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2.5 Duration of Anal Fissure Disease
Anal fissure patients seem to be very tolerant because they suffer from their pain for
an exceptionally long time before they seek treatment. There are several studies that
analyze the duration of suffering from the first symptoms until the start of therapy.
In eight trials involving 491 patients who had been treated with glyceryl trinitrate
(GTN), the period of suffering lasted between 2 and 240 months (Table 2.5). For
405 patients in seven botulinum toxin trials (BTX), the period of suffering lasted
between 3 and 94 months (Table 2.6). A total of 842 patients (in nine trials), who
Table 2.5 Duration of symptoms before GTN therapy for anal fissure in 16 trials with 491 patients
Author (year)
Anal fissure patients
Mean duration of symptoms before
therapy
(n) (months)
Bacher et al. (1997) 20 6
Bacher et al. (1997) 15 5.5
Lund and Scholefield (1997) 38 12 (2–240)
Richard et al. (2000) 38 1.9 ± 2.75
Richard et al. (2000) 44 2.3 ± 3.65
Altomare et al. (2000) 59 10.5 ± 9
Altomare et al. (2000) 60 15 ± 21
Evans et al. (2001) 27 6–8
Evans et al. (2001) 33 6–8
Colak et al. (2003) 52 18 (3–36)
Colak et al. (2003) 37 14 (6–24)
Mustafa et al. (2005) 10 8.95 (4–24)
Mustafa et al. (2005) 10 7.65 (4–22)
Schiano et al. (2006) 16 17.5 (6–31)
Schiano et al. (2006) 16 16.88 (8–34)
Schiano et al. (2006) 16 15.19 (7–31)
Total 491
Table 2.6 BTX therapy for anal fissure in 12 trials with 405 patients
Author (year)
Anal fissure patients
Mean duration of symptoms before
therapy
(n) (months)
Jost and Schimrigk (1995) 25 3–94
Maria et al. (1998) 15 17.5 ± 5
Brisinda et al. (1999) 25 9.5 ± 6.8
Brisinda et al. (1999) 25 14.7 ± 10.7
Brisinda et al. (2002) 75 12 ± 12
Brisinda et al. (2002) 75 13 ± 12
Brisinda et al. (2004) 50 13.4 ± 10.7
Brisinda et al. (2004) 50 13.1 ± 11.5
Giral et al. (2004) 10 10 ± 6
Giral et al. (2004) 10 11 ± 6
Massoud et al. (2005) 25 18.2 ± 24.7
Massoud et al. (2005) 20 10.1 ± 8.5
Total 405
2.5 Duration of Anal Fissure Disease
14
had undergone sphincterotomy, showed symptoms for a period of 1–96 months
(Table 2.7). On average, the duration of anamnesis lasted more than 10 months.
2.6 Secondary Changes
A chronic anal fissure can present morphological findings which are secondary
changes, such as hypertrophied anal papillae, sentinel tags, cryptitis, or anal
fistulae.
2.6.1 Hypertrophied Anal Papilla
A hypertrophied anal papilla often forms at the proximal edge of a chronic anal fis-
sure. Synonyms are anal fibroma, “anal polyp,” papillitis hypertrophicans, and
“cat’s tooth” (Wienert and Mlitz 1995).
Anal papillae are present by nature. Their enlargement is considered as a conse-
quence of chronic or chronically recurring inflammation processes, namely, in the
sense of a proliferative fibrotic progression in the region of the pectinate line
(Groisman and Polak-Charcon 1998; Marti and Givel 1992; Nicholls and Glass
1988; Schinella 1976; Schutte and Tolentino 1962, 1971; Wienert and Grußendorf
1975). As a rule, this fibrotic progression is the consequence of anitis, cryptitis or
papillitis. The hypertrophied anal papilla is sessile or pedunculated – polypoid,
rarely with more than one tip, varying in size from that of a millet seed to a cherry,
Table 2.7 Duration of symptoms before sphincterotomy in 17 trials with 842 patients
Author (year)
Anal fissure patients
Mean duration of symptoms
before sphincterotomy
(n) (months)
Jensen et al. (1984) 30 9 (6–30)
Jensen et al. (1984) 28 11 (5–26)
Hananel and Gordon (1997) 312 1–60
Evans et al. (2001) 27 6–8
Evans et al. (2001) 30 6–8
Richard et al. (2000) 38 22.8 ± 33
Richard et al. (2000) 44 27.6 ± 43.8
Libertiny et al. (2002) 35 5 (2–12)
Libertiny et al. (2002) 35 6 (2–18)
Mentes et al. (2003) 50 25 (2–72)
Mentes et al. (2003) 61 20 (2–96)
Giral et al. (2004) 11 11 ± 6
Giral et al. (2004) 10 10 ± 6
Arroyo et al. (2004) 40 20 ± 21
Arroyo et al. (2004) 40 22 ± 20
Brown et al. (2007) 24 13 (3–22)
Brown et al. (2007) 27 12 (5–50)
Total 842
2 Chronic Anal Fissure
15
with a slightly reddened base and a mostly whitish top which is occasionally eroded
by an inflammation. It has a firm consistency and a relatively small surface area.
The prevalence rate of hypertrophied anal papillae varies in the corresponding
medical literature between 5 and 45% (Table 2.8).
In case of bigger and then possibly prolapsing anal papillae, a foreign body sen-
sation and an urgent but futile need to defecate can occur besides the pain caused by
the anal fissure (Kusunoki et al. 1991; Wienert and Mlitz 1995).
Histologically, it is edematous, loose, partly fibrous connective tissue with an
increase of capillary vessels. Occasionally, an acanthotically broadened squamous
epithelium shows on the surface. As a result of mechanical irritation, deposits of
exudates can sometimes be seen in the upper layers of the epidermis and also in the
skin lamella (Wienert and Grußendorf 1975).
In terms of differential diagnosis, anal thromboses, condylomata, deep-reaching
rectum polyps, amelanotic melanoma, and also anal canal carcinoma must be excluded.
Performing fissurectomy, the excision is carried out as far as above the pectinate
line and includes the ablation of the hypertrophied anal papilla. The histological
examination of the surgical specimen is obligatory.
2.6.2 Anal Cryptitis
When probing the cranial area of an anal fissure, it is not unusual that besides a
hypertrophied anal papilla, a pathologically altered anal crypt can be found. Distinct
from the orthological crypt, the probe head cannot be recognized as shimmering
through, due to the inflammatory and edematous changes in the area of the crypt
roof (Dohrenbusch et al. 1986; Klosterhalfen et al. 1988). Occasionally, secretion or
pus is discharged from the crypt during probe examination.
In the course of fissurectomy, the pathologically altered crypt is ablated en bloc
jointly with the anal fissure.
The incidence of cryptitis is rated by Eißer (1990) at 61% (n = 131) and by
Schwaner (2002) at 83% (n = 60).
Table 2.8 Prevalence rates of hypertrophied anal papillae in 10 trials with 3721 patients (in %)
Author (year)
Patients Prevalence of hypertrophied anal papilla
(n) (%)
Soß (1973) 269 10
Abcarian (1975) 22 45
Böttcher (1977) 508 5
Boulos and Araujo (1984) 28 8
Stürmlinger (1986) 153 10
Khubchandani and Reed (1989) 1077 19
Eißer (1990) 131 27
Oh et al. (1995) 1391 8
Richard et al. (2000) 82 23
Schwaner (2002) 60 30
Total 3721
2.6 Secondary Changes
16
The predominant location of crypts in the dorsal and ventral sectors, as described
by Krakovic (1974), could explain the high incidence of anal fissures in these areas.
2.6.3 Sentinel Tags
Bulging skin is frequently found at the distal edge of the anal fissure, which is often
visible already to the naked eye (sentinel tag, anal skin tag). The sentinel tag is a
secondary skin tag which is probably the response to a local inflammation.
We analyzed 12 trials with a total of 3855 anal fissure patients (Table 2.9).
Depending on the author, sentinel tags were found in a range between 9 and 75% of
the cases.
The sentinel tag can indicate the existence of a chronic anal fissure. It has a firm
consistence and therefore causes problems for inexperienced examiners in differen-
tial diagnosis (e.g. anal verge carcinoma).
When excising the anal fissure, the sentinel tag, too, should always be ablated
(Brühl and Schmauz 1999; Gupta and Kalaskar 2003). Histologic examination dis-
closes the following findings (Wienert and Grußendorf-Conen 1975): the epidermis,
which is mostly orthokeratotic and calloused, often shows at the proximal end of the
excised material the transition into the nonkeratinized stratified squamous epithe-
lium of the anoderm. This is composed of several cell layers and exhibits in numer-
ous cases rete pegs which are acanthotically thickened or, in a sectional view, appear
as a dendritic network. Generally, the adjoining connective tissue does not differ
from the tissue that forms the dermal papillary layer in normal skin. It is multinucle-
ated and fibrillar; the thin bundles of connective tissue are only loosely interwoven.
Regularly, elastic fibers can be identified, which behave under histological staining
in the same way as in the normal cutis. Close observation of cells reveals particu-
larly in the vicinity of vessels, apart from fibroblasts, mastocytes and histiocytes in
Table 2.9 Prevalence of sentinel tag in 12 trials with 3855 patients (in %)
Author (year)
Patients Sentinel tag prevalence
(n) (%)
Soß (1973) 269 27
Abcarian (1975) 22 63
Böttcher (1977) 508 9
Boulos and Araujo (1984) 28 53
Stürmlinger (1986) 153 18
Khubchandani and Reed (1989) 1077 32
Eißer (1990) 131 38
Oh et al. (1995) 1391 47
Richard et al. (2000) 82 60
Schwaner (2002) 60 75
Arroyo et al. (2004) 80 74
Parellada (2004) 54 46
Total 3855
2 Chronic Anal Fissure
17
normal frequency. Besides a certain abundance of blood vessels, the regular pres-
ence of lymphangiectasia attracts attention. Sebaceous glands and hair follicles are
to be seen as often as smaller cutaneous nerves. Perivascular small-cell infiltrates
can be predominantly found in the area of subepidermal vessels. They have a round-
ish shape and are relatively far removed from each other.
2.6.4 Anal Fistula/Abscess
As chronification of the anal fissure proceeds, increased secretion can lead to an
undermining of the sentinel tag from cranial to caudal. At first, a sinus (an incom-
plete fistula) occurs, later a breakthrough into the perianal region. A short, superfi-
cial subcutaneous fistula develops which begins at the floor of the anal fissure
(Notaras 1988). Khubchandani and Reed (1989) found such fistulae in 10% of 1077
fissure patients. Gabriel (1963), too, describes anal fistula as a frequent event, yet
hardly mentioned in medical literature. For MacLeod (1979), this “marginal” fistula
is also associated with chronic anal fissure, but he calls it a “non-genuine anal fis-
tula” insofar as no musculature is concerned.
Moreover, anal fissure patients also exhibit true fistulae which begin in the crypt
and run into the intersphincteric area. Occasionally, an intersphincteric abscess may
develop. Thus, Oh et al. (1995) saw an abscess or intersphincteric fistula in 12.5%
of 1391 fissure patients.
Such an abscess may not be ignored during fissurectomy. For that reason, fistula
and abscess have to be adequately exposed.
Conclusion
Secondary changes – either solitary or in total – occur most likely in patients with
chronic anal fissures. However, they are not always given the necessary attention in
the course of therapy.
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2 Chronic Anal Fissure