non-specific, aimed at softening the stool and facilitating regular bowel movements; this results in healing of almost 50% of acute anal fissures. The risk of recurrent fissure remains high if the causative factors persist. If non-specific medical treatment fails, specific medical treatment can be offered to reversibly decrease hypertonic sphincter spasm. Surgery remains the most effective long-term treatment and should be offered for cases of chronic or complicated anal fissure but also for acute anal fissure with severe pain or for recurrent fissure despite optimal medical treatment. Surgical treatment is based on two principles that may be combined: decreasing sphincter tone and excision of the anal fissure. Lateral internal sphincterotomy (LIS) is the best-evaluated technique and remains the gold standard in English-speaking countries. Since LIS is associated with some risk of irreversible anal incontinence, its use is controversial in France where fissurectomy combined with anoplasty is preferred. Other techniques have been described to reduce the risk of incontinence (calibrated sphincterotomy, sphincteroplasty). The technique of forcible uncalibrated anal dilatation is no longer recommended.

Assessment of haemorrhoidal artery network using Doppler‐guided haemorrhoidal artery ligation for haemorrhoids and pathogenesis implications

“…9 Although this condition is rather common, 10 pathogenesis and aetiology are still incompletely understood. 11,12 This study, along with others, shows that blood flow to the posterior midline of the anus is potentially significantly deficient, even in the absence of anal fissure. 1,13,14 None of our patients who were operated on for haemorrhoidal disease suffered from anal fissure.…”

“…This study also demonstrates that the second blood deficiency location is the 12 o'clock position. Literature shows that this location is the second most common site for non‐specific anal fissure in up to 25% of women and 8% of men, once again proving that the pathogenesis of such a condition might be well due to relative ischaemia.…”

“…The deficient vascularization is thus one of the causes and not the consequence of an anal fissure. Recent advances in the understanding of the pathogenesis of the anal fissure are the sequences of relative ischaemia, local trauma and anal hypertonia …”

Anal self-massage in the treatment of acute anal fissure: a randomized prospective study

“…Inclusion criteria were age ranging from 18 to 70 years, presence of anal pain during bowel movements, detection of acute posterior anal fissure. The fissure was defined as “acute” in the case of an ulceration that developed within one month in the anoderm, without the typical signs of chronic fissure (presence of sentinel tag, fibrous induration of the side edges, and exposure of the fibers of the internal anal sphincter) [12]. Exclusion criteria were concomitant anal pathology (anorectal fistulae, abscesses), previous surgery on the pelvic floor, inflammatory bowel disease, and therapy with nitrates.…”

Increasing efficacy and reducing side effects in treatment of chronic anal fissures

“…Unfortunately, treatment response is often sub-optimal and can lead to poor patient compliance. [10] …”