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© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5_4
4
Problems of Defining Chronic Anal
Fissure
The definition of chronic anal fissure is inconsistent. Some authors define it on the
basis of its time of existence (longer than 6, 8, or 12 weeks), others on the basis of
morphological criteria like the depth of the defect, the condition of the edges of the
fissure, or the existence of secondary changes such as skin tag, hypertrophied anal
papilla, cryptitis, or fistula. All these clinical manifestations can be chronic anal fis-
sure components, separately or jointly.
Due to these varying definitions, it is not astonishing that therapy studies arrive
at different results. For example, studies examining the use of glyceryl trinitrate
yield healing rates between 41 and 85% (n = 12), diltiazem studies (n = 11) state
rates between 41 and 94%, and botulinum toxin therapy studies (n = 22) show
rates between 43 and 92% of the cases. These highly divergent results are particu-
larly attributed to the fact that secondary changes in their different manifestations
have not been taken into account sufficiently enough. Nevertheless, their rele-
vance to the healing process was established in several studies.
Brühl et al. (2011) distinguished anal fissures associated with hypertrophied anal
papilla and/or skin tags from those without such changes. They treated their patients
with 0.3% glyceryl trinitrate ointment. There was not a single case of healing in the
first collective, but 80% of the anal fissures treated in the second collective healed
completely.
When sphincterotomy is performed as therapy for anal fissure, the concurrent
ablation of secondary changes seems to be important in terms of healing, relapse,
and patient satisfaction. Therefore, Gupta (2004) insists on the removal of hypertro-
phied anal papillae as an essential element in the therapy for anal fissure.
Nifedipine trials also demonstrate the inconsistency in the definitions of chronic
anal fissure (Table 4.1).
The ICD-10 code differentiates only between acute anal fissure (K60.0) and
chronic anal fissure (K60.1). Considering the reasons mentioned before, this clas-
sification is insufficient.
To our knowledge, a classification of chronic anal fissures was published for the
first time ever by Thornton et al. (2005):
52
Grade 1: fibers of the internal anal sphincter muscle not visible
Grade 2: deep fissure, fibers of the internal anal sphincter muscle visible
Grade 3: deep, undermined fissure edges
Grade 4: fissure with marginal fistula
We believe this classification to be insufficient and suggest a differentiation of
anal fissures which includes the acute clinical syndrome as well as depth and also
the existence of secondary changes. A stringent classification of anal fissure is
desirable with regard to the choice of therapy. We recommend therefore our novel
classification published in 2010 (Table 4.2).
Table 4.1 Definitions of chronic anal fissure in nine nifedipine trials
Author (year) Definition
Cook et al. (1999) Duration of >2 months
Perrotti et al. (2002) Duration of >2 months
Agaoglu et al. (2003) Duration of >2–3 months, transverse fibers of internal anal sphincter
muscle visible
Ezri and Susmallian
(2003)
Duration of >2–3 months, transverse fibers of internal anal sphincter
muscle visible or existence of anal skin tag
Ho and Ho (2005)
Duration of >1.5 months and/or transverse fibers of internal anal
sphincter muscle visible and presence of anal skin tag and/or
existence of anal papilla
Mustafa et al. (2005) Duration of >2–3 months and transverse fibers of internal anal
sphincter muscle visible and/or existence of anal skin tag
Lysy et al. (2006) Transverse fibers of internal anal sphincter muscle visible, existence
of anal skin tag
Tranqui et al. (2006) Transverse fibers of internal anal sphincter muscle visible
Katsinelos et al. (2006) Duration of >2 months, transverse fibers of internal anal sphincter
muscle visible
Table 4.2 A novel classification of anal fissure by Wienert et al. (2010)
Stage
Anal fissure
Secondary changes
I Acute None
II Chronic, shallow None
II A Chronic, shallow + hypertrophied anal papilla
II B Chronic, shallow + anal skin tag
II C Chronic, shallow + cryptitis
II D Chronic, shallow + fistula
III Chronic, deep
fibers of internal anal sphincter muscle visible
None
III A Chronic, deep
fibers of internal anal sphincter muscle visible
+ hypertrophied anal papilla
III B Chronic, deep
fibers of internal anal sphincter muscle visible
+ anal skin tag
III C Chronic, deep
fibers of internal anal sphincter muscle visible
+ cryptitis
III D Chronic, deep
fibers of internal anal sphincter muscle visible
+ fistula
4 Problems of Defining Chronic Anal Fissure
53
The stages II and III differ only in the depth of the anal fissure.
Example: A deep anal fissure with hypertrophied anal papilla and fistula corre-
sponds to stage III A, D.
If our new classification of the chronic anal fissure were transferred to the defini-
tions in the 18 proctology textbooks published so far (Table 4.3), the problems
would be recognized and the call for a consistent classification would become
imperative.
Conclusion
The application of our novel classification of chronic anal fissure would allow a
meaningful comparison of the therapeutic success gained in the various randomized
controlled trials.
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Table 4.3 Wienert’s classification applied to 18 textbook definitions
Author (year)
Stages of anal fissure
II A II B II C II D III A III B III C III D
Gabriel (1939) + +
Stirnemann and Halter (1970) + + +
Hughes and Cuthbertson (1972) + +
Thomas and Körner (1980) + +
Hansen and Stelzner (1981) + + +
Neiger (1987) + +
Marti and Givel (1992) + + +
Wienert and Mlitz (1995) + + +
Winkler and Otto (1997) + + +
Jensen and Nielsen (1998) + + +
Bailey and Snyder (2000) + +
Lingemann (2001) + +
Buchmann (2002) + +
Stein (2002) + +
Brühl et al. (2011) + + +
Raulf and Kolbert (2006) + + +
Lange et al. (2012) + +
Rohde (2007) + +
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4 Problems of Defining Chronic Anal Fissure