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11 Therapy for Chronic Anal Fissure
167
© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5_12
12
Medical Position Statement
on the Diagnosis and Therapy for
Anal Fissure
On the basis of our experience, we favor the following algorithm for diagnosis and
therapy for an anal fissure disorder.
Due to the deficiencies in most clinical trials at hand, it is impossible to deduce
evidence-based recommendations for therapy.
We miss a widely recognized definition of chronic anal fissure.
We have found that many authors do not take full account of all of the results of
pharmacodynamics with regard to dosage, penetration kinetics, galenic formula-
tion, site of application, and bioavailability of topically applied drugs.
We believe the hypothesis to be questionable at least that hypertonic anal sphinc-
ter is responsible for the formation and development of chronic anal fissures.
We therefore have serious doubts about the reasonability to reduce anal sphincter
hypertonia either by medication or surgery to heal chronic anal fissures (Table 12.1).
Table 12.1 Algorithm for anal fissure diagnosis and treatment
Etiopathogenesis Infection, trauma, reduced perfusion
Symptoms Pain with defecation, blood on stool and/or toilet paper
Diagnosis Inspection, palpation,
speculum,
proctoscopy, probe if
necessary
DD: secondary fissures, erosions,
rhagades,
anal cancer, anal pain syndromes
Findings Acute anal fissure (superficial) Chronic anal fissure without or with
secondary
changes (skin tag, anal papilla, cryptitis,
fistula)
Basic therapy Dietary fiber, no laxatives,
sufficient liquid intake,
warm sitz baths
Dietary fiber, no laxatives,
sufficient liquid intake,
warm sitz baths
Therapy Self-bougienage and/or
diltiazem cream
Self-bougienage and/or diltiazem cream
Development Healing Persistence Healing Persistence
Further therapy in
case of persistence
Fissurectomy Fissurectomy + excision of
secondary changes
Recurrence Conservative or fissurectomy Conservative or fissurectomy
169
© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5
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