The management of patients with primary chronic anal fissure: a position paper

D F Altomare, G A Binda, S Canuti, V Landolfi, M Trompetto, R D Villani, D F Altomare, G A Binda, S Canuti, V Landolfi, M Trompetto, R D Villani

Abstract

Anal fissure is one of the most common and painful proctologic diseases. Its treatment has long been discussed and several different therapeutic options have been proposed. In the last decades, the understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment based on anal sphincter muscle relaxation. Despite some systematic reviews and an American position statement, there is ongoing debate about the best treatment for anal fissure. This review is aimed at identifying the best treatment option drawing on evidence-based medicine and on the expert advice of 6 colorectal surgeons with extensive experience in this field in order to produce an Italian position statement for anal fissures. While there is little chance of a cure with conservative behavioral therapy, medical treatment with calcium channel blockers, diltiazem and nifepidine or glyceryl trinitrate, had a considerable success rate ranging from 50 to 90%. Use of 0.4% glyceryl trinitrate in standardized fashion seems to have the best results despite a higher percentage of headache, while the use of botulinum toxin had inconsistent results. Nonresponding patients should undergo lateral internal sphincterotomy. The risk of incontinence after this procedure seems to have been overemphasized in the past. Only a carefully selected group of patients, without anal hypertonia, could benefit from anoplasty.

References

    1. Cross KL, Massey EJDA, Fowler AL, Monson JRT. The management of anal fissure: ACPGBI position statement. Colorectal Dis. 2008;10(Suppl 3):1–7. doi: 10.1111/j.1463-1318.2008.01681.x.
    1. Orsay C, Rakinic J, Perry Brian W, et al. ASCRS practical parameters for the management of anal fissures. Dis Colon Rectum. 2004;47:2003–2007. doi: 10.1007/s10350-004-0785-7.
    1. CKS/NHS Anal fissure,
    1. Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg. 1996;83:1335–1344. doi: 10.1002/bjs.1800831006.
    1. Goligher JC. Surgery of the anus, Rectum & Colon. 3. London: Balliere & Tindall; 1975.
    1. American Gastroenterology Association (AGA) American gastroenterological association medical position statement: diagnosis and care of patients with anal fissure. Gastroenterology. 2003;124:233–234. doi: 10.1053/gast.2003.50006.
    1. Collins EE, Lund NJ. A review of chronic anal fissure management. Tech Coloproctol. 2007;11:209–223. doi: 10.1007/s10151-007-0355-9.
    1. Lindsey I, Jones OM, Cunningham C, Mortensen NJ. Chronic anal fissure. Br J Surg. 2004;91:270–279. doi: 10.1002/bjs.4531.
    1. Hananel N, Gordon PH. Re-examination of clinical manifestation and response to therapy of fissure-in-ano. Dis Colon Rectum. 1997;40:229–233. doi: 10.1007/BF02054993.
    1. Steele SR, Madoff RD. Systematic review: treatment of anal fissure. Aliment Pharmacol Ther. 2006;24:247–257. doi: 10.1111/j.1365-2036.2006.02990.x.
    1. Notaras MJ. Anal fissure and stenosis. Surg Clin North Am. 1988;68:1427–1440.
    1. Lock MR. Thompson JPS Fissure-in-ano: the initial management and prognosis. Br J Surg. 1977;84:86–88.
    1. Hospital Episode Statistics (2007) Hospital Episode Statistics 2005/2006. Department of Health. National Institute for Health and Clinical Excellence.
    1. SICCR Annual Report (2009).
    1. Ball C. The rectum, its diseases and developmental defects. London: Hodder and Stoughton; 1908.
    1. Brodie BC. Lectures on diseases of the rectum: preternatural contraction of the sphincter ani. Lond Med Gazette. 1835;16:26–31.
    1. Hancock BD. The internal sphincter and anal fissure. Br J Surg. 1977;64:92–95. doi: 10.1002/bjs.1800640204.
    1. Favetta U, Amato A, Interisano A, Pescatori M. Clinical, monometric and sonographic assessment of the anal sphincters. A comparative prospective study. Int J Colorectal Dis. 1996;11:163–166. doi: 10.1007/s003840050035.
    1. Bove A, Balzano A, Perrotti P, Antropoli C, Lombardi G, Pucciani F. Different anal pressure profiles in patients with anal fissure. Tech Coloproctol. 2004;8:151–156. doi: 10.1007/s10151-004-0079-z.
    1. Corby H, Donnelly VS, O’Herlihy C, O’Connell PR. Anal canal pressures are low in women with postpartum anal fissure. Br J Surg. 1997;84:86–88. doi: 10.1002/bjs.1800840132.
    1. Rattan S, Chakder S. Role of nitric oxide as a mediator of internal anal sphincter relaxation. Am J Physiol. 1992;262:G107–G112.
    1. Lund J. Nitric oxide deficiency in the internal anal sphincter of patients with chronic anal fissure. Int J Colorectal Dis. 2006;21:673–675. doi: 10.1007/s00384-005-0757-y.
    1. Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. Dis Colon Rectum. 1994;37:664–669. doi: 10.1007/BF02054409.
    1. Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996;83:63–65. doi: 10.1002/bjs.1800830120.
    1. Kua KB, Kocker HM, Kelkar A, Patel AG. Effect of topical glyceryl trinitrate on anodermal blood flow in patients with chronic anal fissures. ANZ J Surg. 2001;71:548–550. doi: 10.1046/j.1440-1622.2001.02182.x.
    1. Jones OM, Ramalligam T, Lindsey I, Cunningham C, George BD, Mortensen NJ. Digital rectal examination of sphincter pressures in chronic anal fissure is unreliable. Dis Colon Rectum. 2005;48:349–352. doi: 10.1007/s10350-004-0753-2.
    1. Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. BMJ. 1986;292:1167–1169. doi: 10.1136/bmj.292.6529.1167.
    1. Jiang JK, Chiu JH, Lin JK. Local thermal stimulation relaxes hypertonic anal sphincter: evidence of somatoanal reflex. Dis Colon Rectum. 1999;42:1152–1159. doi: 10.1007/BF02238567.
    1. Gough MJ, Lewis A. The conservative treatment of fissure-in-ano. Br J Surg. 1983;70:175–176. doi: 10.1002/bjs.1800700312.
    1. Jensen SL. Maintenance therapy with unprocessed bran in the prevention of acute anal fissure recurrence. J R Soc Med. 1987;80:296–298.
    1. Loder PB, Kamm MA, Nicholls RJ, Phillips RK. Reversible chemical sfincterotomy by local application of glyceryl trinitrate. Br J Surg. 1984;81:1386–1389. doi: 10.1002/bjs.1800810949.
    1. Lund JN, Nystrom PO, Coremans G, et al. An evidence-based treatment algorithm for anal fissure. Tech Coloproctol. 2006;10:177–180. doi: 10.1007/s10151-006-0276-z.
    1. Gorfine SR. Topical nitroglycerin therapy for anal fissures and ulcers. N Engl J Med. 1995;333:1156–1157. doi: 10.1056/NEJM199510263331718.
    1. Lund JN, Armitage NC, Scholefield JH. Use of glyceryl trinitrate ointment in the treatment of anal fissure. Br J Surg. 1996;83:776–777. doi: 10.1002/bjs.1800830615.
    1. Kennedy ML, Sowter S, Nguyen H, Lubowski DZ. Glyceryl trinitrate ointment for the treatment of chronic anal fissure: results of a placebo-controlled trial and long-term follow-up. Dis Colon Rectum. 1999;42:1000–1006. doi: 10.1007/BF02236691.
    1. Bailey HR, Beck DE, Billingham RP, et al. A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures. Dis Colon Rectum. 2002;45:1192–1199. doi: 10.1007/s10350-004-6392-9.
    1. Altomare DF, Rinaldi M, Milito G, et al. Glyceryl trinitrate for chronic anal fissure-healing or headache? Results of a multicenter, randomized, placebo-controlled, double-blind trial. Dis Colon Rectum. 2000;43:174–179. doi: 10.1007/BF02236977.
    1. Lund JN, Scholefield JH. A randomised, prospective, double blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure [published erratum appears in Lancet 349:656] Lancet. 1997;349:11–14. doi: 10.1016/S0140-6736(96)06090-4.
    1. Nelson R. A systematic review of medical therapy for anal fissure. Dis Colon Rectum. 2004;47:422–431. doi: 10.1007/s10350-003-0079-5.
    1. Griffin N, Acheson AG, Tung P, Sheard C, Glazebrook C, Scholefield JH. Quality of life in patients with chronic anal fissure. Colorectal Dis. 2004;6:39–44. doi: 10.1111/j.1463-1318.2004.00576.x.
    1. Graziano A, Svidler Lopez L, Lencinas S, Masciagnoli G, Gualdrini U, Bisisio O. Long-term results of topical nitroglycerin in the treatment of chronic anal fissures are disappointing. Tech Coloproctol. 2001;5:143–147. doi: 10.1007/s101510100016.
    1. Nelson R (2006) Non surgical therapy for anal fissure. Cochrane Database Syst Rev 18:CD003431
    1. Fenton C, Wellington K, Easthope SE. 0.4% nitroglycerin ointment in the treatment of chronic anal fissure pain. Drugs. 2006;66:343–349. doi: 10.2165/00003495-200666030-00006.
    1. Gagliardi G, Pascariello A, Altomare DF, et al. Optimal treatment duration of glyceryl trinitrate for chronic anal fissure: results of a prospective randomized multicenter trial. Tech Coloproctol. 2010;14:241–248. doi: 10.1007/s10151-010-0604-1.
    1. Sands LR. 0.4% nitroglycerin ointment in the treatment of chronic anal fissure pain: a viewpoint by Laurence R. Sands. Drugs. 2006;66:350–352. doi: 10.2165/00003495-200666030-00007.
    1. Knight JS, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg. 2001;88:553–556. doi: 10.1046/j.1365-2168.2001.01736.x.
    1. Carapeti EA, Kamm MA, Phillips RK. Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum. 2000;43:1359–1362. doi: 10.1007/BF02236630.
    1. Bielecki K, Kolodziejczak M. A prospective randomized trial of diltiazem and glyceryl trinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis. 2003;5:256–257. doi: 10.1046/j.1463-1318.2003.00440.x.
    1. Nash GF, Kapoor K, Saeb-Parsy K, Kunanandam T, Dawson PM. The long-term results of diltiazem treatment for anal fissure. Int J Clin Pract. 2006;60:1411–1413. doi: 10.1111/j.1742-1241.2006.00895.x.
    1. Perrotti P, Bove A, Antropoli C, et al. Topical nifedipine with lidocaine ointment vs. active control for treatment of chronic anal fissure: results of a prospective, randomized, doubleblind study. Dis Colon Rectum. 2002;45:1468–1475. doi: 10.1007/s10350-004-6452-1.
    1. Merenstein D, Rosenbaum D. Is topical nifedipine effective for chronic anal fissures? J Fam Pract. 2003;52:190–192.
    1. Ezri T, Susmallian S. Topical nifedipine vs topical glyceryl trinitrate for treatment of chronic anal fissure. Dis Col Rectum. 2003;46:805–808. doi: 10.1007/s10350-004-6660-8.
    1. Jost WH. One hundred cases of anal fissure treated with botulinum toxin: early and long-term results. Dis Colon Rectum. 1997;40:1029–1032. doi: 10.1007/BF02050924.
    1. Maria G, Brisinda G, Bentivoglio AR, Cassetta A, Gui D, Albanese A. Influence of botulinum toxin site of injections on healing rate in patients with chronic anal fissure. Am J Surg. 2000;179:46–50. doi: 10.1016/S0002-9610(99)00255-X.
    1. Minguez M, Melo F, Espi A, et al. Therapeutic effects of different doses of botulinum toxin in chronic anal fissure. Dis Colon Rectum. 1999;42:1016–1021. doi: 10.1007/BF02236694.
    1. Essani R, Sarkisyan G, Beart RW, Ault G, Vukasin P, Kaiser AM. Cost-saving effect of treatment algorithm for chronic anal fissure: a prospective analysis. J Gastrointest Surg. 2005;9:1237–1244. doi: 10.1016/j.gassur.2005.07.007.
    1. Arroyo A, Perez F, Serrano P, et al. Long-term results of botulinum toxin for the treatment of chronic anal fissure: prospective clinical and manometric study. Int J Colorectal Dis. 2005;20:267–271. doi: 10.1007/s00384-004-0644-y.
    1. Brisinda G, Maria G, Sganga G, Bentivoglio AR, Albanese A, Castagneto M. Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures. Surgery. 2002;131:179–184. doi: 10.1067/msy.2002.119314.
    1. Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med. 1998;338:217–220. doi: 10.1056/NEJM199801223380402.
    1. Fruehauf H, Fried M, Wegmueller B, Bauerfeind P, Thumshirn M. Efficacy and safety of botulinum toxin compared with topical nytroglycerin oinment for the treatment of chronic anal fissure: a prospective randomized study. Am J Gastroenterol. 2006;101:2107–2112. doi: 10.1111/j.1572-0241.2006.00722.x.
    1. Watts JM, Bennett RC, Goligher JC. Streching of anal sphincters in treatment of fissure-in-ano. Br Med J. 1964;2:342–343. doi: 10.1136/bmj.2.5405.342.
    1. Sohn N, Eisenberg MM, Weinstein MA, Lugo RN, Ader J. Precise anorectal sphincter dilatation-its role in the therapy of anal fissure. Dis Colon Rectum. 1992;35:322–327. doi: 10.1007/BF02048108.
    1. Marby M, Alexander-Williams J, Buchmann P, et al. A randomized controlled trial to compare anal dilatation with lateral subcutaneous sphincterotomy for anal fissure. Dis Colon Rectum. 1979;22:308–311. doi: 10.1007/BF02609311.
    1. Jensen SL, Lund F, Nielsen OV, Tange G. Lateral subcutaneous sphincterotomy versus anal dilatation in the treatment of fissure in ano in outpatients. A prospective randomized study. BMJ. 1984;289:528–530. doi: 10.1136/bmj.289.6444.528.
    1. Nielsen MB, Rasmussen OO, Pedersen JF, Christiansen J. Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano. An endosonographic study. Dis Colon Rectum. 1993;36:677–680. doi: 10.1007/BF02238595.
    1. Renzi A, Brusciano L, Pescatori M, et al. Pneumatic balloon dilation for chronic anal fissure: a prospective, clinical, endosonographic, and manometric study. Dis Colon Rectum. 2005;48:121–126. doi: 10.1007/s10350-004-0780-z.
    1. Yucel T, Gonullu D, Oncu M, Koksoy FN, Ozkan SG, Aycan O. Comparison of controlled-intermittent anal dilatation and lateral internal sphincterotomy in the treatment of chronic anal fissures: a prospective, randomized study. Int J Surg. 2009;7:228–231. doi: 10.1016/j.ijsu.2009.03.006.
    1. Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs fissurectomy-midline sphincterotomy. Dis Colon Rectum. 1980;23:31–36. doi: 10.1007/BF02587197.
    1. McDonald P, Driscoll AM, Nicholls RJ. The anal dilator in the conservative management of acute anal fissures. Br J Surg. 1983;70:25–26. doi: 10.1002/bjs.1800700109.
    1. Hawley PR. The treatment of chronic fissure-in-ano. A trial of methods. Br J Surg. 1969;56:915–918. doi: 10.1002/bjs.1800561212.
    1. Karamanlis E, Michalopoulos A, Papadopoulos V et al. (2010) Prospective clinical trial comparing sphincterotomy, nitroglycerin ointment and xylocaine/lactulose combination for the treatment of anal fissure. Tech Coloproctol 14(Suppl 1):S21–S23
    1. Boulous PB, Araujo JG. Adeguate internal sphincterotomy for chronic anal fissure: subcutaneous or open technique? Br J Surg. 1984;71:360–362. doi: 10.1002/bjs.1800710517.
    1. Kortbeek JB, Langevin JM, Khoo RE, Heine JA. Chronic fissure in ano: a randomized study comparing open and subcutaneous lateral internal sphincterotomy. Dis Colon Rectum. 1992;35:835–837. doi: 10.1007/BF02047868.
    1. Altomare DF, Rinaldi M, Troilo VL, Marino F, Lobascio P, Puglisi F. Closed ambulatory lateral internal sphincterotomy for chronic anal fissures. Tech Coloproctol. 2005;9:248–249.
    1. Garcia-Aguilar J, Belmonte C, Wong WD, Lowry AC, Madoff RD. Open vs. closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum. 1996;39:440–443. doi: 10.1007/BF02054061.
    1. Leong AF, Seow-Choen F. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure. Dis Colon Rectum. 1995;38:69–71. doi: 10.1007/BF02053862.
    1. Bhardwaj R, Parker MC. Modern perspectives in the management of chronic anal fissures. Ann R Coll Surg Engl. 2007;89:472–478. doi: 10.1308/003588407X202137.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe