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FIG. 6.3 3D high resolution anal manometry. (A) Full registration. The basal pressure is very high and shows wave like patterns. During squeeze there is hardly
any increase in pressure. During push no relaxation takes place. Inflation of the rectal balloon (B) elicits a distention reflex at 30 mL.
Continued
68 ANORECTAL DISORDERS
FIG. 6.3—CONT’D (B) Ultra-slow waves (USW). (C) 3D representation of the high basal pressure. A, anterior; L, left; P, posterior; R, right.
Chapter 6 • Anal Fissure 69
FIG. 6.4 (A) Endoanal ultrasound in a patient with a chronic fissure. The Internal anal sphincter (IAS) is less demarcated by inflammation.
Continued
70 ANORECTAL DISORDERS
FIG. 6.4—CONT’D (B) After 6 weeks, an intersphincteric abscess (A) has developed, between the arrows. The IAS is hardly visible at the location of the fissure/
abscess. EAS, external anal sphincter.
Chapter 6 • Anal Fissure 71
the application of glyceryl trinitrate (GTN) and calcium blockers ointment, as well as
injection of Botulinum toxin (BT), has emerged. The more conservative approach is
reflected by the current guidelines of surgical societies.
17,18
Two systematic reviews and
metaanalyses of the treatment of anal fissure were conducted by Nelson et al. and published in 2017
19,20
as well as the Clinical Practical Guidelines by the American Society
of Colon and Rectal Surgeons
17
; a consen sus of the Association of Coloproctology of Great
Britain and Ireland was published earlier in 2015.
21
6.5.1 Conservative Management
The majority of acute anal fissures will resolve without surgical intervention. When a fissure becomes chronic, healing becomes more difficult. Conservative therapy is aimed at
three components: (1) to remove the underlying pathology responsible for the developing
of the fissure, like constipation, straining (dyssynergia), and possible other anal trauma;
(2) to relax the IAS in order to improve blood flow and thus obtain healing; and (3) to
improve symptoms of the fissure, which are pain and somet imes bleeding.
6.5.1.1 Fiber, Laxatives, Sit Bath, and Pelvic-Floor Therapy
The first step is the regulation of defecation by a fiber-enriched diet and a sufficient fluid
intake of at least 2 L. If this proves to be insufficient, bulking agents and/or laxatives need
to be prescribed. The prescription of 15g of unprocessed bran
22
compared to 7.5 g and 10 g
in combination with warm sit baths
23
had a better healing rate than lidocaine alone.
Sit baths have long been a part of the treatment to improve hygiene and diminish
anal tone and pain. A study in patients with anal fissures, hemorrhoids, and proctalgia
fugax where anal manometry was performed showed that 30 min after immersion in water
of 40°C for 5min anal pressures decreased significantly, but remained unaltered after
immersion at 5°C and 23°C.
24
In general, up to one-third of patients with chronic constipation have an evacuation
disorder, due to a nonrelaxing of the pelvic floor (dyssynergia) as a single cause (12%)
or in combination with slow transit (25%).
25
Treatment of dyssynergia with pelvic-floor
physiotherapy with biofeedback is very effective with long-term positive results of
60%.
26
So far, no biofeedback study has been performed in patients with persistent
chronic anal fissure. In patients with dyssynergia the use of biofeedback is definitely
worthwhile before proceeding to BT or surgery, and it should have a place in the management of chronic anal fissure (
Fig. 6.5).
6.5.1.2 Topical Nitrates
The concept of “chemical sphincterotomy” has had a remarkable expansion. The goal is to
reduce the IAS tone and to increase local blood flow to allow the fissure to heal. A review
comparing the randomized controlled trials (RCTs) shows that the highly promising
results from open studies showed more moderate healing rates in the RCTs.
19,27
GTN
is a nitrogen donor that relaxes the smooth muscle, internal sphincter, and blood vessels.
72 ANORECTAL DISORDERS
Medical treatment
-Life style (fiber, fluid, laxatives)
-Topical CCB or GTN
Failure
Healing: continue life style advice
Dyssynergia?
No
Yes
Pelvic floor physiotherapy
Botox
Failure
Failure
LIS*
Failure
Consider other modalities
-Repeat Botox,LIS
-AAF
Anal fissure
FIG. 6.5 Algorithm of treatment of chronic anal fissure. AAF, anal advancement flap; Botox, Botulinum toxin; CCB,
calcium channel blockers; LIS, lateral internal sphincterotomy; NTG, nitroglycerine. * when low anal pressures
consider anal advancement flap or repeat Botox.
Chapter 6 • Anal Fissure 73
It is used commonly and shows healing rates of between 49% and 68% at doses ranging
between 0.2% and 0.8%. GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.9% vs 35.5%, P <.0009), but late recurrence of fissure was
common, in the range of 50% of those initially cured. Based on pooled analysis of studies
this represents a 13.5% improvement in the absolute rate of healing compared to placebo
or lidocaine.
17
The failure of GTN is due to is short duration of effect, requiring frequent
dosages of up to six times a day, with increasing side effects, including headaches and dizziness, which limit its use.
Isosorbide dinitrate (ISDN) is a similar agent and, commonly, a dosage of 1%–2%
is used.
6.5.1.3 Calcium Channel Blockers
Topical calcium channel blockers (CCB) (diltiazem, nifedipine) also cause smooth-muscle
relaxation by means of calcium channel blockage. They have also shown positive results in
open studies but seemed less effective in RCT.
17
Topical application (2%, four times daily)
has a higher healing rate than oral dosage (60 mg, twice daily) (65% vs 38%). Comparative
studies of GTN and CCB have shown equivalent healing but fewer side effects with CCB,
and 50% of patients failing treatment on GTN may heal with CCB.
28
A systematic metaa-
nalysis suggested a higher cure rate for CCB compared to NGC.
19
Therefore CCB seems
preferable as a first choice due to fewer associated side effects.
17
6.5.1.4 Botulinum Toxin
BT is an exotoxin produced by bacterium Clostridium botulinum. After local inject ion
the toxin binds to presynaptic nerve terminals at the neuromuscular junction, thereby
preventing release of acetylcholine and resulting in temporary muscle paralysis. It was
known as a treatment for muscle spasm in striated muscles like strabismus. It was first
introduced in 1993 as a new treatment for anal fissure.
29
The majority of studies involve
comparisons with topical agents and it is associate d with a modest healing rate varying
from 37% to 43%. A systemati c review showed comparable results of topical agents.
19
A study in 99 patients with chronic anal fissures compared treatment using a combination of BT and CCB with that of LIS and showed healing rates of 65% and 94%,
respectively.
Generally, a dose 30–50 IU BT is injected into the IAS in the posterior commissure on
both sides of the fissure. This can be done in the outpatient clinic or as a surgical procedure under (local) anesthesia, the latter offers the possibility of adding debridement of the
fissure, which is thought to improve healing.
17
A metaana lysis of 1577 patients from 34 prospective studies, with doses varying from
5IU to 150 IU per session showed an efficiency ranging from 33% to 96%. No dose dependency was found either for efficacy or for side effects.
30
A systematic review of six RCTs
describing 393 patients comparing BT with GTN showed equal rates of healing of the fissures and of recurrence. BT was associated with a higher rate of transient anal incontinence, but significantly fewer total side effects and headache compared with GTN.
31
74 ANORECTAL DISORDERS
Side effects from BT treatment are increased urinary residual volume, heart block, skin
and allergic reaction, muscle weakness (fecal incontinence), postural hypotension, and
changes in heart rate and blood pressure; fortunately, serious side effects are very rare.
32
The most common effects are incontinence for flatus in 18% and stool in 5%.
3
A combination of topical agents in conjunction with BT has been suggested to improve
healing and symptoms. After failed topical treatment, BT treatment may improve symptom relief and avoid the need for sphincterotomy. The effect of BTwears off after 3 months
and recurrences of up to 50% have been reported.
17–21
It might be worthwhile continuing
pelvic-floor physiotherapy with biofeedback to optimize the effect. If there is continuous
severe dyssynergia, injection in the external sphincter or puborectal muscle may also be
an option. A drawback in BT treatment is the costs involved.
6.5.2 Surgical Management
Surgical treatment of chronic anal fissure should only be considered after failed conservative therapy. To date, LIS is the treatment of choice and is recommended by the various
colon and rectal societies.
17,21
6.5.2.1 Lateral Internal Sphincterotomy
Originally sphincterotomy was performed posteriorly, but due to key-hole deformity and
fecal incontinence the LIS was developed.
13
The technique has evolved over time especially concerning the length of the incision. It is performed with a radial incision in the
anoderm, laterally exposing the IAS muscle fibers. Then under direct vision, the distal
third is dived with scalpel or scissors. The wound can be left open or closed primarily.
A closed variant approaches the internal sphincter via the perianal skin at the lateral
side. The major concern with LIS is the risk of fecal incontinence, which is what has
led to the more conservative approaches and the development of better conservative therapies like local ointments (GNT, CCB) and BT. A review using 3D ultrasound to determine
the proportion of IAS that may be divided during LIS in women suggests that less than
25%, thus less than 1 cm, is save; no incontinence was observed.
33
Multiple studies have
evaluated the difference between open and closed sphincterotomy and no significant
difference was found. The healing rates are similar for open (93%–95%) and closed
techniques (90%–97%) and the incontinence rate varies between 2% and 5%.
3,17,19
Other complications of LIS are ecchymosis, which is frequently seen around the edge
of the wound. Hematoma, hemorrhage, and perianal abscess are fortunately rare
complications (1%).
3
LIS is the surgical treatment of choice for refractory anal fissures.
6.5.2.2 Anal Advancement Flap
Anal advancement flap (AAF) has also been used as a treatment for chronic anal fissure. It
involves the use of a subcutaneous flap, with the incision being made from the anal verge,
extended caudally, advanced into the anal canal to cover the fissure, and sutured. Few
Chapter 6 • Anal Fissure 75
studies have bee n performed and show healing rates of up to 80%–100% with less fecal
incontinence.
17,19
A systematic review of four studies found that AAF was associated with
less fecal incontinence, but similar wound complications, as well as a similar rate of
unhealed figures after LIS. Further multicenter RCTs are required to provide stronge r evidence.
34
Adding AAF to Botox treatment or LIS could decrease postoperative pain and
allows for primary wound healing.
17
6.5.2.3 Other Older Therapies
Anal (manual) dilatation has mostly been abandoned due to the risk of fecal incontinence
and inferiority to LIS, which has replaced the practice. Fissurectomy entails excision of the
granulation tissue, hypertrophied papilla, and scar, with or without primary closure. Some
effect has been reported, but it is inferior to LIS. Generally, fissure excision does not
improve healing rates when combined with sphincterotomy and may lead to unnecessary
risk of fecal incontinence.
3,19
6.5.2.4 Novel Therapies
Two pilot studies of autologous adipose tissue transplant in six and eight patients, respectively, following failed conservative therapy, have shown promising results. Healing
occurred after an average of 5 weeks and persisted in 75%–100% for up to 1 year.
35,36
No
incontinence occurred.
One study treated five patients with sacral nerve stimulation after failed conservative
therapy and all were cured after 3 weeks with no recurrence after 1year.
37
6.6 Practical Therapeutical Guideline and Work-Up
Overall, LIS is superior to nonsurgical therapies in achieving a sustained cure for an anal
fissure. CCB are more effective than GTN and with less risk of headache. Fecal incontinence risk following LIS is currently 3.4%–4.4% and there is no difference between open
and closed LIS.
19
A network metaanalysis of RCTs showed healing rates for LIS of 93.1%, manual dilatation of 84.4%, fissurectomy or anoplasty of 79.8%, BT of 62.6%, and nitroglycerine (NTG)/
CCB of 58.6%. Incontinence rates were 9.4%, 18.2%, 4.9%, 4.1%, and 3%, respectively.
20
With these extensive reviews and recommendations from the m edical societies
17–21
the
general idea is a step-up policy with lifestyle, conservative treatment, ointments, and, subsequently, BT. If all this fails, a LIS seems indicated after fully informing the patients of the
risk of fecal incontinence. Cleaning the edges of the fissure can be added to the treatment.
Occasionally, a fissurectomy or a flap can also offer an alternative to LIS. In view of continuing new data, pelvic-floor physiotherapy with biofeedback should be added to this
schedule (
Fig. 6.5). A prospective trial is on its way.
76 ANORECTAL DISORDERS
6.7 Special Conditions
6.7.1 Inflammatory Bowel Disease
Perianal symptoms are frequently seen in patients with Crohn’s disease and have a prevalence of up to 39% depending upon the population examined, with a great impact on
their quality of life.
38
A large survey of more than 60,000 patients with inflammatory bowel
disease (41% Crohn’s disease) in the United States revealed a prevalence of 4% chronic
anal fissure overall. Crohn’s disease patients were affected twice as often as patients with
ulcerative colitis. Men and women were equally affected. Younger patients (20–50years)
were more commonly affected (7%) than elderly patients (60–90 yea rs) (1.5%).
39
One study showed that the location of the fissures was posterior in only 56% of cases,
22% were anterior, 15% lateral, and 7% both anterior and posterior.
40
Historically, conservative treatment is advocated due to the surgical complications.
Regulation of the diarrhea by antidiarrheal medication or bulking the stool is advocated.
Next, as in classical anal fissures, topical CCB or nitroglycerin 0.4% is prescribed two to
three times a day for 8weeks; effects of up to 66% have been described.
40
LIS has been
performed in patients with Crohn’s disease; 48 patients in six retrospective studies have
been described. Of these patients, 40% suffered from postoperative complications and
40% of these (16% of the whole group) underwent a proctectomy.
41
Botox in combination
with an LIS did not improve results and had the same complication rate.
40
This underlines
the advisability of a conservative approach. Biological therapies have not improved
healing.
42
The current ECCO-ESCP (European Crohn´s and Colitis Organisation) ESCP and European Society of Colo-Proctology) Consensus on Surgery for Crohn’s disease does not
address surgery for anal fissures.
43
6.7.2 Human Immunodeficiency Virus
HIV-associated ulcers are usually broad-based deep cavitating ulcers. Often there is a
concomitant proctitis or other infections like herpes simplex, lues or
lymfogranuloma.
44
Highly active antiretroviral therapy has no impact on the prevalence of HIV-associated
anorectal patho logy. The initial treatment is the same as for classical anal fissures. Surgery,
like debridement and LIS can be helpful in some cases
45
; however, caution in surgical
therapy seems warranted. Anal carcinoma should be excluded.
6.7.3 Lues
Anal fissures can be found in patients with lues, often in combination with HIV. The
diagnosis can be obtained by a biopsy or swab from the ulcer.
46
Treatment is with
antibiotics.
Chapter 6 • Anal Fissure 77
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