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40
B. Perakath and N. Agarwal
15–20 % if patient continues to remain on
high-fi ber diet. Hence, lifelong dietary
modifi cation is recommended.
4.8.2.1.1 Chemical Sphincterotomy
The one who progresses to chronicity still
responds well to nonoperative management available in the form of local ointments of mainly
nitrates and calcium channel blockers defi ned as
chemical sphincterotomy agents. The ideal topical treatment for anal fi ssure should reduce pain
and heal the fi ssure with minimal recurrence,
without impairing the continence, and with low
side effects.
4.8.2.1.2 Topical Nitroglycerine
Topical nitroglycerine (local application) is a
nitrate donor and a vasodilator. It aids in improving local blood fl ow. It also reduces internal
sphincter muscle spasm by release of nitric oxide
from glyceryl trinitrate (GTN) metabolism at cellular level. Nitric oxide acts via guanylate cyclase
pathway leading to chemical sphincterotomy
(Kennedy et al. 1999 ) and thereby relieves pain
and promotes healing. Nitroglycerine local preparation is available in both 0.2 and 0.4 % concentrations. It is applied two to three times per day
with a gloved fi nger for 8 weeks. It relives pain
for 2–6 h. Healing has been reported in 70–80 %
patients. Its usage has decreased the recurrence
rate by 50 % compared to placebo (Nelson et al.
2012 ). Dose escalation or specialized dose-
delivery device 0.75 ml of 0.3 % GTN ointment
(2.25 mg) three times intra-anal application using
a cannula or transdermal patch has been shown
not to improve the healing rate (Bailey et al.
2002 ). Headache is the main side effect which
limits its use. Other side effects include rebound
hypertension, syncope, crescendo angina, and
allergic dermatitis.
4.8.2.1.3 Topical Diltiazem (2 %)
Topical diltiazem (2 %), a calcium channel
blocker, is applied twice a day for 8 weeks. It acts
by blocking the calcium channels in the cells
which when stimulated do not contract so much.
The anal sphincter relaxes which lowers resting
anal pressure and promotes healing. Studies have
shown promising results and an overall healing
rate of 88 %. In contrast to glyceryl trinitrate
ointment, topical diltiazem has very limited
adverse drug effects (Knight et al.
2001 ). These
include headache, drowsiness, mood swings, and
perianal itching. Oral diltiazem 60 mg was fond
to be inferior to topical diltiazem (38 %) with
more side effects (Jonas et al. 2001 ).
4.8.2.1.4 Topical Nifedipine (0.3 %)
Topical nifedipine (0.3 %), another calcium
channel blocker, causes smooth muscle relaxation and thereby healing in 94.5 % cases. Oral
nifedipine (20 mg twice a day for 6 weeks) results
in less healing rate with more side effects
(Antropoli et al. 1999 ; Cook et al. 1999 ).
4.8.2.1.5 Topical Bethanechol
Topical bethanechol is a parasympathomimetic choline carbamate which is a selective
muscarinic receptor agonist and promotes synthesis of nitrous oxide which lowers the resting
anal pressure. Bethanechol is not hydrolyzed
by acetylcholinesterase and therefore has a
long duration of action. Topical bethanechol
0.1 % application locally has shown to heal
fissures in up to 60 % without side effects
(Carapeti et al. 2000 ).
4.8.2.1.6 Botulinum Toxin
Botulinum toxin inhibits the release of acetylcholine from nerve endings and has been used in
conditions like torticollis and achalasia cardia.
By inhibiting neuromuscular transmission, it paralyzes muscles within hours. This action lasts for
3–4 months till regeneration of nerve endings.
About 10–100 units are injected on either side of
fi ssure and/or in the bed of fi ssure in the internal
sphincter (Minguez et al.
1999 ). Success rate of
60–80 % has been reported after 2 months. It
rises to 100 % after second injection. It has been
reported to be more effective in young and elderly
females. It can be done on outpatient basis. Side
effects include heart block, skin allergy, increased
residual urine, muscle weakness, postural hypotension with fl uctuations in heart rate and blood
pressure, and transient incontinence in 10 %
4 Anal Fissure
41
patients. The cost is also the limiting factor for its
use. These apart from the exact dose and the
number of repetitions of the injections and the
precise site are still being studied. There is limited evidence for use of this modality of treatment (Minguez et al. 2002 ). However, botulinum
can be repeated as required (Brisinda et al. 2002 ).
4.8.2.1.7 Topical Sildenafi l
Topical sildenafi l by inhabiting phospodiasterase 5 (PDE5) increases intracellular concentration of
cGMP as PDE5 is integral to the degradation of
cGMP which is responsible for smooth muscle
relaxation. It also acts through indirect enhancement of nitric oxide which is responsible for degradation of cGMP.0.75 ml of 10 % (75 mg) cream
is used by 1 ml preloaded syringe for intra-anal
installation. Its side effects are transient itching
and burning in the perianal area. However, adequate literature is not available to comment on its
use for anal fi ssure (Rakinic et al. 2007 ).
4.8.2.1.8 Minoxidil
Minoxidil, a potassium channel opener, induces
smooth muscle relaxation and vasodilatation has
shown low healing rates of 30 % only (Rakinic
et al. 2007 ).
Conservative and medical treatment is an
effective way of treating chronic anal fi ssure and
may obviate need for anesthesia and surgery,
therefore should be offered to the patients either
not fi t or not willing for surgery. Patients with
failure of medical treatment and recurrence
should be advised surgical intervention.
4.8.2.2 Surgical Management
Those individuals who fail to respond or recur after
initial healing as also those with severe unbearable
pain and the ones who develop complications need
surgical intervention. Fissures with secondary
changes also require some surgical intervention.
Surgery may be considered even without trail of
chemical sphincterotomy after failure of conservative treatment in a patient with severe unbearable
pain, a step which entails immediate relief and
eliminates need for any further treatment with substantial satisfaction of the patients with reasonably
acceptable complications.
Fig. 4.8 Keyhole deformity
The main principles of fi ssure surgery are
relieving of internal anal sphincter spasm,
reducing maximum anal resting pressure, correction of ischemia, and ulcer healing.
There are various procedures described in the
literature starting from maximum anal stretching
to closed lateral sphincterotomy which is
presently accepted as the gold standard in fi ssure
surgery.
4.8.2.2.1 Internal Sphincterotomy
In 1951, Eisenhammer described the division of
the hypertrophied internal anal sphincter to
release the tension which leads to healing of fi ssure (Eisenhammer
1951 ). It is done laterally in
the right or the left quadrant, depending on the
comfort and handedness of the surgeon and to
avoid a keyhole deformity with its consequences
which may occur at 6 o’clock position (Fig.
Both closed and open methods are described
without any signifi cant difference in outcome
(Wiley et al. 2004 ), though the closed variety is
largely accepted as the gold standard in the treatment of refractory fi ssure in ano. The surgery can
be performed under any anesthesia, but general is
preferred for better assessment of sphincters.
Many do it under local anesthesia which has faster
recovery but increased recurrence rates (Casillas
et al. 2005 ; Fleischer et al. 1994 ); the procedure
can be done as daycare procedure. The lower 1/3
of the IS is cut below the level of the dentate line,
at a position between 3 and 5 o’clock through a
stab incision in the closed variety, by directing the
4.8 ).
42
B. Perakath and N. Agarwal
Fig. 4.9 Position of fi nger and knife for lateral internal
sphincterotomy
knife edge from lateral to medial and the extended
index fi nger of the surgeons left hand in the anal
canal serving as a guide to safeguard the mucosa
(Fig. 4.9 ). The remaining fi bers are broken by the
tip of the fi ngers and pressure applied for hemostasis. The resultant tiny wound is left open. In the
open variety, the internal sphincter is identifi ed
and divided using a scalpel blade or electrocautery through a small incision radial or curvilinear
at the inter- sphincteric grove area. The incision is
closed with a 3-0 Vicryl interrupted sutures. The
sentinel tag and the polyp may be excised if the
same are large enough for regression, thereby
causing some discomfort to the patient.
Statistically, no signifi cant differences were
observed regarding healing and complication
rates following closed and open sphincterotomy
(Lewis et al.
1988 ; Garcia-Aguilar et al. 1996 ).
Evidence is split between classical long
sphincterotomy against tailored conservative
sphincterotomy (Garcea et al. 2003 ). In tailored
sphincterotomy, the internal sphincter is divided
only till the upper limit of the fi ssure, whereas in
classical or long sphincterotomy, the upper limit
of sphincterotomy is at the level of the dentate
line. The anal canal may be short especially in
women partly because of previous obstetric injuries. Care should be taken prior to LIS, especially
in women, to clarify the boundaries of the sphincterotomy in order to help avoid continence problems postoperatively. Other patients at higher
risk of incontinence like those with previous
sphincter injury, multiple vaginal deliveries,
infl ammatory bowel diseases, and underlying
impaired incontinence also require extra attention before attempting LIS to avoid worsening
sphincter function. Tailored sphincterotomy may
give comparable results with lesser risk of incontinence in such patients (Littlejohn and Newstead
1997 ). Though dentate group may have faster
symptomatic relief, long-term results were not
signifi cantly different in the two groups.
By dividing the internal anal sphincter, sphincteric spasm is eliminated, resulting in quicker
healing. Lateral internal sphincterotomy results
in pain relief in 99 % of the patients with a recurrence rate of 3 %. The resultant incontinence is
6 % for fl atus and 1 % for feces (Hyman 2004 ;
Saad and Omer 1992 ; Brown et al. 2007 ). The
complications of lateral anal sphincterotomy is
the risk of fecal incontinence (12–33 %) and
infections (1–2 %), fi stula (1 %), ecchymosis,
and hematoma (Casillas et al. 2005 ). LIS is supe-
rior to posterior midline sphincterotomy with
faster healing, less pain, and less risk of incontinence (Abcarian 1980 ).
Carbon dioxide laser and cryo have been
used to divide the sphincter and vaporization
of fi ssure locally, but the high cost of laser unit
and cryo sound prevents its wider acceptance.
Sphincterotomy using radiofrequency surgery
has been reported to be useful for fi ssures associated with abscess, papilla, polyp, fi stula, and
hemorrhoids which can be treated in the same sitting. The entire procedure is quick and bloodless.
However, it needs a radiofrequency generator,
and being a new introduction with no controlled
or randomized trials available, this treatment
modality needs further studies to analyze its
long-term results (Gupta
2003 ; Pfenninger and
Zainea 2001 ).
Choice of treatment (surgical vs. chemical
sphincterotomy) for chronic anal fi ssure is at
present controversial. LIS group had a substantially higher rate of fi ssure healing at 6 months
than did the (glyceryl trinitrate) GTN group
(92.1 % vs. 27.2 %, P < 0.01). However, side
effects were signifi cantly greater in the GTN
group (84 % vs. 30 %, P < 0.01), including 20 %
of patients who had to discontinue the GTN due
4 Anal Fissure
43
to intractable headaches (Richard et al. 2000 ).
However, proponents of pharmacological therapy
correctly note that a signifi cant proportion of fi ssure patients are cured following this approach,
often with no side effects and without the cost,
risk, and inconvenience of surgery.
4.8.2.2.2 Fissurotomy and Posterior Sphincterotomy
These procedures are not recommended anymore
since they involve dividing the internal sphincter
through the fi ssure in the posterior midline where
vascular supply is sparse resulting in higher failure and recurrence rates (Saad and Omer 1992 ).
4.8.2.2.3 Fissurectomy
Gabriel in 1948 described fi ssurectomy as to excise
the sentinel tag and hypertrophy papillae along
with the chronically indurated edges of the nonhealing wound. This is combined with either a lateral sphincterotomy or stretching. Sphincterotomy
at the base of the fi ssurectomy wound that is at 6
o’clock position causes a keyhole deformity and
associated consequences and hence best avoided
(Abcarian 1980 ). Fissurectomy itself leads to a
large uncomfortable external wound which takes
nearly 4–6 weeks to heal. Some surgeons have
used skin graft to cover these wounds.
4.8.2.2.4 Anal Dilatation or Stretch (Lord’s Procedure)
First described by Recamier ( 1829 ), this opera-
tion is simple to perform and does not need any
special equipment or any special after care. It is
still a favorite method among many general surgeons though condemned badly today for the
complications it causes. It is done under deep GA
with two fi ngers of each hand, stretching the anal
sphincters for 3–4 min, though the same varies
among surgeons. The procedure is started with
one fi nger followed gradually by two (one fi nger
of each hand) and then three and fi nally with two
fi ngers of each hand. There is uncontrolled
stretching and subsequent tearing of both the
internal and external sphincter at various locations causing temporary paralysis of internal anal
sphincter and external sphincter and therefore
complete relief of pain. Impaired continence is
observed in 12–27 % of patients (Isbister and
Prasad 1995 ) and recurrence in 6–7 %. This pro-
cedure may also be complicated by bleeding,
perianal bruising, strangulation of prolapsed hemorrhoids, perianal infection, Fournier’s gangrene,
bacteremia, and rectal procidentia. In 1992, Sohn
and collegues described anal dilatation, precisely
opened to 4.8 cm or with a 40mm rectosigmoid
balloon, has been found to cure successfully the
fi ssure in 93 % and 94 %, respectively, of each
group and to be associated with fever complications. Post-op assessment with endoanal ultrasound and anal manometry showed signifi cant
reduction in mean resting pressure (MRP) (Sohn
et al. 1992 ). Contraindication to anal stretching
includes short anal canal, straight AR angle, old
age with lax sphincters, and large internal piles.
Anal dilatation, manual or pneumatic, is associated with a higher fi ssure recurrence rate than LIS
as well as a higher rate of incontinence. Anal dilatation techniques produce uncontrolled sphincter
injury and should no longer be used.
4.8.2.2.5 V-Y Mucosal Advancement Flap
This procedure is indicated in low-pressure
sphincters where sphincterotomy is less benefi cial (Jonas et al. 2001 ) especially in obstetric-
related chronic fi ssure in ano. This fl ap is used to
cover defect in mucosa over the fi ssure (after fi ssurectomy or LIS), if delay is anticipated either at
the time of primary surgery or as second procedure if fi ssure does not heal. Experience is limited with other interventions like controlled
sphincterotomy using pneumatic dilatation, ablative procedures involving energy sources like
cryotherapy, laser, radiofrequency, etc.
4.8.2.2.6 Internal Anal Sphincterolysis
A technique of fi nger fragmentation of the internal
sphincter proposed by P. J. Gupta showed immediate relief of pain in 86 and 91 % healing rate in
4 weeks and recurrence rate of 6 %. The technique
is simple and easy to perform (Gupta
2007 ).
4.8.2.2.7 Direct Current Treatment
This outpatient procedure using direct current
probe has been reported on small group of patients
of anal fi ssure having associated hemorrhoids.
44
B. Perakath and N. Agarwal
It was found to be effective and safe nonsurgical
method of treatment in selected patients of chronic
anal fi ssure who do not respond to other conservative measures (Machicado et al. 1997 ).
4.8.3 Recurrence
Recurrence could be because of recurrent disease
or incomplete procedure (LIS). Medical treatment can be tried. If it fails, patient should be
evaluated by digital examination under anesthesia or endoanal ultrasound. If LIS was found
incomplete, it should be completed on the same
side or can be done a fresh on the opposite side.
If initial sphincterotomy was complete, it can be
repeated on the other side.
4.8.4 Special Situations
Secondary fi ssure in ano requires treatment of the
underlying disease condition or elimination of
the cause. Treatment of anal fi ssures in patient
with Crohn’s disease and human immunodefi ciency syndrome are challenging. Conservative
medical therapy is treatment of choice. If it fails,
LIS can be tried. Repeat surgical intervention
may be necessary and rates of anal incontinence
may be higher. Recent studies have shown benefi ts with conservative lateral anal sphincterotomy
(Fleshner et al. 1995 ). Anal fi ssure in HIV
patients remain a diffi cult problem and needs
thorough examination in order to differentiate it
from HIV-related perianal ulcers and may benefi t
from judicious use of limited sphincterotomy
(Abramowitz et al.
sis should be treated with anoplasty with advancement fl ap along with LIS. Fissure with grade I or
II piles are treated with LIS and sclerotherapy or
rubber band ligation. Associated III degree piles
are dealt by LIS and hemorrhoidectomy
(Fig. 4.10 ). Anal fi ssure in homosexuals should
be biopsied and wound cultured. These ulcers
need aggressive debridement. Intralesional steroids may be useful. Sphincterotomy is reserved
for patients who do not respond to medical treatment. For anal fi ssure with Crohn’s disease,
2009 ). Associated anal steno-
Fig. 4.10 Chronic anal fi ssure associated with
hemorrhoids
diarrhea and abdominal pain are the characteristic features, and such patients require complete
evaluation including biopsy. Conservative medical treatment is the choice of treatment, and if it
fails, the lateral internal anal sphincterotomy can
be performed.
4.9 Prevention
Most cases of anal fi ssure follow from a bout of
severe constipation and diarrhea. Patients often
recall feeling the anus “tear.” Prevention of constipation by dietary and therapeutic measures
will help prevent fi ssures from occurring in the
fi rst place. Patients should be reassured and
encouraged not to resist the urge for defecation.
They should be educated about the need for regular bowel habit and to avoid prolonged straining
(Gupta
must as continuous use of high fi ber diet reduces
recurrence rate from 30–70 % to 15–20 %.
2004 ). Lifelong dietary modifi cation is a
Conclusion
The etiology of anal fi ssure is unclear, and it
appears that multiple factors play a role in its
pathogenesis. Most primary anal fi ssures can
be managed with medical therapy, and lateral
anal sphincterotomy should be reserved for
failed medical management and in recurrent
and chronic fi ssure. Thorough examination is
imperative in cases of atypical and secondary
4 Anal Fissure
45
fi ssure in ano. Further investigation in order
to aid proper diagnosis and eliminate the
underlying cause before operative management
may be required. Overall results are good with
appropriate medical and surgical management.
Bibliography
Abcarian H. Surgical correction of chronic anal fi ssure:
results of lateral internal sphincterotomy Vs
fi ssurectomy- midline sphincterotomy. Dis Colon
Rectum. 1980;23:31–6.
Abramowitz L, Benabderrahmane D, Baron G, Walker F,
Yeni P, Duval X. Systematic evaluation and description
of anal pathology in HIV-infected patients during the
HAART era. Dis Colon Rectum. 2009;52(6):1130–6.
Antropoli C, Perrotti P, Robino M, et al. Nifedipine for
local use in conservative treatment of anal fi ssure: preliminary results of a multicentre study. Dis Colon
Rectum. 1999;42:1011–5.
Bailey H, Beck DE, Billingham RP, et al. A study to deter-
mine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal
fi ssures. Dis Colon Rectum. 2002;45:1192–9.
Brisinda G, Maria G, Sganga G, et al. Effectiveness of higher
doses of botulinum toxin to induce healing in patients
with chronic anal fi ssures. Surgery. 2002;131:179–84.
Brown CJ, Dubreuil D, Santoro L, et al. Lateral internal
sphincterotomy is superior to topical nitroglycerin for
healing chronic anal fi ssure and does not compromise
long-term fecal continence: six-year follow-up of a
multicenter, randomized, controlled trial. Dis Colon
Rectum. 2007;50(4):442–8.
Carapeti EA, Kamm MA, Phillips RK, et al. Topical
diltiazem and bethanechol decrease anal sphincter
pressure and heal anal fi ssures without side effects.
Dis Colon Rectum. 2000;43(10):1359–62.
Casillas S, Hull TL, Zutshi M, et al. Incontinence after a
lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum. 2005;48(6):1193–9.
Cook TA, Humphreys MM, Mortenson NJ. Oral nifedip-
ine reduces resting anal pressure and heals chronic
anal fi ssure. Br J Surg. 1999;86:1269–73.
Dodi G, Bogoni F, Infantino A, et al. Hot or cold in anal pain?
A study of the changes in internal anal sphincter pressure
profi les. Dis Colon Rectum. 1986;29(4):248–51.
Eisenhammer S. The surgical correction of chronic inter-
nal anal (sphincteric) contracture. S Afr Med J. 1951;
25(28):486–9.
Fleischer M, Marini CP, Statman R, et al. Local anesthesia
is superior to spinal anesthesia for anorectal surgical
procedures. Am Surg. 1994;60(11):812–5.
Fleshner PR, Schoetz Jr DJ, Roberts PL, et al. Anal fi ssure
in Crohn’s disease: a plea for aggressive management.
Dis Colon Rectum. 1995;38(11):1137–43.
Garcea G, Sutton C, Mansoori S. Results following
conservative lateral sphincterotomy for the treatment
of chronic anal fi ssures. Colorectal Dis Off J Assoc
Coloproctol G B Irel. 2003;5(4):311–4.
Garcia-Aguilar J, Balmonte C, Wong W, et al. Open vs
closed sphincterotomy for chronic: long term results.
Dis Colon Rectum. 1996;39:440–3.
Gupta PJ. Sphincterotomy with radio frequency surgery: a
new treatment technique of fi ssure in ano and associated
pathologies. Rom J Gastroenterol. 2003;12(1):37–40.
Gupta PJ. Treatment of fi ssure in ano- revisited. Afr
Health Sci. 2004;4(1):58–62.
Gupta PJ. Internal anal sphincterolysis for chronic anal
fi ssure: a prospective, clinical, and manometric study.
Am J Surg. 2007;194(1):13–6.
Hyman N. Incontinence after lateral internal sphincterot-
omy: a prospective study and quality of life assessment. Dis Colon Rectum. 2004;47(1):35–8.
Isbister WH, Prasad J. Fissure in ano. Aust N Z J Surg.
1995;65(2):107–8.
Jensen SL. Maintenance therapy with unprocessed bran in
the prevention of acute anal fi ssure recurrence. J R Soc
Med. 1987;80(5):296–8.
Jonas M, Neal KR, Abercrombie JF, et al. A randomized
trial of oral vs. topical diltiazem for chronic anal
fi ssures. Dis Colon Rectum. 2001;44(8):1074–8.
Kennedy ML, Sowter S, Nguyen H. Glyceryl trinitrate
ointment for the treatment of chronic anal fi ssure:
results of a placebo-controlled trial and long-term
follow- up. Dis Colon Rectum. 1999;42(8):1000–6.
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C.
Topography of the inferior rectal artery: a possible
cause of chronic, primary anal fi ssure. Dis Colon
Rectum. 1989;32(1):43–52.
Knight JS, Birks M, Farouk R. Topical diltiazem ointment
in the treatment of chronic anal fi ssure. Br J Surg.
2001;88(4):553–6.
Lewis TH, Corman ML, Prager ED, et al. Long term
effects of open and closed sphincterotomy for anal
fi ssure. Dis Colon Rectum. 1988;31:368–71.
Littlejohn DR, Newstead GL. Tailored lateral sphincter-
otomy for anal fi ssure. Dis Colon Rectum. 1997;40:
1439–42.
Machicado GA, Cheng S, et al. Resolution of chronic anal
fi ssures after treatment of contiguous internal hemorrhoids with direct current probe. Gastrointest Endosc.
1997;45:157–62.
Madalinski MH. Identifying the best therapy for chronic
anal fi ssure. World J Gastrointest Pharmacol Ther.
2011;2(2):9.
Minguez M, Melo F, Espi A, et al. Therapeutic effects of
different doses of botulinum toxin in chronic anal
fi ssure. Dis Colon Rectum. 1999;42:1016–21.
Minguez M, Herreros B, Espi A, et al. Long-term follow-
up (42 months) of chronic anal fi ssure after healing
with botulinum toxin. Gastroenterology. 2002;123(1):
112–7.
Nelson RL, Thomas K, Morgan J, et al. Non surgical ther-
apy for anal fi ssure. Cochrane Database Syst Rev.
2012;2, CD003431.
Pfenninger JL, Zainea GG. Common anorectal condi-
tions, part II. Am Fam Physician. 2001;64(1):77–88.
46
B. Perakath and N. Agarwal
Rakinic CV, Boehler M, Advani V, et al. Anal fi ssure. Clin
Colon Rectal Surg. 2007;25(3):133–7.
Recamier lCA (1829). Quoted by OH Goodsall and WE
Miles. Disease of the Anus and rectum, pan 1.
Longmans. London 1900.
Richard CS, Gregoire R, Plewes EA, et al. Internal
sphincterotomy is superior to topical nitroglycerin in
the treatment of chronic anal fi ssure: results of a
randomized, controlled trial by the Canadian
Colorectal Surgical Trials Group. Dis Colon Rectum.
2000;43:1048–57.
Saad AM, Omer A. Surgical treatment of chronic fi ssure-
in- ano: a prospective randomised study. East Afr Med
J. 1992;69(11):613–5.
Schouten WR, Briel JW, Auwerda JJ. Ischaemic nature of
anal fi ssure. Br J Surg. 1996;83(1):63–5.
Sohn N, Eisenberg M, Weinstein M, Lugo R, Ader J.
Precise anorectal sphincter dilatation-Its role in the
therapy of anal fi ssures. Diseases of the Colon &
Rectum. 1992;35(4):322–7.
Wiley M, Day P, Rieger N. Open vs. closed lateral internal
sphincterotomy for idiopathic fi ssure-in-ano: a prospective, randomized, controlled trial. Dis Colon
Rectum. 2004;47(6):847–52.
Zaghiyan KN, Fleshner P. Anal fi ssure. Clin Colon Rectal
Surg. 2011;24(1):22–30.
Perianal Sepsis and Fistula
Parvez Sheikh and Prasang Bajaj
5
5.1 Introduction
Anal fi stula and anal sepsis are the part of
spectrum of anorectal suppurative diseases. The
abscess represents the acute infl ammatory event,
whereas the fi stula is representative of the chronic
process. A perianal abscess (also known as ano-
rectal abscess or anal sepsis) is an infection of the
soft tissues surrounding the anal canal with formation of a discrete abscess cavity. A fi stula-in-
ano is a hollow tract lined with granulation tissue
connecting a primary opening inside the anal
canal to a secondary opening in the perianal skin
through which an abscess has been drained or has
spontaneously ruptured. In some fi stulas, there
may be only an internal opening leading to a
blind tract. Symptoms generally affect quality of
life signifi cantly and range from minor discomfort and drainage with resultant hygienic problems to distressing sepsis. Treating an abscess is
relatively straightforward. However, eradicating
anorectal fi stulas is challenging and often
P. Sheikh , MS, FICS, FAIS (*)
Department of Colorectal Surgery , Saifee Hospital ,
21 M, Karve Road, Charni Road (E) ,
Mumbai 400004 , India
parvezsheikh@hotmail.com
e-mail:
P. Bajaj , MS, FIAGES
Consultant Minimal Access, Colorectal and General
Surgery , Rajawadi Hospital , Mumbai , India
Dr.prasangbajaj@gmail.com
e-mail:
frustrating for both the surgeon and the patient.
The lack of any standard surgical procedure and
heterogeneity of anorectal fi stula warrants the
surgeon to use his “judgment” more than in most
colorectal diseases.
References to fi stula-in-ano date to antiquity.
The fascination with fi stula-in-ano for more than
2000 years is manifested by the numerous papers
and books on the subject. Hippocrates, in about
430 BC, made reference to surgical therapy for
fi stulous disease, and he was the fi rst person to
advocate the use of a seton (from the Latin seta, a
bristle). In 1376, the English surgeon John
Arderne (1307–1390) wrote Treatises of Fistula
in Ano; Haemmorhoids, and Clysters , which
described fi stulotomy and use of seton. Historical
references indicate that Louis XIV was treated
for an anal fi stula in the eighteenth century. In the
late nineteenth and early twentieth centuries,
prominent physician and surgeons, such as
Goodsall and Miles, Milligan and Morgan, and
Thompson and Lockhart-Mummery, made substantial contributions to the treatment of anal
fi stula.
5.2 Anatomy
Evaluation and treatment of perianal abscess
and fi stula disease require a thorough understanding of anatomy of anal canal and potential
spaces. Knowledge of anatomy helps to deter-
© Springer India 2016
N.A. Chowdri, F.Q. Parray (eds.), Benign Anorectal Disorders:
A Guide to Diagnosis and Management, DOI 10.1007/978-81-322-2589-8_5
47
48
P. Sheikh and P. Bajaj
Levator
Ani
Ext sphincter
Int sphincter
Anal gland
Fig. 5.1 Anatomy of the anal canal and rectum
mine the origin and to understand the subsequent course of this disease process (Fig. 5.1 ).
The inner circular muscle of the rectal wall
descends into the anal canal, where it becomes
the internal sphincter. This is surrounded by an
outer funnel-shaped layer of muscular tissue
that is composed of the levator ani, puborectalis, and external sphincter muscles. These two
layers are separated by the intersphincteric
plane, a fi brous extension of the outer longitudinal muscle layer of the rectum as it extends
down into the anal canal. The mucocutaneous
junction is the site of the dentate line, which is
the site of the anal valves. Proximal to each anal
valve is an anal crypt or sinus, which macroscopically appears as a small pit. The anal
glands, which lie either in the intersphincteric
plane or the internal sphincter, empty into these
anal crypts.
Perianal space is a potential space in the area
of anal verge, where a low intersphincteric tract
drains. The intersphincteric space lies between
two sphincters, and inferiorly it is in continuity
with the perianal space. The supra levator space
is an upward continuation of the intersphincteric space and is bounded superiorly by peritoneum, inferiorly by levator ani, medially by
rectal wall and laterally by pelvic wall.
Ischiorectal space extends from levator ani
above to perineum below. Deep postanal space
lies between tip of the coccyx and rectal wall
between levator ani above and anococcygeal
ligament below.
5.3 Epidemiology and Etiology
Anal sepsis can occur at any age though it is more
common in third or fourth decade of life. In children,
it is more common in babies under 12 months of age.
Males are affected more frequently than females,
with a male-to-female ratio of 2–3:1 (Isbister 1987 ).
This male predominance is particularly marked in
infancy. Approximately 30 % of patients with anorectal abscesses have a previous history of similar
abscesses (Ramunjam et al. 1984 ).
Many factors have been associated with development of anal sepsis like malignancy, trauma,
tuberculosis, foreign bodies, infl ammatory bowel
disease, simple skin infection, and actinomycosis.
However, most anal sepsis originates from an
infected anal gland. Obstruction of these glands
leads to stasis, bacterial overgrowth, and ultimately abscess formation. This represents cryptoglandular theory of anal sepsis which is responsible
for almost 90 % of all anal fi stulas. Mixed aerobic
and anaerobic bacteria account for 72 % of cases,
while pure aerobic and anaerobic infection only
accounted for 9 % and 19 % of cases, respectively
(Brook and Fraizer 1997 ). Common organisms
implicated include E.coli , bacteroides , and entero-
coccus species. The presence of skin-derived bacteria such as Staphylococcus indicates an abscess
resulting from the secondary infection of blocked
apocrine glands (Grace et al. 1982 ; Henrichsen
and Christiansen 1986 ). Review of the literature
shows that the incidence of gut-derived and skinderived organisms in patients with anorectal
abscesses with fi stula ranged from 85 to 100 %
and 0 to 38 %, respectively (Takayuki et al.
2008 ).
The likelihood of patients developing anal fi stula
after drainage of an anorectal abscess is similarly
higher in patients whose infection is caused by a
gut organism.
5.4 Classifi cation
5.4.1 Anorectal Abscess
Anorectal abscesses are classifi ed according to the
location of the abscess cavity. In order of
decreasing frequency they are perianal, ischiorectal,
5 Perianal Sepsis and Fistula
Peritoneum
Levator ani muscle
Puborectalis muscle
Deep external
sphincter muscle
Internal
sphincter muscle
Transverse septum
Fig. 5.2 Perianal spaces
49
Supralevator space
Ischioanal space
Intershincteric space
Perianal space
intersphincteric (also called submucosal), and
supralevator (Nelson 2002 ). One or more spaces
can be involved by a given suppurative process at a
time. For example, an intersphincteric abscess can
extend to involve the supralevator space. From
intersphincteric, supralevator, or ischiorectal space,
pus can extend circumferentially to the opposite
side via the deep postanal space resulting in what is
called a horseshoe abscess. These abscesses can
also extend to the scrotum and may cause Fournier’s
gangrene; extend to the labia and can get diagnosed
as Bartholin’s abscess; can extend to the thigh, calf,
and abdominal wall; and lead to necrotizing fasciitis (Fig.
5.2 ).
5.4.2 Anal Fistula
Many different classifi cations were given for
fi stula- in-ano; however, the most useful classifi cation is the one described by Parks et al. in 1976
(Fig. 5.3 ). Parks classifi ed fi stula-in-ano on the
basis of course taken by main tract in relation to
the anal sphincters, i.e., intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. These groups can be further subclassifi ed
on the basis of secondary tracts and other fi ner
anatomical details (Parks et al. 1976 ). The Park’s
classifi cation is not complete and in fact may
not be accurate in some instances, e.g., the
suprasphincteric classifi cation as described by
Park’s does not represent the natural spread of the
disease. All supralevator extensions are actually
upward extensions of an intersphincteric, tract,
and the only other way the supralevator space can
be reached is via an iatrogenic route.
Fistulas can also be classifi ed as simple or
complex. Complex fi stula includes recurrent fi stula, fi stula with multiple tracts, anterior fi stula in
females, high fi stulas, and fi stula with extension
to adjacent organs (Fig. 5.4a–c ).
5.5 Diagnosis
5.5.1 Anorectal Abscess
Patients with anorectal abscess can present in two
ways, either as a draining sepsis or as contained
infection. Patients with contained infection present with indolent onset of increasing pain around
the anus, rectum, or buttocks. Later on, there can
be severe, non-relieving, constant, throbbing pain
with pressure sensation. Pain is commonly associated with systemic symptoms like fever and
sweating. Patients with draining anorectal abscess
also present with complaints of offensive discharge on their undergarments or on toilet paper,
along with the history described above. Onset of
discharge is associated with relief of pain.