Anal Fissure
Anal Fissure
Karen N.Zaghiyan,M.D.1and Phillip Fleshner,M.D.2,3
ABSTRACT
Anal?ssure is one of the most common anorectal problems.Anal?ssure is largely associated with high anal sphincter pressures and most treatment options are based on
reducing anal pressures.Conservative management,using increased?ber and warm baths,
results in healing of approximately half of all anal?ssures.In?ssures that fail conservative
care,various pharmacologic and surgical options offer satisfactory cure https://www.wendangku.net/doc/9315940521.html,teral
internal sphincterotomy remains the gold standard for de?nitive management of anal
?ssure.This review outlines the key points in the presentation,pathophysiology,and
management of anal?ssure.
KEYWORDS:Anal?ssure,?ssure in ano,sphincterotomy,anal sphincter hypertonia Objectives:On completion of this article,the reader should be able to summarize the etiology and management of anal?ssure.
A nal?ssure is a tear in the anoderm distal to the dentate line.It can be categorized as acute or chronic. Acute?ssures present with anal pain,spasm,and/or bleeding with defecation.The diagnosis can typically be con?rmed by physical examination and anoscopy in the of?ce if tolerated by the patient.By gentle separation of the buttocks and examination of the anus,a linear separation of the anoderm can be identi?ed at the lower half of the anal canal.Approximately90%of anal?ssures in both men and women are located posteriorly in the midline.Anterior?ssures occur in10%of patients,more commonly women.Fewer than1%of?ssures are located off a midline position or are multiple in number.These atypical?ssures may be associated with Crohn’s disease, sexually transmitted diseases(human immunode?ciency disease[HIV],syphilis,or herpes),anal cancer,or tuber-culosis.Whereas acute?ssures typically heal with med-ical management after4to6weeks,chronic?ssures persist beyond6weeks.Chronic?ssures are also asso-ciated with raised edges,exposed internal sphincter muscle,distal sentinel tag,and hypertrophied anal pap-illa at the internal apex.
PATHOGENESIS
Despite extensive investigation of this disease,the exact etiology of anal?ssure remains unclear.It appears that constipation with passage of hard stools or anal trauma may instigate the?ssure.However,in many instances patients do not report constipation or may have a history of watery diarrhea.In addition,many?ssures heal within weeks whereas others go on to become chronic in nature. Various studies have suggested that both anorectal mechanics and blood?ow to the anal canal may play a role in anal?ssure development.Initial reports from the 1970s and1980s have implicated internal sphincter hypertonia in anal?ssure pathogenesis.1–3More recent studies have used anorectal manometry to demonstrate hypertonia of the internal sphincter and have shown fewer internal anal sphincter relaxations in patients with
1Department of Surgery,Cedars-Sinai Medical Center,Los Angeles, California;2Division of Colon and Rectal Surgery,Cedars-Sinai Medical Center,Los Angeles,California;3Department of Surgery, UCLA School of Medicine,Los Angeles,California.
Address for correspondence and reprint requests:Phillip Fleshner,M.D.,Division of Colon and Rectal Surgery,Cedars-Sinai Medical Center,8737Beverly Blvd.,Ste.101,Los Angeles,CA90048(e-mail:PFleshner@https://www.wendangku.net/doc/9315940521.html,).
Anorectal Disease;Guest Editor,Gerald A.Isenberg,M.D.
Clin Colon Rectal Surg2011;24:22–30.Copyright#2011by Thieme Medical Publishers,Inc.,333Seventh Avenue,New York,NY 10001,USA.Tel:+1(212)584-4662.
DOI:https://www.wendangku.net/doc/9315940521.html,/10.1055/s-0031-1272820.
ISSN1531-0043.
22
chronic anal?ssures.4,5In addition,relative ischemia of the posterior anal canal has been implicated in chronic, nonhealing anal?ssures.Postmortem angiography of the inferior rectal artery has demonstrated that the posterior commissure of the anal canal is poorly perfused in85%of patients compared with other sections.6Anal hyper-tonicity may aggravate perfusion to the anal canal. Pressure on the vessels passing perpendicularly through the internal anal sphincter muscle during increased sphincter tone may compromise perfusion to the poste-rior commissure where blood?ow is already sparse.6 Doppler laser?ow studies have clearly shown lower anodermal blood?ow at the?ssure site compared with the posterior commissure of controls.5,7Internal sphinc-terotomy,the gold standard for the treatment of anal ?ssure,has been shown to decrease internal sphincter pressures and increase anodermal blood?ow.7In addi-tion,it has been demonstrated that administration of anesthesia both decreases anal pressure and increases anodermal blood?ow.5
The pathophysiology of anterior?ssures may be different than chronic posterior?ssures.Jenkins and colleagues showed that anterior?ssure patients were signi?cantly more likely to have occult external sphincter injury and impaired external sphincter function compared with posterior?ssure patients.In addition, anterior?ssures were identi?ed in a younger and pre-dominantly female group of patients.In these patients, maximum squeeze pressure was signi?cantly lower com-pared with the posterior?ssure group.Also,maximum resting pressure was not signi?cantly elevated compared with controls,but was signi?cantly elevated in posterior ?ssures.These?ndings may have important implications for the management and treatment of this common subgroup of anal?ssure patients.8 NONOPERATIVE MANAGEMENT
The majority of initial anal?ssures can be managed medically.In fact,almost half will heal with conservative therapy alone using warm baths and increased?ber intake.9–11Warm sitz baths may lead to healing of anal?ssures via a somatoanal re?ex that results in relaxation of the internal anal sphincter.12In a random-ized study conducted by Jensen,treatment with10g of unprocessed bran twice daily and warm sitz baths for15minutes twice daily and after each bowel move-ment resulted in quicker symptomatic relief and better healing at3weeks(88%)compared with2%lignocaine ointment or2%hydrocortisone cream.13In a separate randomized prospective study,treatment with15g of unprocessed bran in three divided doses daily was shown to have signi?cantly fewer recurrences(16%)compared with patients receiving7.5g of bran daily(60%) (p<0.01).14According to the practice parameters set by the American Society of Colon and Rectal Surgeons,increased?uid and?ber ingestion,the use of sitz baths,
and if necessary,the use of stool softeners are safe,have
few side effects,and should be the initial therapy for all patients with anal?ssure.15
When conservative measures fail,the next step
in the management of anal?ssure has traditionally
been surgery.However,given the potential risk of incontinence with surgery,the last decade has brought
signi?cant interest and investigation in the use of phar-macologic agents to reduce anal pressures and avoid surgical intervention.
Topical Nitrates
Organic nitrates such as glyceryl trinitrate(GTN) undergo cellular metabolism to release nitric oxide (NO).16Nitric oxide works as an inhibitory neurotrans-
mitter in the internal anal sphincter resulting in sphinc-
ter relaxation.17The topical application of GTN in
dilute form(0.2%)has been shown to cause decreased
anal resting pressures.18Various studies have since emerged to investigate the use of GTN to treat anal
?ssures.In a Cochrane Review of53randomized con-
trolled trials(RCTs)of nonsurgical therapies for anal
?ssures and15RCTs that speci?cally looked at GTN versus placebo,GTN was found to be marginally but
signi?cantly better than placebo in healing anal?ssures (49%vs37%,p<0.004).However,late recurrence was shown to be common(>50%)in those initially cured.19
In addition,dose made no difference in healing of anal
?ssures in three studies that compared doses of GTN ranging from0.05%to0.4%GTN.20–22Cure rates were similar with the use of a topical application of GTN around the anus versus a dermal patch at a distant location.23,24The key drawback,however,to GTN therapy is the high incidence of side effects,primarily headaches and light-headedness.In fact,up to20%of patients cease GTN therapy due to the severity of their headaches.25–27
Calcium Channel Blockers
Calcium channel blockers(CCBs)relax the internal anal sphincter by blocking the in?ux of calcium into the cytoplasm of smooth muscle cells.28It has been shown
that both nifedipine(0.2–0.5%gel)and diltiazem(2% cream)promote?ssure healing by decreasing mean anal resting pressure.29–31Topical CCBs have been shown to
be better than both lignocaine ointment and hydro-cortisone cream,with up to95%remission in two studies.31,32Compared with GTN,topical application
of CCBs has been shown to be equally effective with
fewer side effects in various prospective,randomized studies.33–35The principal side effect is mild headache,
seen in up to25%of patients.33Topical nifedipine has
also been compared with lateral internal sphincterotomy
ANAL FISSURE/ZAGHIYAN,FLESHNER23
with healing rates of97%and100%at8weeks.Long-term follow up at19months showed healing rates of 93%and100%for the nifedipine and lateral internal sphincterotomy(LIS)groups,respectively.36On the other hand,oral calcium channel blockers have been shown to have poor healing rates(<20%at4weeks in one study),high side-effect pro?le,and high therapeutic dropout.30,37Thus,with reasonable healing potential and minimal risk to the patient,topical CCBs are an acceptable choice for the medical management of chronic anal?ssure.
Botulinum Toxin
Botulinum toxin is produced by Clostridium botulinum and acts as an inhibitory neurotransmitter preventing release of acetylcholine from the presynaptic terminals. It has been shown to cause relaxation of both the external and internal anal sphincters lasting for up to 3months.28,38Jost and Schimrigk reported the?rst case of anal?ssure treated with botulinum toxin in 1993.39Since then,there has been increased interest in the use of botulinum toxin injections for the treatment of anal?ssures.
There have been various studies on dosing and location of injection of the botulinum toxin,but the most common location is directly into the internal anal sphincter on either side of midline.27,40–43Retrograde endoscopic delivery of BOTOX1(Allergan,Inc.,Irvine, CA)into the internal anal sphincter has also been described as being more accurate and better tolerated by patients in one group.44The value of this dosing regime awaits validation.Doses have varied between5to 100units of BOTOX1,45,46with various studies suggesting a dose-dependent ef?cacy of BOTOX1 treatment.47–49It appears that the type of botulinum toxin A preparation(Dysport1;Speywood Biopharm Ltd,Wrexham,UK vs the American preparation BOTOX1;Allegran,Irvine,CA)does not in?uence ef?cacy.49
Compared with placebo,injection of botulinum toxin into the internal anal sphincter has been shown to be signi?cantly better at healing anal?ssures(73%)and in symptomatic relief(87%)at2-month follow up.40 Botulinum toxin has also been compared with other means of‘‘chemical sphincterotomy.’’Various random-ized prospective studies have compared botulinum toxin injection with glyceryl trinitrate for the treatment of chronic anal?ssures.27,50,51According to a meta-analysis of180patients included in these studies,botulinum toxin and glyceryl trinitrate had equal healing rates, but glyceryl trinitrate had higher side effects and head-aches.52In another prospective study,overall cure rates between nitroglycerine ointment,diltiazem ointment, and botulinum toxin injection were similar at54%, 53%,and51%,respectively.53Overall recurrence of anal?ssure with botulinum toxin therapy is common (up to55%),46but retreatment with a higher dose may be effective.45,48The main side effect with botulinum toxin injection is mild incontinence to?atus and stool,lasting up to3weeks.45,50Although the risk is signi?cantly lower compared with lateral internal sphincterotomy, there have been two case reports of long-term fecal incontinence with botulinum toxin injection of the anal canal.54,55Nonetheless,comparison with lateral internal sphincterotomy reveals that botulinum toxin injection of the internal anal sphincter has lower healing rates and higher recurrence,but comes with a lower chance of long-term incontinence.In a randomized controlled trial by Arroyo and colleagues,one-year healing with botulinum toxin injection was45%versus 93%with lateral internal sphincterotomy.Fissure recur-rence was55%within one year compared with8%with lateral internal sphincterotomy.46One single-center, retrospective study found that the use of botulinum toxin injection helped prevent surgery in73%of patients who presented with anal?ssure in2004compared with patients in1993when sphincterotomy was?rst-line therapy.56Thus,botulinum toxin injection offers rea-sonable success with minimal side effects and is a reasonable option for‘‘chemical sphincterotomy’’in the management of chronic anal?ssure.
Yet,the question remains as to whether botuli-num toxin injection can be used when other medical therapy has failed.Two prospective randomized trials evaluating patients with chronic anal?ssures that have failed previous pharmacologic management showed poor healing rates(as low as27%)with subsequent botulinum toxin injection.57,58In the study by Jones et al,37%of all patients treated with botulinum toxin resorted to sur-gery.Interestingly,12of30patients in this study had low baseline mean resting anal pressures(mean of 56mm Hg)and had a paradoxical response to treatment with botulinum toxin,with a rise in their mean resting pressures.58This patient population may have a different anal?ssure pathophysiology not based on sphincter hypertonia.Thus,attempts at botulinum toxin injection in patients that have already failed other chemical sphincterotomy may be futile.The use of botulinum toxin injection for treatment of recurrent anal?ssure after lateral internal sphincterotomy has been investi-gated,but the study was?awed with an extremely high incidence of recurrent anal?ssures after sphincterot-omy.59
Unproven Therapies
The internal anal sphincter is stimulated by a1-adrener-gic innervation and is inhibited by cholinergic innerva-tion by the sacral parasympathetic?bers60.Topical bethanechol,a muscarinic agonist,has been shown to cause a dose-dependent reduction of anal pressure,with
24CLINICS IN COLON AND RECTAL SURGERY/VOLUME24,NUMBER12011
a maximal24%reduction seen with0.1%bethanechol.61 In a subsequent study,0.1%bethanechol yielded a60% healing rate at8weeks with no reported side effects in a small series of15patients.62Although this data appears promising,large,prospective studies are needed before any treatment recommendations can be made.Indor-amine,an a1-adrenoreceptor antagonist and minoxidil,a smooth muscle relaxer,have been ineffective at healing anal?ssure in small RCTs.63,64
OPERATIVE MANAGEMENT
When conservative measures fail,a surgical approach becomes necessary for the de?nitive management of the chronic anal?ssure.Dilation of the anal canal for the treatment of anal?ssure was?rst described in the1860s, but was popularized in the1960s.In1964,Watts and colleagues reported on99patients with anal?ssures treated with anal stretch.They describe the procedure as a manual stretching of the anal canal with two,then four?ngers applying considerable outward force on the lateral walls of the anal canal.Dilation is performed for no less than4minutes.They reported satisfactory early relief of symptoms in95%of patients,with?ssure recurrence noted in16%of patients.65Since that time, various studies have emerged comparing anal stretch procedure with other surgical procedures,primary lateral internal sphincterotomy.Despite extensive study,there has been signi?cant variability in the reported outcomes due to lack of standardization and reproducibility of the techniques employed.In addition,anal stretch has been scrutinized for causing extensive damage to internal and external sphincters leading to incontinence.A recent randomized controlled trial enrolled108patients as-signed to anal dilation(AD)versus left lateral sphincter-otomy(LLS).Average follow-up was11.2months. Signi?cantly more patients reported minor incontinence in the AD than in the LLS group.Recurrence occurred in11%of AD patients versus2%of LLS patients.66In addition,a Cochrane Review of seven randomized con-trolled trials,comparing anal stretch with internal sphincterotomy signi?cantly favored sphincterotomy over anal stretch for ef?cacy(OR?3.35;95% CI?1.55–7.26)and incontinence to?atus or feces (OR?4.03;95%CI?2.04–7.46).67
In an effort to standardize the method of anal dilation,pneumatic balloon dilation(PBD)has been developed.Sohn and colleagues?rst described PBD using a40-mm rectosigmoid balloon.68A recent randomized controlled trial looked at PBD rather than manual dilation in comparison to lateral internal sphinc-terotomy(LIS)for the treatment of chronic anal?ssure. Pneumatic dilation was performed with a40-mm diam-eter by60-mm-long anal balloon(Microvasive,Genova, Italy)with the balloon in?ated to20psi for6minutes. Overall healing rates at6weeks were83and92%for PBD and LIS,respectively.Based on preoperative and postoperative manometry,both techniques reduced anal pressures by$30%.The PBD group did demonstrate
mild transient fecal incontinence;however,at24-month
follow-up,the incidence of incontinence in the PBD
group was0%,but16%in the LIS group(p<0.0001).69 Thus,with a better ability to standardize the technique
and produce reproducible results,pneumatic balloon dilation may become a preferable alternative to anal dilation.
Nonetheless,lateral internal sphincterotomy still stands as the surgical treatment of choice for refractory
anal?ssures and may be offered without pharmacologic treatment failure according to the practice parameters by
the American Society of Colon and Rectal Surgeons.15 Reports of sphincterotomy for various anal pathologies probably date back to the1700s.70However,internal sphincterotomy for the management of anal?ssure was
?rst described and popularized in the1950s by Eisen-hammer.71,72Lateral internal sphincterotomy quickly gained recognition as the posterior approach was found
to result in large wounds and incontinence due to a‘‘key-
hole deformity.’’Lateral internal sphincterotomy is per-formed with a radial incision in the anoderm laterally exposing the internal sphincter muscle?bers.Then,
under direct vision,the distal4/5th of the internal sphincter muscle is divided with a scalpel or scissors.
The wound can be left open or closed primarily.In1969, Notaras described a technique that he called lateral subcutaneous sphincterotomy,now also known as a closed lateral internal sphincterotomy.This resulted in
even smaller wounds and fecal soiling rates dropped to
6%compared with30–41%with a posterior internal sphincterotomy.73This technique involves a narrow-bladed scalpel such as a cataract knife introduced through the perianal skin on the lateral side and pushed subcutaneously upwards between the internal sphincter
and the skin lining the anal canal.When the point of the
blade is at the dentate line the internal sphincter is divided by cutting medial to lateral.A defect can be
felt under the skin between the retracted edged of the internal sphincter.A second approach for closed lateral internal sphincterotomy is the lateral to medial approach.
In this operation,the scalpel is inserted into the inter-sphincteric groove and directed up to the dentate line.
At this point,the internal sphincter is divided,cutting laterally to medially toward the surgeon’s?nger in the
anal canal.74–77
Since the1950s and1960s,numerous studies
have evaluated different methods of sphincterotomy. Various randomized controlled trials have compared
open versus closed techniques.Healing rates appear to
be similar,with open techniques ranging from93%
to95%and closed approaches ranging from90%to 97%.There appears to be no difference in major incon-tinence rates,which range from2%to5%.75,76,78
ANAL FISSURE/ZAGHIYAN,FLESHNER25
A meta-analysis of operative techniques for anal?ssure also demonstrated no difference for persistence or in-continence between the open or closed technique.79 When comparing lateral internal sphincterotomy with midline posterior sphincterotomy,again there appears to be no signi?cant difference in persistence of symptoms or incontinence in two meta-analyses of retrospective studies.67,74,79Several studies have evaluated adjuncts to various surgical approaches.For example,one study reported higher patient satisfaction rates when hyper-trophied anal papillae and?brous anal polyps were removed at the time of LIS.80The value of this maneu-ver,however,remains unclear as the results have not been validated.
Since the description of the technique of lateral internal sphincterotomy by Eisenhammer in the 1950s,71,72current practice remains that the division of the internal sphincter be taken to the dentate line. However,with high reports of incontinence with LIS, there has been a more prudent approach to division of the sphincter that may yield lower incontinence rates. Littlejohn and colleagues described a technique of tail-ored left lateral sphincterotomy,wherein the sphincter is divided up to the height of the?ssure.81They showed a 99%initial healing rate,0.7%incidence of urgency,1% gas incontinence,and35%minor staining.Since then, various randomized,prospective studies have compared this technique with a larger sphincterotomy.Sphincter-otomy to the?ssure apex has been shown to have lower rates of mild incontinence(2%)compared with sphinc-terotomy to the dentate line(11%).82However,this comes with a higher overall treatment failure rate on long-term follow-up(13%)compared with a larger sphincterotomy either to the dentate line(0%)or to an anal diameter of30mm(3%).82–84Thus,a traditional, longer sphincterotomy,with fewer treatment failures and an acceptable rate of mild incontinence,appears to be the preferred technique.
Other complications associated with lateral internal sphincterotomy are ecchymosis,hematoma, and wound infection.In the past,there has been fear that closure of these wounds would result in a higher complication rate,such as wound infection.Two pro-spective,randomized studies compared primary closure of the wound after LIS with leaving the wound open to heal secondarily.85,86In the study by Aysan and colleagues,there was a signi?cantly faster healing rate of15.05?5.60days with wound closure versus33.94?
6.67days when wounds were left open(p<0.001).85In
a combined analysis,the advantage of closure was not statistically signi?cance(p?0.35,95%CI:0.13–1.00).67 Also,there was no signi?cant difference in the com-plication rate between primary wound closure versus leaving the wound open to heal secondarily.85,86
The management of anal?ssure largely relies on relieving anal hypertonicity.Patients with anterior anal ?ssures have been shown to have signi?cantly lower anal pressures,suggesting a different pathophysiology in the development of these?ssures.8,87In support of this idea, there have also been reports of a paradoxical contraction response of low-pressure?ssures to treatment with botulinum toxin.58,88These patients are at particularly high risk for incontinence with measures directed at reducing anal hypertonia.Various small studies have shown success with advancement anoplasty,or?ssurec-tomy with advancement anoplasty,in patients with low-pressure anal?ssures with success rates ranging from 87%to100%.89–91Thus,it is especially important to approach anterior and low-pressure?ssures more cau-tiously.Advancement?ap surgery may be an acceptable ?rst approach to low-pressure?ssures.When encoun-tered with a patient with an anterior?ssure,it may be bene?cial to perform anorectal manometry before pro-ceeding with a treatment algorithm.
Various studies have also evaluated advancement ?ap surgery for all chronic anal?ssure types.The procedure typically involves a subcutaneous?ap with an incision made from the anal verge extending caudally. The skin?ap is then advanced into the anal canal and positioned to cover the anal?ssure and sutured in place. Two independent studies showed98%success rate with advancement anoplasty for the treatment of chronic anal?ssure,irrespective of anal tone.92,93Another study showed100%success rate and no recurrence at 12months in10patients who underwent?ssurectomy and V-Y anoplasty with injection of botulinum toxin in the treatment of anterior chronic?ssure with hypertonia of the internal anal sphincter.94In a recent pilot study of 8patients,autologous adipose tissue transplant has also shown75%healing of anal?ssure and80%resolution of anal stenosis in patients with chronic anal?ssure who failed previous medical and surgical therapy.95Although these studies have shown promising results,larger pro-spective studies and longer follow-up is needed before further recommendations can be made in comparison to lateral internal sphincterotomy.
SPECIAL CONSIDERATIONS
Anal?ssure is a common?nding in patients with perianal Crohn’s disease.96–98In the past,?ssures associated with Crohn’s disease were thought to be asymptomatic and more commonly located off-mid-line.96,98However,more recent data suggests that the majority are actually symptomatic(up to85%)and posterior(up to66%),although off midline,multiple, and asymptomatic?ssures occur more commonly in Crohn’s disease patients compared with the general population.97,99Various reports have suggested that perianal Crohn’s disease can be successfully treated with topical ointments,metronidazole,prednisone,or sulfasa-lazine.97,98,100In addition,surgical management of these
26CLINICS IN COLON AND RECTAL SURGERY/VOLUME24,NUMBER12011
Crohn’s disease patients with anal?ssure has been feared due to presumed risks of incontinence in a population prone to diarrhea as well as poor wound healing, infections,and?stula formation.However,more recent reports have shown successful healing of Crohn’s disease ?ssures after anorectal surgery.97,99,101Fleshner and associates showed88%healing of anal?ssures after ?ssurectomy,closed lateral internal sphincterotomy,or a combination of both.In comparison,medical manage-ment alone healed50%of?ssures.Abdominal surgery for Crohn’s disease offered no signi?cant healing of anal?ssures compared with medical management alone. Factors found to be predictive of healing with medical therapy include male gender,painless?ssure,and acute ?ssure.On long-term follow-up,26%of patients devel-oped a?stula or abscess from the base of the?ssure, but there was no signi?cant difference in medically or surgically treated patients.99Thus,most?ssures associ-ated with Crohn’s disease can be treated medically, but those who fail to resolve and remain symptomatic can be managed surgically with acceptable risk.
Anal lesions in HIV-positive patients are a dif?cult problem with early reports of poor healing and high rates of incontinence after surgery.102,103 Appropriate classi?cation of these lesions is necessary for proper management.Benign anal?ssures are nar-row,usually located low in the anal canal and associated with a hypertonic anal sphincter.These must be differ-entiated from HIV-associated anal ulcers,which are typically broad-based,deep,or cavitating lesions asso-ciated with low anal sphincter tone.104For the manage-ment of benign anal?ssures,Viamonte and colleagues advocate conservative therapy followed by lateral inter-nal sphincterotomy after failure of medical therapy.On the other hand,anal ulcers are much more dif?cult to treat,and these patients should undergo examination under anesthesia,cultures,biopsy,and wide debride-ment.104Various other studies have reported sphinc-terotomy results for anal?ssure in the HIV-positive population.However,these are mostly small series, without long-term follow-up,thus making if dif?cult to make any strong treatment recommendations.103,105 In addition,the incidence of anal lesions has not changed signi?cantly since introduction of highly active retroviral therapy(HAART).106Thus,anal?ssure remains a dif?-cult problem in the management of HIV-patients and should be approached cautiously,especially in a setting of advanced disease or baseline incontinence. CONCLUSION
Anal?ssure is a common problem.The pathophysiology is based on high sphincter pressures and management is generally aimed toward reducing anal pressures.Anal ?ssures can generally be treated with conservative man-agement,but pharmacologic management with topical calcium channel blockers,topical nitrates,and botuli-
num toxin injection are reasonable options with minimal
side effects and good cure https://www.wendangku.net/doc/9315940521.html,teral internal sphinc-terotomy remains the gold standard for de?nitive management of anal?ssures,but comes with a risk of incontinence.Open or closed techniques can be used
with similar healing and complication rates.Anal stretch should be abandoned in the management of anal?ssure. Larger studies with longer follow-up are needed before recommendations can be made about various other treatment modalities for anal?ssure.Particular attention
must be paid to anterior anal?ssures as they are typically associated with low anal pressures.These patients should undergo anorectal manometery testing preoperatively. Those patients with sphincter hypotonia who fail con-servative management should undergo advancement anoplasty.Atypical anal?ssures associated with Crohn’s disease or HIV should be approached cautiously. However,recent data suggests that lateral internal sphincterotomy may be tolerated well in these patients
when conservative management fails.
REFERENCES
1.Nothmann BJ,Schuster MM.Internal anal sphincter
derangement with anal?ssures.Gastroenterology1974;
67(2):216–220
2.Hancock BD.The internal sphincter and anal?ssure.Br J
Surg1977;64(2):92–95
3.Gibbons CP,Read NW.Anal hypertonia in?ssures:cause
or effect?Br J Surg1986;73(6):443–445
4.Farouk R,Duthie GS,MacGregor AB,Bartolo DC.
Sustained internal sphincter hypertonia in patients with
chronic anal?ssure.Dis Colon Rectum1994;37(5):424–429
5.Schouten WR,Briel JW,Auwerda JJ.Relationship between
anal pressure and anodermal blood?ow.The vascular
pathogenesis of anal?ssures.Dis Colon Rectum1994;
37(7):664–669
6.Klosterhalfen B,Vogel P,Rixen H,Mittermayer C.
Topography of the inferior rectal artery:a possible cause
of chronic,primary anal?ssure.Dis Colon Rectum1989;
32(1):43–52
7.Schouten WR,Briel JW,Auwerda JJ,De Graaf EJ.
Ischaemic nature of anal?ssure.Br J Surg1996;83(1):63–65
8.Jenkins JT,Urie A,Molloy RG.Anterior anal?ssures are
associated with occult sphincter injury and abnormal
sphincter function.Colorectal Dis2008;10(3):280–285
9.Shub HA,Salvati EP,Rubin RJ.Conservative treatment of
anal?ssure:an unselected,retrospective and continuous
study.Dis Colon Rectum1978;21(8):582–583
10.Hananel N,Gordon PH.Re-examination of clinical
manifestations and response to therapy of?ssure-in-ano.
Dis Colon Rectum1997;40(2):229–233
11.Gough MJ,Lewis A.The conservative treatment of?ssure-
in-ano.Br J Surg1983;70(3):175–176
12.Jiang JK,Chiu JH,Lin JK.Local thermal stimulation
relaxes hypertonic anal sphincter:evidence of somatoanal
re?ex.Dis Colon Rectum1999;42(9):1152–1159
13.Jensen SL.Treatment of?rst episodes of acute anal?ssure:
prospective randomised study of lignocaine ointment versus
ANAL FISSURE/ZAGHIYAN,FLESHNER27
hydrocortisone ointment or warm sitz baths plus bran.
Br Med J(Clin Res Ed)1986;292(6529):1167–1169
14.Jensen SL.Maintenance therapy with unprocessed bran in
the prevention of acute anal?ssure recurrence.J R Soc Med 1987;80(5):296–298
15.Perry WB,Dykes SL,Buie WD,Rafferty JF;Standards
Practice Task Force of the American Society of Colon and Rectal Surgeons.Practice parameters for the management of anal?ssures(3rd revision).Dis Colon Rectum2010;53(8): 1110–1115
16.Fung HL.Clinical pharmacology of organic nitrates.Am J
Cardiol1993;72(8):9C–13C,discussion14C–15C
17.O’Kelly TJ.Nerves that say NO:a new perspective on the
human rectoanal inhibitory re?ex.Ann R Coll Surg Engl 1996;78(1):31–38
18.Loder PB,Kamm MA,Nicholls RJ,Phillips RK.‘Reversible
chemical sphincterotomy’by local application of glyceryl trinitrate.Br J Surg1994;81(9):1386–1389
19.Nelson R.Non surgical therapy for anal?ssure.Cochrane
Database Syst Rev2006;(4):CD003431
20.Carapeti EA,Kamm MA,McDonald PJ,Chadwick SJ,
Melville D,Phillips RK.Randomised controlled trial shows that glyceryl trinitrate heals anal?ssures,higher doses are not more effective,and there is a high recurrence rate.Gut 1999;44(5):727–730
21.Bailey HR,Beck DE,Billingham RP,et al;Fissure Study
Group.A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal?ssures.Dis Colon Rectum2002;45(9): 1192–1199
22.Schole?eld JH,Bock JU,Marla B,et al.A dose?nding
study with0.1%,0.2%,and0.4%glyceryl trinitrate ointment in patients with chronic anal?ssures.Gut2003;52(2): 264–269
23.Zuberi BF,Rajput MR,Abro H,Shaikh SA.A randomized
trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal?ssures.Int J Colorectal Dis2000;
15(4):243–245
24.Colak T,Ipek T,Urkaya N,Kanik A,Dirlik M.A
randomised study comparing systemic transdermal treat-ment and local application of glyceryl trinitrate ointment in the management of chronic anal?ssure.Eur J Surg Suppl 2003;(588):18–22
25.Hyman NH,Cataldo PA.Nitroglycerin ointment for anal
?ssures:effective treatment or just a headache?Dis Colon Rectum1999;42(3):383–385
26.Dorfman G,Levitt M,Platell C.Treatment of chronic anal
?ssure with topical glyceryl trinitrate.Dis Colon Rectum 1999;42(8):1007–1010
27.Brisinda G,Maria G,Bentivoglio AR,Cassetta E,Gui D,
Albanese A.A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal?ssure.N Engl J Med1999;341(2):65–69 28.Bhardwaj R,Vaizey CJ,Boulos PB,Hoyle CH.
Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal?ssures.Gut2000;46(6): 861–868
29.Chrysos E,Xynos E,Tzovaras G,Zoras OJ,Tsiaoussis J,
Vassilakis SJ.Effect of nifedipine on rectoanal motility.
Dis Colon Rectum1996;39(2):212–216
30.Jonas M,Neal KR,Abercrombie JF,Schole?eld JH.A
randomized trial of oral vs.topical diltiazem for chronic anal ?ssures.Dis Colon Rectum2001;44(8):1074–107831.Antropoli C,Perrotti P,Rubino M,et al.Nifedipine for
local use in conservative treatment of anal?ssures: preliminary results of a multicenter study.Dis Colon Rectum1999;42(8):1011–1015
32.Perrotti P,Bove A,Antropoli C,et al.Topical nifedipine
with lidocaine ointment vs.active control for treatment of chronic anal?ssure:results of a prospective,randomized, double-blind study.Dis Colon Rectum2002;45(11):1468–1475
33.Kocher HM,Steward M,Leather AJ,Cullen PT.
Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal?ssure.Br J Surg2002;89(4): 413–417
34.Ezri T,Susmallian S.Topical nifedipine vs.topical glyceryl
trinitrate for treatment of chronic anal?ssure.Dis Colon Rectum2003;46(6):805–808
35.Bielecki K,Kolodziejczak M.A prospective randomized
trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal?ssure.Colorectal Dis2003;
5(3):256–257
36.Katsinelos P,Papaziogas B,Koutelidakis I,et al.Topical
0.5%nifedipine https://www.wendangku.net/doc/9315940521.html,teral internal sphincterotomy for the
treatment of chronic anal?ssure:long-term follow-up.Int J Colorectal Dis2006;21(2):179–183
37.Ho KS,Ho YH.Randomized clinical trial comparing oral
nifedipine with lateral anal sphincterotomy and tailored sphincterotomy in the treatment of chronic anal?ssure.Br J Surg2005;92(4):403–408
38.Jost WH.One hundred cases of anal?ssure treated with
botulin toxin:early and long-term results.Dis Colon Rectum1997;40(9):1029–1032
39.Jost WH,Schimrigk https://www.wendangku.net/doc/9315940521.html,e of botulinum toxin in anal
?ssure.Dis Colon Rectum1993;36(10):974
40.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?ssure.N Engl J Med 1998;338(4):217–220
41.Maria G,Brisinda G,Bentivoglio AR,Cassetta E,Gui D,
Albanese A.In?uence of botulinum toxin site of injections on healing rate in patients with chronic anal?ssure.Am J Surg2000;179(1):46–50
42.Othman I.Bilateral versus posterior injection of botulinum
toxin in the internal anal sphincter for the treatment of acute anal?ssure.S Afr J Surg2010;48(1):20–22
43.Jost WH,Schimrigk K.Therapy of anal?ssure using
botulin toxin.Dis Colon Rectum1994;37(12):1321–1324 44.Kinney TP,Shah AG,Rogers BH,Ehrenpreis ED.
Retrograde endoscopic delivery of botulinum toxin for anal ?ssures.Endoscopy2006;38(6):654
45.Jost WH,Schrank B.Repeat botulin toxin injections in anal
?ssure:in patients with relapse and after insuf?cient effect of ?rst treatment.Dig Dis Sci1999;44(8):1588–1589
46.Arroyo A,Pe′rez F,Serrano P,Candela F,Lacueva J,
Calpena R.Surgical versus chemical(botulinum toxin) sphincterotomy for chronic anal?ssure:long-term results of
a prospective randomized clinical and manometric study.
Am J Surg2005;189(4):429–434
47.M?′nguez M,Melo F,Esp?′A,et al.Therapeutic effects of
different doses of botulinum toxin in chronic anal?ssure.
Dis Colon Rectum1999;42(8):1016–1021
48.Brisinda G,Maria G,Sganga G,Bentivoglio AR,Albanese
A,Castagneto M.Effectiveness of higher doses of
28CLINICS IN COLON AND RECTAL SURGERY/VOLUME24,NUMBER12011
botulinum toxin to induce healing in patients with chronic anal?ssures.Surgery2002;131(2):179–184
49.Brisinda G,Albanese A,Cadeddu F,et al.Botulinum
neurotoxin to treat chronic anal?ssure:results of a randomized‘‘Botox vs.Dysport’’controlled trial.Aliment Pharmacol Ther2004;19(6):695–701
50.Brisinda G,Cadeddu F,Brandara F,Marniga G,Maria G.
Randomized clinical trial comparing botulinum toxin injections with0.2per cent nitroglycerin ointment for chronic anal?ssure.Br J Surg2007;94(2):162–167
51.De Nardi P,Ortolano E,Radaelli G,Staudacher C.
Comparison of glycerine trinitrate and botulinum toxin-a for the treatment of chronic anal?ssure:long-term results.
Dis Colon Rectum2006;49(4):427–432
52.Sajid MS,Vijaynagar B,Desai M,Cheek E,Baig MK.
Botulinum toxin vs glyceryltrinitrate for the medical manage-ment of chronic anal?ssure:a meta-analysis.Colorectal Dis 2008;10(6):541–546
53.Gil J,Luja′n J,Herna′ndez Q,Gil E,Salom MG,Parrilla P.
Screening for the effectiveness of conservative treatment in chronic anal?ssure patients using anorectal manometry.
Int J Colorectal Dis2010;25(5):649–654
54.Smith M,Frizelle F.Long-term faecal incontinence
following the use of botulinum toxin.Colorectal Dis2004;
6(6):526–527
55.Brown SR,Matabudul Y,Shorthouse AJ.A second case of
long-term incontinence following botulinum injection for anal?ssure.Colorectal Dis2006;8(5):452–453
56.Floyd ND,Kondylis L,Kondylis PD,Reilly JC.Chronic
anal?ssure:1994and a decade later—are we doing better?
Am J Surg2006;191(3):344–348
57.Iswariah H,Stephens J,Rieger N,Rodda D,Hewett P.
Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic?ssure in ano.ANZ J Surg2005;
75(7):553–555
58.Jones OM,Ramalingam T,Merrie A,et al.Randomized
clinical trial of botulinum toxin plus glyceryl trinitrate vs.
botulinum toxin alone for medically resistant chronic anal ?ssure:overall poor healing rates.Dis Colon Rectum 2006;49(10):1574–1580
59.Brisinda G,Cadeddu F,Brandara F,et al.Botulinum toxin
for recurrent anal?ssure following lateral internal sphinc-terotomy.Br J Surg2008;95(6):774–778
60.Frenckner B,Ihre T.In?uence of autonomic nerves on the
internal and sphincter in man.Gut1976;17(4):306–312 61.Carapeti EA,Kamm MA,Evans BK,Phillips RKS.Topical
diltiazem and bethanechol decrease anal sphincter pressure without side effects.Gut1999;45(5):719–722
62.Carapeti EA,Kamm MA,Phillips RK.Topical diltiazem
and bethanechol decrease anal sphincter pressure and heal anal?ssures without side effects.Dis Colon Rectum2000;
43(10):1359–1362
63.Pitt J,Dawson PM,Hallan RI,Boulos PB.A double-blind
randomized placebo-controlled trial of oral indoramin to treat chronic anal?ssure.Colorectal Dis2001;3(3):165–168 64.Muthukumarassamy R,Robinson SS,Sarath SC,Raveen-
dran R.Treatment of anal?ssures using a combination of minoxidil and lignocaine:a randomized,double-blind trial.
Indian J Gastroenterol2005;24(4):158–160
65.Watts JM,Bennett RC,Goligher JC.Stretching of
anal sphincters in treatment of?ssure-in-ano.BMJ1964;
2(5405):342–34366.Ram E,Vishne T,Lerner I,Dreznik Z.Anal dilatation
versus left lateral sphincterotomy for chronic anal?ssure:a
prospective randomized study.Tech Coloproctol2007;
December3[Epub ahead of print]
67.Nelson RL.Operative procedures for?ssure in ano.
Cochrane Database Syst Rev2010;(1):CD002199
68.Sohn N,Eisenberg MM,Weinstein MA,Lugo RN,Ader J.
Precise anorectal sphincter dilatation—its role in the therapy
of anal?ssures.Dis Colon Rectum1992;35(4):322–327
69.Renzi A,Izzo D,Di Sarno G,et al.Clinical,manometric,
and ultrasonographic results of pneumatic balloon dilatation
https://www.wendangku.net/doc/9315940521.html,teral internal sphincterotomy for chronic anal?ssure:a
prospective,randomized,controlled trial.Dis Colon Rec-
tum2008;51(1):121–127
70.Whitney ET.Posterior sphincterotomy.Am J Surg1948;
75(6):761–771
71.Eisenhammer S.The surgical correction of chronic internal
anal(sphincteric)contracture.S Afr Med J1951;25(28):
486–489
72.Eisenhammer S.The evaluation of the internal anal
sphincterotomy operation with special reference to anal
?ssure.Surg Gynecol Obstet1959;109:583–590
73.Notaras https://www.wendangku.net/doc/9315940521.html,teral subcutaneous sphincterotomy for anal
?ssure—a new technique.Proc R Soc Med1969;62(7):713
74.Hoffmann DC,Goligher https://www.wendangku.net/doc/9315940521.html,teral subcutaneous internal
sphincterotomy in treatment of anal?ssure.BMJ1970;
3(5724):673–675
75.Arroyo A,Pe′rez F,Serrano P,Candela F,Calpena R.Open
versus closed lateral sphincterotomy performed as an
outpatient procedure under local anesthesia for chronic anal
?ssure:prospective randomized study of clinical and
manometric longterm results.J Am Coll Surg2004;
199(3):361–367
76.Wiley M,Day P,Rieger N,Stephens J,Moore J.Open vs.
closed lateral internal sphincterotomy for idiopathic?ssure-
in-ano:a prospective,randomized,controlled trial.Dis
Colon Rectum2004;47(6):847–852
77.Lewis TH,Corman ML,Prager ED,Robertson WG.
Long-term results of open and closed sphincterotomy for
anal?ssure.Dis Colon Rectum1988;31(5):368–371
78.Kortbeek JB,Langevin JM,Khoo RE,Heine JA.Chronic
?ssure-in-ano:a randomized study comparing open and
subcutaneous lateral internal sphincterotomy.Dis Colon
Rectum1992;35(9):835–837
79.Nelson RL.Meta-analysis of operative techniques for
?ssure-in-ano.Dis Colon Rectum1999;42(11):1424–1428,
discussion1428–1431
80.Gupta PJ,Kalaskar S.Removal of hypertrophied anal
papillae and?brous anal polyps increases patient satisfaction
after anal?ssure surgery.Tech Coloproctol2003;7(3):
155–158
81.Littlejohn DR,Newstead GL.Tailored lateral sphincter-
otomy for anal?ssure.Dis Colon Rectum1997;40(12):
1439–1442
82.Elsebae MM.A study of fecal incontinence in patients with
chronic anal?ssure:prospective,randomized,controlled
trial of the extent of internal anal sphincter division
during lateral sphincterotomy.World J Surg2007;31(10):
2052–2057
83.Mente BB,Ege B,Leventoglu S,Oguz M,Karadag A.
Extent of lateral internal sphincterotomy:up to the dentate
line or up to the?ssure apex?Dis Colon Rectum2005;
48(2):365–370
ANAL FISSURE/ZAGHIYAN,FLESHNER29
84.Mente BB,Gu¨ner MK,Leventoglu S,Akyu¨rek N.Fine-
tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs.up to the?ssure apex.Dis Colon Rectum2008;51(1):128–133
85.Aysan E,Aren A,Ayar E.A prospective,randomized,
controlled trial of primary wound closure after lateral internal sphincterotomy.Am J Surg2004;187(2):291–294 86.Kang GS,Kim BS,Choi PS,Kang DW.Evaluation of
healing and complications after lateral internal sphincter-otomy for chronic anal?ssure:marginal suture of incision vs.
open left incision:prospective,randomized,controlled study.Dis Colon Rectum2008;51(3):329–333
87.Bove A,Balzano A,Perrotti P,Antropoli C,Lombardi G,
Pucciani F.Different anal pressure pro?les in patients with anal?ssure.Tech Coloproctol2004;8(3):151–156,discussion 156–157
88.Lindsey I,Jones OM,Cunningham C.A contraction
response of the internal anal sphincter to Botulinum toxin: does low-pressure chronic anal?ssure have a different pathophysiology?Colorectal Dis2010;(May)17[Epub ahead of print]
89.Kene?ck NJ,Gee AS,Durdey P.Treatment of resistant anal
?ssure with advancement anoplasty.Colorectal Dis2002;
4(6):463–466
90.Patti R,Fama`F,Barrera T,Migliore G,Di Vita G.
Fissurectomy and anal advancement?ap for anterior chronic anal?ssure without hypertonia of the internal anal sphincter in females.Colorectal Dis2010;12(11):1127–1130
91.Patti R,Fama`F,Tornambe`A,Restivo M,Di Vita G.Early
results of?ssurectomy and advancement?ap for resistant chronic anal?ssure without hypertonia of the internal anal sphincter.Am Surg2010;76(2):206–210
92.Giordano P,Gravante G,Grondona P,Ruggiero B,Porrett
T,Lunniss PJ.Simple cutaneous advancement?ap ano-plasty for resistant chronic anal?ssure:a prospective study.
World J Surg2009;33(5):1058–1063
93.Chambers W,Sajal R,Dixon A.V-Y advancement?ap as
?rst-line treatment for all chronic anal?ssures.Int J Colorectal Dis2010;25(5):645–648
94.Patti R,Fama`F,Tornambe`A,Asaro G,Di Vita G.
Fissurectomy combined with anoplasty and injection of
botulinum toxin in treatment of anterior chronic anal?ssure with hypertonia of internal anal sphincter:a pilot study.
Tech Coloproctol2010;14(1):31–36
95.Lolli P,Malleo G,Rigotti G.Treatment of chronic anal
?ssures and associated stenosis by autologous adipose tissue transplant:a pilot study.Dis Colon Rectum2010;53(4): 460–466
96.Williams DR,Coller JA,Corman ML,Nugent FW,
Veidenheimer MC.Anal complications in Crohn’s disease.
Dis Colon Rectum1981;24(1):22–24
97.Sweeney JL,Ritchie JK,Nicholls RJ.Anal?ssure in Crohn’s
disease.Br J Surg1988;75(1):56–57
98.Fielding JF.Perianal lesions in Crohn’s disease.J R Coll
Surg Edinb1972;17(1):32–37
99.Fleshner PR,Schoetz DJ Jr,Roberts PL,Murray JJ,Coller
JA,Veidenheimer MC.Anal?ssure in Crohn’s disease:a plea for aggressive management.Dis Colon Rectum 1995;38(11):1137–1143
100.Buchmann P,Keighley MR,Allan RN,Thompson H, Alexander-Williams J.Natural history of perianal Crohn’s disease.Ten year follow-up:a plea for conservatism.Am J Surg1980;140(5):642–644
101.Wolkomir AF,Luchtefeld MA.Surgery for symptomatic hemorrhoids and anal?ssures in Crohn’s disease.Dis Colon Rectum1993;36(6):545–547
102.Wexner SD,Smithy WB,Milsom JW,Dailey TH.The surgical management of anorectal diseases in AIDS and pre-AIDS patients.Dis Colon Rectum1986;29(11):719–723 103.Weiss EG,Wexner SD.Surgery for anal lesions in HIV-infected patients.Ann Med1995;27(4):467–475
104.Viamonte M,Dailey TH,Gottesman L.Ulcerative disease of the anorectum in the HIVtpatient.Dis Colon Rectum 1993;36(9):801–805
105.Barrett WL,Callahan TD,Orkin BA.Perianal manifes-tations of human immunode?ciency virus infection:expe-rience with260patients.Dis Colon Rectum1998;41(5): 606–611,discussion611–612
106.Gonzalez-Ruiz C,Heart?eld W,Briggs B,Vukasin P, Beart RW.Anorectal pathology in HIV/AIDS-infected patients has not been impacted by highly active antiretro-viral therapy.Dis Colon Rectum2004;47(9):1483–1486
30CLINICS IN COLON AND RECTAL SURGERY/VOLUME24,NUMBER12011