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Gabriel WB (1939) Anal fissure. Br Med J 11:519–521
Hahn O (1928) Zur Therapie der Hämorrhoiden und Analfissuren. Dtsch Med Wochenschr 52:10
Heidenhain (1910) Aus der Praxis. Münch Med Wochenschr 57:139
Hill T Ch (1912) Besprechung zur Therapie der Analfissuren. Med Klinik 29
Hiller RJ (1931) The anal sphincter and the pathogenesis of anal fissure and fistula. Surg Gynecol
Obstet 52:921–940
Hirschmann LJ (1914) Handbook of diseases of the rectum. St. Louis, CB Mosby
Jost WH, Schimrigk K (1993) Use of botulinum toxin in anal fissure (letter). Dis Colon Rectum
36:974
Katzenstein M (1903) Die Behandlung der Fissura ani. Therapie Gegenwarrt 43:544–547
Leusden FP (1925) Die Afterschrunde (Fissura ani) und ihre Behandlung. Med Klin 43:14–16
Loder PB, Kamm MA, Nicholls RJ et al (1994) “Reversible chemical sphincteromy” by local
application of glyceryl trinitrate. Br J Surg 81:1386–1389
Meissl (1926) Über das Wesen und die Behandlung der Fissura ani. Wien Med Wochenschr. 21.
Cited in Zentralbl Chir 1927;2:104–105
Melchior E (1910) Ueber die Gefahren der forcierten Dehnung des Sphincter ani. Münch Med
Wschr 38:1989–1991
Morgagni GB (1921) Ragadi anali. Morgagni 34, Dez. 5, 1920. Cited in Herold. Zentralbl Chir
39:1449
Notaras MJ (1971) The treatment of anal fissure by lateral subcutaneous internal sphincterotomy.
A technique and results. Br J Surg 58:96–100
Orbach E (1928) Eine einfache Behandlungsmethode der Fissura ani mit Jodalcet. Dtsch Med
Wochenschr 49:2063–2064
Parks AG (1967) The management of fissure-in-ano. Hosp Med 1:737–738
Passavant. Cited in Delley LA (1855)
Peters W (1920) Die Analfissuren. Z ärztl Fortbildung 17:371–373
Philipowicz J (1927) Zur Therapie der Analfissur Zentralbl Chir 13:788–790
Quenu E, Hartmann H (1922/1923) Chirurgie du rectum. Cited in: Rick J. Fissura ani [disserta-
tion]. Universität Bonn
Rappert E (1938) Zur Behandlung der Fissura ani. Zentralbl Chir 50:2768–2770
Récamier JCA (1838) Extension, massage et percussion cadencée dans le traitement des contrac-
tures musculaires. Rev Med Fr Etranger 1:74–89
Reichle R (1940) Fissura ani. Mastdarmfisteln Med Klinik 19:516–518
Rick J (1922) Fissura ani [dissertation]. Universität Bonn
Rosenbach O (1900) Zur Pathogenese und Therapie der sogenannten Fissura ani. Berlin Klin
Wochenschr 10:204–207
Samson RB, Stewart WRC (1970) Sliding skin grafts in the treatment of anal fissures. Dis Colon
Rectum 13:372–375
Svehla K (1902) Neue Symptome der Fissura ani bei Kindern. Centralbl Chir 11:309
Terrel (1913) Cited in Rappert E (1938)
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9 Historical Aspects of Anal Fissure Pathology
99
© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5_10
10
Therapy for Acute Anal Fissure
The therapy for acute anal fissure comprises the following methods: (1) basic ther-
apy, (2) self-bougienage, (3) local therapy, (4) manual anal dilatation, and (5) lateral
internal sphincterotomy.
10.1 Basic Therapy
The basis of each treatment is stool regulation with the help of dietary fibers (among
others, bran, linseed, psyllium seed husks, Mucofalk
®
) and sufficient intake of liq-
uids to reach a formed stool and thus a physiological dilatation of the anal canal.
Jensen (1986) achieved very fast healing in 87% of his cases with sitz baths and the
administration of dietary fibers, and was able to prove a significant reduction of the
relapse rate.
10.2 Self-Bougienage
The patient himself carries out protracted sphincter dilatation by means of a coni-
cally tapering anal dilator, made of plastic or glass (Fig. 10.1). The length of the
dilator is designed in such a way that the surgical anal canal in its entire length can
be dilated. The tip of the anal dilator is covered with lubricants and is introduced as
far as possible with cautious pressure and then left there for a few minutes. In the
case of a very narrow anus or strong pain, the dilator is inserted only a little in the
beginning. Bougienage should be repeated several times a day for a few minutes in
a relaxed posture, for example, while lying down or squatting. In a survey among
coloproctologists, 82% of the participants considered the use of anal dilators to be
an important element in the treatment for anal fissure (Kraemer et al. 1998).
Klug and Knoch (1993) prescribed self-bougienage for 20 anal fissure patients
and recorded a healing rate of 90% within 21 days. After 4 weeks of dilatation
treatment, Gaj et al. (2006) observed a healing rate of 90% (20 patients),
100
McDonald et al. (1983) of 68.6% (35 patients) within 6 weeks, and Lock and
Thompson (1977) recorded a healing rate of only 55% (137 patients) after 9
weeks. Gough and Lewis (1983) reported a healing rate of 41.9% (43 patients)
within 8 weeks.
10.3 Local Therapy
10.3.1 Sitz Baths
Trials with healthy and proctological patients describe the positive effect of a warm
sitz bath of 40, 45 and 50°C (sic!) for a duration of 10 min each (Shafik 1993). It is
believed to reduce rectal neck pressure and, as a consequence, lead to a reduced
sphincter tone of the internal anal sphincter muscle. Jensen (1986) treated 32
patients for acute anal fissure with a warm sitz bath of 40 °C for 15 min twice daily
and additional 2x10 g of dietary fibers per day. After 3 weeks, a healing rate of 87%
was recorded. Gupta (2006), however, saw in a randomized controlled trial of 52
anal fissure patients no advantage of such a treatment with regard to the healing rate.
A survey among coloproctologists revealed that the sitz bath treatment was sup-
ported by only 52% of the practitioners (Kraemer et al. 1998).
10.3.2 Local Anesthetics/Corticosteroids
After the application of 2% lidocaine gel three times a day over a period of 4 weeks,
Gough and Lewis (1983) saw healing in 43.6% of 39 anal fissure patients. Jensen
(1986) prescribed lidocaine gel for three times a day and found a healing rate of
60% during a 3-week therapy. The application of a 2% hydrocortisone ointment
Fig. 10.1 Anal dilator (Dr. KADE)
10 Therapy for Acute Anal Fissure
101
three times a day effected healing in 82.4% of the cases (Jensen 1986). When a
combination of 1% lidocaine and 1% hydrocortisone was used, the healing rate after
3 weeks was 50% (Antropoli et al. 1999).
10.3.3 Glyceryl Trinitrate
Healing rates between 56% and 100% were found in five clinical trials with 86
patients (Table 10.1).
10.3.4 Nifedipine
According to Antropoli et al. (1999), the topical application of 0.2% nifedipine gel
(n = 141) showed a healing rate of 95% within 3 weeks. According to Katsinelos
et al. (2006), the healing rate after the use of 0.5% nifedipine ointment (n = 31) was
85.2% within 8 weeks. The relapse rate was 16%, and that of complications like
vertigo or headache 7.4%.
10.4 Sclerotherapy
Vantrappen et al. (1967) described the subcutaneous injection of 2.5% quinine ure-
thane into the perifissural tissue. Healing occurred in 14 of the 25 patients. During
the 1930s, Blond had already treated acute anal fissures in a similar way (Blond and
Hoff 1936).
Antebi et al. (1985) injected Sotradecol (an agent for the sclerotherapy for vari-
cose veins) into 96 anal fissure patients and achieved a healing rate of 80.2%.
10.5 Manual Anal Dilatation (MAD)
Samsi et al. (1971) carried out MAD in patients with acute anal fissure (n = 204) and
recorded complete healing in 85% of patients.
Table 10.1 Healing rates after glyceryl trinitrate therapy for acute anal fissure in five trials with
86 patients (in %)
Author Anal fissure patients Healing rates after GTN therapy
n N Percent
Bacher et al. (1997) 8 7 92
Hasegawa et al. (2000) 16 13 81
Hyman and Cataldo (1999) 16 9 56
Manookian et al. (1998) 42 29 69
Ward et al. (2000) 4 4 100
Total 86 62
10.5 Manual Anal Dilatation (MAD)
102
10.6 Lateral Internal Sphincterotomy (LIS)
Marya et al. (1980) saw in patients with acute anal fissure (n = 100) the indication
for lateral internal sphincterotomy. Sohn and Weinstein (1997) also saw the indica-
tion, but describe their technique only.
Conclusion
The results of clinical trials show healing rates of 42–90% after self-bougienage,
after the application of local anesthetics and/or corticosteroids of 44–82%, and
after the topical administration of nifedipine of 85–95%. Warm sitz baths alleg-
edly lead to a reduction of the anal sphincter tone and thus to pain relief. MAD
and lateral internal sphincterotomy for acute anal fissure should not be applied
anymore because of the high incontinence rate and in view of the high healing
rates under conservative therapy.
The spontaneous healing rate is probably high, but scientifically unverified,
and therefore without proof.
The use of laxatives does not lead to the desired physiological dilatation of the
anal canal, and is therefore contraindicated.
Acute anal fissure should be treated conservatively, not surgically. Ideal is the
application of a locally anesthetizing ointment that also increases blood flow,
which again supports wound healing.
References
Antebi E, Schwartz P, Gilon E (1985) Sclerotherapy for the treatment of fissure in ano. Surg
Gynecol Obstet 160:204–206
Antropoli C, Perotti P, Rubino M et al (1999) Nifedipine for local use in conservative treatment of
anal fissures. Dis Colon Rectum 42:1011–1015
Bacher H, Mischinger HJ, Werkgartner G et al (1997) Local nitroglycerin for treatment of anal
fissures: an alternative to lateral sphincterotomy. Dis Colon Rectum 40:840–845
Blond K, Hoff H (1936) Das Hämorrhoidalleiden. Deuticke, Leipzig
Gaj F, Precca A, Crispino P (2006) Efficacy of anal dilators in the treatment of acute anal fissure.
A controlled clinical trial. Chir Ital 58:761–765
Gough MJ, Lewis A (1983) The conservative treatment of fissure in ano. Br J Surg 70:175–176
Gupta P (2006) Randomized, controlled study comparing sitz-bath and no-sitz-bath treatments in
patients with acute anal fissures. ANZ J Surg 76:718–721
Hasegawa H, Radley S, Morton DG et al (2000) Audit of topical glyceryl trinitrate for treatment of
fissure-in-ano. Ann R Coll Surg Engl 82:27–30
Hyman NH, Cataldo TA (1999) Nitroglycerin ointment for anal fissures: effective treatment or just
a headache? Dis Colon Rectum 42:383–385
Jensen SL (1986) Treatment of first episode of acute anal fissure: a prospective randomized study
of lignocaine ointment versus hydrocortisone ointment or warm sitz bath plus bran. Br Med
J 292:1167–1169
Katsinelos P, Kountouras J, Paroutoglou G et al (2006) Aggressive treatment of acute anal fissure
with 0.5% nifedipine ointment presents its evolution to chronicity. World J Gastroenterol
12:6203–6206
10 Therapy for Acute Anal Fissure
103
Klug W, Knoch HG (1993) Objektivierung der Wirksamkeit des therapeutischen Dilators bei der
Behandlung der akuten Analfissur. coloproctology 15:22–28
Kraemer M, Bussen D, Leppert R et al (1998) Bundesweite Umfrage zum therapeutischen
Vorgehen bei Hämorrhoidalleiden und Analfissur. Chirurg 69:215–218
Lock MR, Thompson JPS (1977) Fissure-in-ano: the initial management and prognosis. Br J Surg
64:355–358
Manookian CM, Fleshner P, Moore B et al (1998) Topical nitroglycerin in the management of anal
fissure: an explosive outcome! Am Surg 64:962–964
Marya SKS, Mittal SS, Singla S (1980) Lateral subcutaneous internal sphincterotomy for acute
fissure in ano. Br J Surg 67:299
McDonald P, Driscoll M, Nicholls RJ (1983) The anal dilator in the conservative management of
acute anal fissures. Br J Surg 70:25–26
Samsi AB, Kher R, Thomas KP et al (1971) Sphincter-stretching in the management of acute fis-
sure in ano. J Postgrad Med 18:86–89
Shafik A (1993) Role of warm-water bath in anorectal conditions. J Clin Gastroenterol
16:304–308
Sohn N, Weinstein MA (1997) Anal dilatation for anal fissures. Semin Colon Rectal Surg
8:17–23
Vantrappen G, Goethals C, Hendrickx H (1967) Treatment of complicated anal fissures by scleros-
ing injections and fissurectomy. Dis Colon Rectum 10:365–368
Ward DJ, Müller BJ, Schache DJ et al (2000) Cut or paste? The use of glyceryl trinitrate paste in
the treatment of acute and chronic anal fissure. Aust N Z J Surg 70:19–21
References
105
© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5_11
11
Therapy for Chronic Anal Fissure
11.1 Preliminary Note
Amazingly enough, the healing rates after treatment for chronic anal fissure stated in
randomized controlled trials are extremely divergent. There are many reasons for that.
In some trials, anal fissures are not exactly defined; others speak of acute and
chronic fissures. There are also trials which take only the duration of disease as the
basis. Other authors indeed treat the morphological findings differently, but apply
different criteria when they also describe the existence of a skin tag and/or hypertro-
phied anal papilla and/or anal cryptitis and/or fistula as a diagnostic criterion in
addition to the actual anal fissure. A look at the results of nifedipine trials in Table
11.1 illustrates that practice.
But how important the existence of secondary changes is with regard to the heal-
ing rate after conservative and surgical therapy, has been proved by Brühl and
Schmauz (1999) and also by Gupta and Kalasskar (2003). Brühl and Schmauz com-
pared healing rates in anal fissure patients with hypertrophied anal papilla and/or
skin tag with the healing rates of patients without these secondary changes. The first
group did not show a single case of healing under local glyceryl trinitrate therapy;
the second group, however, showed healing in 80% of the cases. Gupta was able to
prove that lateral sphincterotomy and simultaneous removal of the hypertrophied
anal papilla lead to better results, less pain, less secretion, less pruritus ani, and to
greater patient satisfaction (89%) than in those cases in which the anal papilla had
not been removed (64%).
Another reason for the varying healing rates lies in the differing application of
topical medication, namely, intra-anal, perianal, or a combination of both.
Galenics certainly play an important role, too. Glyceryl trinitrate, for example, is
incorporated in the following components: paraffin (yellow, white, liquid), Vaseline,
glycerine, or also in lanolin with Vaseline. Ointments, creams, and gels are used as
different topical medications. The local availability of the agent, and thus its effi-
ciency, is influenced by the various basic components of the topical medication, the
differing solubility, the velocity of the solution process, and the diffusibility.
106
Performing lateral sphincterotomy, most authors purely schematically transect
the internal anal sphincter muscle as far as the pectinate line or even higher without
having an exact idea of the actual size of the muscle. Depending on the author,
between 33% and 57% of the muscle width is dissected if the internal anal sphincter
muscle is transected as far as the pectinate line (see Chap. 11.3.1).
Also, the measurement methods to provide objective evidence of the therapeutic
effect have to be evaluated critically.
Various instruments and not approved techniques are used for pressure measure-
ment. Thus, some authors performed continuous-flow anorectal manometry, others
intermittent manometry. Water or air-filled balloons, open perfused catheters, or
electronic pressure sensors were used as measuring instruments. The diameters of
the differing balloon systems lay between 1 and 25 mm. In many cases, the collec-
tives of patients and control groups were too small to allow representative conclu-
sions. In addition, one has to consider that the measuring results are, for instance,
dependent on age, gender, and time of day as well as on the stage of the anal fissure
disorder (painfulness) and the diameter of the pressure probe. As a rule, an older
chronic anal fissure is accompanied by a lower resting pressure than a new one.
Also, the process of anorectal manometry as such can produce artifacts. The
insertion of the catheter intensifies the pain, a spasm occurs, that is, the involuntary
cramp of both the anal sphincter muscles. Jostarndt et al. (1986) found a significant
correlation between pain and resting pressure: the greater the pain, the higher the
resting pressure.
Laser Doppler flowmetry is employed for the identification of possible regional
underperfusion. For this purpose, a helium-neon laser is used, whose radiation is
coupled into the skin. Measurement by Laser Doppler flowmetry is considered as a
relative measure of the microvascular blood flow of the skin, and is mostly given in
arbitrary units. Absolute flowmetry measurements are not feasible because relevant
parameters are not known. They comprise the vascular architecture within the mea-
suring range, local hematocrit, the hemoglobin level, the thickness of the epidermis,
Table 11.1 Definitions of chronic anal fissure in eight clinical nifedipine trials
Author (year) Definition
Cook et al. (1999) Duration of continued presence more than 2 months
Perrotti et al. (2002) Duration of continued presence more than 2 months
Agaoglu et al. (2003) Duration of continued presence more than 2–3 months, fibers of
internal anal sphincter muscle visible
Ezri and Susmallian
(2003)
Duration of continued presence more than 2–3 months,fibers of
internal anal sphincter muscle visible or presence of anal skin tag
Ho and Ho (2005) Duration of continued presence more than 1.5 months
and/or fibers of internal anal sphincter muscle visible
and presence of anal skin tag and/or presence of anal papilla
Mustafa et al. (2005) Duration of continued presence more than 2–3 months
and fibers of internal anal sphincter muscle visible and/or presence
of anal papilla
Tranqui et al. (2006) Fibers of internal anal sphincter muscle visible
Katsinelos et al. (2006) Duration of continued presence more than 2 months, fibers of
internal anal sphincter muscle visible
11 Therapy for Chronic Anal Fissure
107
and subsequently the exact penetration depth (1–6 mm) of the laser beam. The sig-
nal reflected from an unmoving white surface corresponds to the flux number zero.
The test signal on the skin contains information received from capillaries, arterioles,
and venules.
The definition of the term “healing” presents a particular problem. According to
conservative therapy trials as well as after exclusive lateral sphincterotomy, so-
called secondary changes remain in situ because they are incapable of remission,
neither after these therapies nor spontaneously. How have these findings to be
assessed? Are they the cause of relapse? Were fistula formation avoidable, if “heal-
ing” had also led to the remission of these changes?
Lindsey et al. (2004) have presented the following four stages of “anal fissure
healing”:
Stage I: Fissure healed/symptoms resolved/no surgery required
Stage II: Fissure unhealed/symptoms resolved/no surgery required
Stage III: Fissure unhealed/symptoms satisfactorily improved/no surgery
required
Stage IV: Fissure unhealed/symptoms not satisfactorily improved/surgery
required
Obviously, the authors are satisfied with their findings concerning Stages I–III
and regard these results as “healing.” Scholz et al. (2007) have come to the same
assessment.
For reasons mentioned above, it does not make sense to summarize these ran-
domized controlled clinical trials to establish a meta-analysis or a systematic review
and to make a recommendation based on scientific evidence as practiced by Nelson
(2005, 2008), for instance.
11.2 Conservative Therapy
11.2.1 Glyceryl Trinitrate
Glyceryl trinitrate (GTN, glycerol trinitrate, glycerine trinitrate) is a rather unstable,
poorly water-soluble liquid. The intake of 0.01 g of the substance leads to headache.
GTN is especially used in the therapy of angina pectoris and cardiac insufficiency
because of its vasodilating effect induced by the release of nitrogen monoxide. It is
available in Germany as rectal ointment (0.4% Rectogesic
®
) for pain relief of
chronic anal fissure. A comparative cost accounting was done under the assumption
that Rectogesic
®
therapy achieves healing rates which are nearly as high as those
after sphincterotomy. The result was that Rectogesic
®
treatment will cost £ 616
compared to £ 840 for sphincterotomy treatment (Christie and Guest 2002).
After topical application of glyceryl trinitrate, a decrease in anal resting pressure
occurs, which provides therefore a better perfusion of the anoderm and pain relief.
Since the effect lasts only for a few hours (Ciccaglione et al. 2000; Jonas et al.
2002), a more frequent application over a period of some weeks becomes
necessary.
11.2 Conservative Therapy
108
The clinical trials reviewed by us rest upon differing durations of treatment. The
following authors applied GTN one to three times per day for 8 weeks: Bailey et al.
(2002); Bielecki and Kolodziejczak (2003); Brisinda et al. (2007); Carapeti et al.
(1999); De Nardi et al. (2006); Evans et al. (2001); Hashmat and Ishfaq (2007);
Jonas et al. (2002); Jones et al. (2006); Libertiny et al. (2002); Lund and Scholefield
(1997); Mustafa et al. (2005); Sileri et al. (2007); Zuberi et al. (2000). The following
authors applied GTN for six weeks: Brisinda et al. (1999); Chaudhuri et al. (2001);
Christie and Guest (2002); Colak et al. (2003); Hyman and Cataldo (1999); Jonas
et al. (1999); Lund and Scholefield (1997); Maan et al. (2004); Mishra et al. (2005);
Richard et al. (2000); Watson et al. (1996). But there are also reports of shorter or
significantly longer periods of therapy. The long-term therapy with nitrates can lead
to a weakening of the pharmacological effect (tachyphylaxis). The concentration of
GTN in topical medication varies between 0.1% and 0.8%. Despite differing con-
centrations (0.1–0.4%), the healing rate in 304 anal fissure patients was always 50%
after intra-anal application for a period of 8 weeks (Bailey et al. 2002). Carapeti
et al. (1999) treated patients with increasing doses of 0.1–0.6% GTN and described
similar effects. During a dose-finding study, Watson et al. (1996) treated 19 patients
with 0.2–0.8% GTN ointment. To achieve the desired 25% decrease in anal resting
pressure, 15 of the 19 patients required a concentration higher than 0.2%. After 6
weeks, nine patients were free of anal fissures. Scholefield et al. (2003) increased
systematically the GTN doses in a placebo- controlled RCT. After 2 months, 37.5%
of the patients in the placebo group were healed. The healing rate after the applica-
tion of 0.1% GTN was 46.9%, 40.4% when 0.2% GTN was applied, and 54.1%
after a dose of 0.4% GTN.
Differences arise also due to the variety of carriers used for the production of
drugs for topical application. Thus, GTN is embedded in paraffin, be it yellow,
white, or liquid (Altomare et al. 2000; Bassotti et al. 2000; Brisinda et al.; Carapeti
et al.; Dorfman et al. 1999; Hasegawa et al. 2000; Hashmat and Ishfaq; Kennedy
et al. 1999; Loder et al. 1994; Lund et al. 1996; Pitt et al. 2001; Watson et al.).
GTN embedded in Vaseline was applied by Bacher et al. 1997; Hyman and
Cataldo, in glycerin (Oettlé 1997); and in lanolin/Vaseline (Brown et al. 2007;
Colak et al.; Richard et al.). Obviously, the magistral preparation of a GTN topical
medication is difficult. Azarnoff et al. (2007) analyzed a 0.3% GTN ointment
which had been prepared by 24 American pharmacies, and noticed nonconformity
with US pharmacopeia in 46% of cases. The median concentration was only
0.2008%, for example.
Also, the sites of GTN application are not uniform. Some authors apply GTN
perianally, some intra-anally, and others both perianally and intra-anally.
Torrabadella and Salgado (2005) treated 11 patients intra-anally and 15 patients
perianally by applying GTN ointment of the same dose. They found a higher heal-
ing rate and a significantly better decrease in the anal resting pressure when GTN
was applied intra-anally.
Many questions remain unanswered on the basis of these findings. Which topical
medication carrier combined with which GTN concentration is the best choice?
How many times a day and for which period of time should therapy be carried out?
11 Therapy for Chronic Anal Fissure