Anal Fissure

Definition:

  • Ulcer or split in the skin lined (distal) part of the anal canal.
  • Classical symptom is stab like / cutting glass pain on defecation
  • Most fissure are acute and heal spontaneously.
  • Common site is posterior midline (women-10% anterior)

Common Causes:

  • Constipation-hard faecal bolus
  • Childbirth(3-10%)
  • Crohn’s disease -Management is medical- Immunosuppressives, Antibiotics, Little role for surgical treatment
  • Occasional diarrheal especially in children
  • Anal SCC
  • Post-operative – haemorrhoidectomy

Chronic fissure;

- (Fissure becomes chronic when it fails to heal for >6 weeks)
  • Thick indurated edges
  • Sentinel tag
  • Absence of granulation tissue with white fibres of Internal Anal Sphincter (IAS) visible at base.
  • There is associated spasm of IAS causing pain and discomfort

Spasm of internal sphincter

  • Leading cause of non-healing is spasm of the internal anal sphincter
  • Poor blood supply and perfusion –posterior midline ischemia
  • Treatment (both medical and surgical) is aimed at restoring the normal tone of the IAS

Treatment

  • Medical /Non-operative treatment
    • Stool softeners
    • Sitz baths
    • Topical anaesthetics 2 % Lignocaine Jelly
    • Anti-inflammatory ointment
  • Pharmaceutical Treatment
    • Topical Nitroglycerin GTN(nitric oxide) -Rectogesic 0.2% ointment
    • Topical calcium channel blockers
    • Oral calcium channel blockers
    • Botulinum toxin injections
  • Surgical treatment
    • Lateral internal sphincterotomy (LIS) -(Currently Recommended Surgical Management)
    • Anal advancement flap (alternative to LIS)
    • Fissurectomy
    • Anal dilation (considered but not recommended
  • Rectogesic ointment -GTN
    • Reducing intra-anal pressure (relax IAS)
    • Vasodilatory effect on anal vessels -Topical paste applied three time a day
    • 0.2% strength (compared with 2% strength for GTN patches)
    • >80% fissures healed in 2-3 weeks
    • Side effects include headaches, flushing and dizziness on standing, burning sensation in the anus, development of tolerance.
    • 25% of patients will be unable to tolerate
    • Calcium channel blockers (topical) is an alternative
    • 1- 2% Diltiazem cream-less S/E
  • Botulinum toxin (Botox®) injection
    • Rapid action-within few hours
    • Non traumatic
    • Effect last 3-4 month –enough for fissure to heal
    • No damage /division of IAS
    • Very good option in females-already attenuated IAS
  • Surgery-Lateral sphincterotomy;
    • 96% healing rate
      • Partial division of Internal sphincter
      • S/e-30 incontinence- Females at greater risk due to anatomically shorter anal sphincter and pre-existing childbirth injury.

    Advantages

    • Can be performed under LA as a day case
    • Wounds heal quickly
    • Low recurrence rates
    • Can perform concomitant procedure without increased risk of complication Ref; Leong, Dis Colon Rectum 1994; 37:1130-1132

    Disadvantages

    • Impaired continence - up to 38% notice some change
    • Soiling - 27% (open) vs 16% (closed); p< 0.001
    • Stool - 12% vs 3%; p< 0.001
    • Flatus - 30% vs 24%; p< 0.062

    Ref; Garcia-Aguilar, Dis Colon Rectum 1996; 440-443 (549 patients)

  • Lords manoeuvre;
    • Forceful dilatation (8 fingers)of the sphincter complex is not practiced now days
  • If fissure is not Non healing
    • Consider Crohn’s disease
    • HIV
    • Malignancy

Botox VERSUS Lateral internal Sphincterotomy (LIS)

  • RCT, 111 patients
  • 20-30 IU Botox(R) injected anteriorly (50) vs open LIS (61)
LIS Botox
Healing @ 1/12 82% 74% (p = 0.023)
Healing @ 6/12 96% 87% (p = 0.212)
Healing @ 12/12 94% 75% (p = 0.008)
Incontinence 16% 0% (p < 0.001)
Return to work 15 days 1days (p < 0.0001)

Mentes, Dis Colon Rectum 2003; 46:232-237