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Anal fissure

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Not to be confused with intergluteal cleft.

Anal fissure
Other namesFissure in ano, rectal fissure
An anal fissure
SpecialtyGastroenterology Edit this on Wikidata

An anal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper and undergarments, or sometimes in the toilet. If acute they are painful after defecation,[1] but with chronic fissures, pain intensity often reduces and becomes cyclical.[2]

Causes

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Most anal fissures are caused by stretching of the anal mucous membrane beyond its capability.[3]

Superficial or shallow anal fissures look much like a paper cut, and may be hard to detect upon visual inspection; they will generally self-heal within a couple of weeks. However, some anal fissures become chronic and deep and will not heal. The most common cause of non-healing is spasming of the internal anal sphincter muscle which results in impaired blood supply to the anal mucosa. The result is a non-healing ulcer, which may become infected by fecal bacteria.

In adults, fissures may be caused by constipation, the passing of large, hard stools, or by prolonged diarrhea. In older adults, anal fissures may be caused by decreased blood flow to the area. When fissures are found laterally, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, acquired immunodeficiency syndrome (AIDS) or inflammatory bowel disease should be considered as possible causes.[4] Some sexually transmitted infections can promote the breakdown of tissue resulting in a fissure: syphilis, herpes, chlamydia and human papilloma virus.[5]

Other common causes of anal fissures include: childbirth trauma in women,[6] anal sex,[7][8] Crohn's disease,[6] ulcerative colitis,[9] and poor toileting in young children.[10]

Diagnosing

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External anal fissures on the anal verge can be diagnosed by visual inspection.[citation needed]

In case of chronic anal fissure the sentinel piles on anal verge, papilla next to dentate line and fissures also commonly referred to in combination as classic fissure triad can also be seen during diagnosis.

Internal anal fissures stretching from anal verge till dentate line in adults on anterior side, posterior side or within any part of the inner circumference of the anal sphincter muscle can be diagnosed with a beak proctoscope of 23 mm diameter, a Hill Ferguson retractor of 23 mm diameter, a Park anal retractor or by digital rectal examination with a finger through the anal sphincter.

Narrow anal fissures might not be felt by finger palpation during the rectal exam due to gloves reducing tactile sensitivity.[11]

Note that colonoscopy, sigmoidoscopy, or normal proctoscopy is for diagnosing internal hemorrhoids and other internal rectal diseases and not for diagnosing anal fissures.[relevant?]

Prevention

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For adults, the following may help prevent anal fissures:

  • Avoiding straining when defecating. This includes treating and preventing constipation by eating food rich in dietary fiber, drinking enough water, occasional use of a stool softener, and avoiding constipating agents.[12] Similarly, prompt treatment of diarrhea may reduce anal strain.
  • Careful anal hygiene after defecation, including using soft toilet paper and cleaning with water, plus the use of sanitary wipes.
  • In cases of pre-existing or suspected fissure, use of a lubricating ointment (It is important to note that hemorrhoid ointment is contraindicated because it constricts small blood vessels, thus causes a decrease in blood flow, which prevents healing).

In infants, frequent diaper change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough fluids (i.e. breastmilk, proper ratios when mixing formulas) is beneficial. In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.[13]

Treatment

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Non-surgical treatments are recommended initially for acute and chronic anal fissures.[14][15] These include topical nitroglycerin or calcium channel blockers (e.g. diltiazem), or injection of botulinum toxin into the anal sphincter.[16]

Other measures include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.[17][18]

Medication

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Local application of medication to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[19][20][21][22] and then calcium channel blockers in 1999 with nifedipine ointment,[23][24] and the following year with topical diltiazem.[25] Branded preparations are now available of topical nitroglycerine ointment (Rectogesic (Rectiv) as 0.2% in Australia and 0.4% in UK and US[26]), topical nifedipine 0.3% with lidocaine 1.5% ointment (Antrolin in Italy since April 2004) and diltiazem 2% (Anoheal in UK, although still in Phase III development). A common side effect drawback of nitroglycerine ointment is headache, caused by systemic absorption of the drug, which limits patient acceptability.

A combined surgical and pharmacological treatment, administered by colorectal surgeons, is the direct injection of botulinum toxin (Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993. However, in many cases involving Botox injections, the patients eventually had to choose another cure as the injections proved less and less potent, spending thousands of dollars in the meantime for a partial cure. Lateral sphincterotomy is the Gold Standard for curing this condition.[27] Combination of medical therapies may offer up to 98% cure rates.[28]

Surgery

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Surgical procedures are generally reserved for people with anal fissures who have tried medical therapy for at least one to three months and have not healed. It is not the first option in treatment.

The main concern with surgery is the development of anal incontinence. Anal incontinence can include the inability to control gas, mild fecal soiling, or loss of solid stool. Some degree of incontinence can occur in up to 45 percent of patients in the immediate surgical recovery period. However, incontinence is rarely permanent and is usually mild. The risk should be discussed with one's surgeon.

Surgical treatment, under general anaesthesia, is either anal stretch (Lord's operation) or lateral sphincterotomy where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter spasming and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general or regional anaesthesia. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.

Lateral internal sphincterotomy

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Lateral internal sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%).[29] In this procedure the internal anal sphincter is partially divided in order to reduce spasming and thus improve the blood supply to the perianal area.

This improvement in the blood supply helps to heal the fissure, and the weakening of the sphincter is also believed to reduce the potential for recurrence.[30] The procedure is generally performed as a day surgery after the patient is given general anesthesia. The pain from the sphincterotomy is usually mild and is often less than the pain of the fissure itself. Patients often return to normal activity within one week.

LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%).[31]

Though lateral internal sphincterotomy (LIS) is considered safe on a short-term basis, there are concerns about its long-term safety. Pankaj Garg et al. published a systematic review and meta-analysis in which they analyzed the long-term continence disturbance two years after the LIS procedure. They found the incidence of long-term continence disturbance to be 14%, so caution and careful patient selection are needed before undergoing LIS.[32]

Anal dilation

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Anal dilation, or stretching of the anal canal (Lord's operation), has fallen out of favour in recent years, primarily due to the unacceptably high incidence of fecal incontinence.[33] In addition, anal stretching can increase the rate of flatus incontinence.[34] The incidence of incontinence is thought to be due to a lack of standardization and that proper technique results in little chance that it will occur.[35]

In the early 1990s, however, a repeatable method of anal dilation proved to be very effective and showed a very low incidence of side effects.[36] Since then, at least one other controlled, randomized study has shown there to be little difference in healing rates and complications between controlled anal dilation and LIS,[37] while another has again shown high success rates with anal dilation coupled with low incidence of side effects.[38]

Fissurectomy

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Fissurectomy involves excision of the skin on and around the anal fissure and excision of the sentinel pile if one is present. The surgical wound can be left open. New skin tissue grows and it heals.[citation needed]

  • Fissurectomy wound 1.5 weeks after the OP
    Fissurectomy wound 1.5 weeks after the OP
  • Fissurectomy wound 3.5 weeks after the OP
    Fissurectomy wound 3.5 weeks after the OP
  • Fissurectomy wound 12.5 weeks after the OP
    Fissurectomy wound 12.5 weeks after the OP

Epidemiology

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The incidence of anal fissures is around 1 in 350 adults.[10] They occur equally common in men and women and most often occur in adults aged 15 to 40.[10]

See also

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References

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  1. ^ Gott, M. D.; Peter, H. (5 March 1998). "New Therapy Coming for Anal Fissures". The Fresno Bee. Fresno, CA: McClatchy Co. p. E2, "Life" section.
  2. ^ Nelson, Richard L. (12 November 2014). "Anal fissure (chronic)". BMJ Clinical Evidence. 2014: 0407. ISSN 1752-8526. PMC 4229958. PMID 25391392.
  3. ^ "Anal Fissures". www.hopkinsmedicine.org. 19 April 2022. Retrieved 2 November 2023.
  4. ^ Pfenninger, John L.; Zainea, George G. (July 2001). "Common Anorectal Conditions". American Family Physician. 64 (1). American Academy of Family Physicians: 77–89. Archived from the original on 5 August 2012.
  5. ^ "Anal Fissure – Causes". NHS Choices. Archived from the original on 4 February 2013.
  6. ^ a b Collins, E. E.; Lund, J. N. (September 2007). "A Review of Chronic Anal Fissure Management". Techniques in Coloproctology. 11 (3): 209–223. doi:10.1007/s10151-007-0355-9. PMID 17676270. S2CID 8520860.
  7. ^ "What Causes Anal Fissures?". WebMD. Archived from the original on 27 July 2017. Retrieved 20 July 2017.
  8. ^ Ferri, Fred F. (2015). Ferri's Clinical Advisor 2016. Elsevier Health Sciences. p. 108. ISBN 9780323378222.
  9. ^ "Anal Fissure Treatment, Symptoms & Surgery - Cleveland Clinic: Health Library". Cleveland Clinic. Archived from the original on 22 August 2013.
  10. ^ a b c "Anal Fissure – Basics – Epidemiology". Best Practice. British Medical Journal. 23 April 2012. Retrieved 30 June 2012.
  11. ^ Man, Tanita; Jiang, Jun; Schulz, Manuela; Kükrek, Haydar; Betzl, Julia; Machens, Hans-Günther; Erne, Holger C.; Moog, Philipp (December 2022). "Surgical experience and different glove wearing conditions affect tactile sensibility". Heliyon. 8 (12): e12550. Bibcode:2022Heliy...812550M. doi:10.1016/j.heliyon.2022.e12550. PMC 9803715. PMID 36593852.
  12. ^ Basson, Marc D. (28 January 2010). "Constipation". eMedicine. New York, NY: WebMD. Archived from the original on 15 February 2010. Retrieved 5 April 2010.
  13. ^ Kliegman, Robert M.; Abramson, Jon S., eds. (2011). Nelson Textbook of Pediatrics (19 ed.). Philadelphia, Pa: Saunders, Elsevier. ISBN 978-0-8089-2420-3.
  14. ^ Nelson RL, Thomas K, Morgan J, Jones A (2012). "Non surgical therapy for anal fissure". Cochrane Database of Systematic Reviews. 2 (2): CD003431. doi:10.1002/14651858.CD003431.pub3. PMC 7173741. PMID 22336789.
  15. ^ Haq., Z.; Rahman, M.; Chowdhury, R.; Baten, M.; Khatun, M. (2005). "Chemical Sphincterotomy—First Line of Treatment for Chronic Anal Fissure". Mymensingh Medical Journal. 14 (1): 88–90. PMID 15695964.
  16. ^ Shao, WJ; Li, GC; Zhang, ZK (September 2009). "Systematic review and meta-analysis of randomized controlled trials comparing botulinum toxin injection with lateral internal sphincterotomy for chronic anal fissure". International Journal of Colorectal Disease. 24 (9): 995–1000. doi:10.1007/s00384-009-0683-5. PMID 19266207. S2CID 21869421.
  17. ^ "Anal Fissure – Treatment Overview". WebMD. Archived from the original on 5 October 2011. Retrieved 27 September 2011.
  18. ^ Poritz, Lisa Susan. "Anal Fissure Treatment & Management". Medscape. Archived from the original on 31 October 2011. Retrieved 27 September 2011.
  19. ^ Loder, P.; Kamm, M.; Nicholls, R.; Phillips, R. (1994). "'Reversible Chemical Sphincterotomy' by Local Application of Glyceryl Trinitrate". British Journal of Surgery. 81 (9): 1386–1389. doi:10.1002/bjs.1800810949. PMID 7953427. S2CID 45517748.
  20. ^ Watson, S.; Kamm, M.; Nicholls, R.; Phillips, R. (1996). "Topical Glyceryl Trinitrate in the Treatment of Chronic Anal Fissure". British Journal of Surgery. 83 (6): 771–775. doi:10.1002/bjs.1800830614. PMID 8696736. S2CID 27460928.
  21. ^ Simpson, J.; Lund, J.; Thompson, R.; Kapila, L.; Scholefield, J. (2003). "The Use of Glyceryl Trinitrate (GTN) in the Treatment of Chronic Anal Fissure in Children". Medical Science Monitor. 9 (10): PI123–126. PMID 14523338.
  22. ^ Lund, J. N.; Scholefield, J.H. (4 January 1997). "A Randomised, Prospective, Double-blind, Placebo-controlled Trial of Glyceryl Trinitrate Ointment in Treatment of Anal Fissure". The Lancet. 349 (9044): 11–14. doi:10.1016/S0140-6736(96)06090-4. PMID 8988115. S2CID 8780826.
  23. ^ Antropoli, C.; Perrotti, P.; Rubino, M.; Martino, A.; De Stefano, G.; Migliore, G.; Antropoli, M.; Piazza, P. (1999). "Nifedipine for Local Use in Conservative Treatment of Anal Fissures: Preliminary Results of a Multicenter Study". Diseases of the Colon and Rectum. 42 (8): 1011–1015. doi:10.1007/BF02236693. PMID 10458123. S2CID 29343690.
  24. ^ Katsinelos, P.; Kountouras, J.; Paroutoglou, G.; Beltsis, A.; Chatzimavroudis, G.; Zavos, C.; Katsinelos, T.; Papaziogas, B. (2006). "Aggressive Treatment of Acute Anal Fissure with 0.5% Nifedipine Ointment Prevents Its Evolution to Chronicity". World Journal of Gastroenterology. 12 (38): 6203–6206. doi:10.3748/wjg.v12.i38.6203. PMC 4088118. PMID 17036396.
  25. ^ Carapeti, E.; Kamm, M.; Phillips, R. (2000). "Topical Diltiazem and Bethanechol Decrease Anal Sphincter Pressure and Heal Anal Fissures without Side Effects". Diseases of the Colon and Rectum. 43 (10): 1359–1362. doi:10.1007/BF02236630. PMID 11052511. S2CID 25450627.
  26. ^ "Rectiv". drugs.com. Archived from the original on 2 September 2011. Retrieved 27 September 2011.
  27. ^ Jost, W.; Schimrigk, K. (1993). "Use of Botulinum Toxin in Anal Fissure". Diseases of the Colon and Rectum. 36 (10): 974. doi:10.1007/BF02050639. PMID 8404394. S2CID 44959287.
  28. ^ Tranqui, P.; Trottier, D.; Victor, C.; Freeman, J. (2006). "Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin" (PDF). Canadian Journal of Surgery. 49 (1): 41–45. PMC 3207506. PMID 16524142. Archived (PDF) from the original on 14 December 2023. Retrieved 14 December 2023.
  29. ^ "Anal Fissure". The Lecturio Medical Concept Library. 16 October 2020. Retrieved 28 June 2021.
  30. ^ Villanueva Herrero, J. A.; Henning, W.; Sharma, N.; Deppen, J. G. (2022). "Internal Anal Sphincterotomy". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID 29630265. Retrieved 28 June 2021.
  31. ^ Wolff, B. G.; Fleshman, J.W.; Beck, D. E.; Church, J. M. (2007). The ASCRS Textbook of Colon and Rectal Surgery. Springer. p. 180. ISBN 978-0-387-24846-2. Retrieved 15 July 2009.
  32. ^ Garg P, Garg M, Menon GR (March 2013). "Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis". Colorectal Disease. 15 (3): e104–17. doi:10.1111/codi.12108. PMID 23320551. S2CID 23739830.
  33. ^ Becker, Horst Dieter (2005). Urinary and Fecal Incontinence: An Interdisciplinary Approach. Springer Science & Business Media. p. 105. ISBN 9783540222255. OCLC 185042351. Retrieved 17 August 2014.
  34. ^ Sadovsky, R. (1 April 2003). "Diagnosis and management of patients with anal fissures – Tips from Other Journals". American Family Physician. 67 (7): 1608. Archived from the original (Reprint) on 29 January 2006. Retrieved 12 May 2009.
  35. ^ Gupta PJ (2004). "Treatment of fissure in ano- revisited". Afr Health Sci. 4 (1): 58–62. PMC 2141661. PMID 15126193.
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  37. ^ Yucel, T.; Gonullu, D.; Oncu, M.; Koksoy, F. N.; Ozkan, S. G.; Aycan, O. (June 2009). "Comparison of Controlled-intermittent Anal Dilatation and Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissures: A Prospective, Randomized Study". International Journal of Surgery. 7 (3): 228–231. doi:10.1016/j.ijsu.2009.03.006. PMID 19361582.
  38. ^ Renzi, A.; Brusciano, L.; Pescatori, M.; Izzo, D.; Napolitano, V.; Rossetti, G.; del Genio, G.; del Genio, A. (January 2005). "Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study". Diseases of the Colon and Rectum. 48 (1): 121–126. doi:10.1007/s10350-004-0780-z. PMID 15690668. S2CID 42818812.
  • Lund, J. N.; Nyström, P. O.; Coremans, G.; Herold, A.; Karaitianos, I.; Spyrou, M.; Schouten, W. R.; Sebastian, A. A.; Pescatori, M. (October 2006). "An evidence-based treatment algorithm for anal fissure". Techniques in Coloproctology. 10 (3): 177–180. doi:10.1007/s10151-006-0276-z. PMID 16969620. S2CID 5736917.
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