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der Entstehung der Analdrüsen sowie deren Bedeutung in der Pathogenese der chronischen
Analfissur [dissertation]. RWTH Aachen University
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5 Epidemiology and Etiopathogenesis
67
© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5_6
6
Signs and Symptoms
6.1 Anorectal Pain
The main symptom of anal fissure is persisting pain caused by defecation. It can last for
several hours and abates very slowly. It can be burning, stabbing, piercing, dull, or even
exert pressure. It can radiate into neighboring areas and become manifest or even increase
while sitting, walking, or coughing. Passing of gas, too, can trigger pain symptoms.
The intensity of pain does not correlate with the extent of the anodermal defect,
but decreases with chronicity. Many patients use laxatives to keep the stool as soft
as possible and thereby reduce pain during defecation.
Quite often, defecation is even suppressed to avoid a new pain attack. But this
can lead to the impaction of stool.
As already mentioned, the intensity of pain decreases with time. This
explains the wide range of pain complaints during anamnesis (46–100%), as is
shown by the analysis of 14 publications which comprise 4047 anal fissure
patients (Table 6.1).
Conclusion
The main symptom of anal fissure disease is intense anorectal pain provoked by on
defecation.
6.2 Anal Bleeding
After defecation, a strip of bright red blood is often found on the column of stool
and/or on the toilet paper.
The analysis of 13 studies concerning 4019 patients (Table 6.2) shows that the
symptom “rectal bleeding” is found within a range from 33 to 88% of the cases, that
is, 72.6% on average.
Anal bleeding is not exclusively caused by anal fissures. Other proctological
diseases, like hemorrhoidal disease, colorectal carcinomas, polyps, chronic
68
inflammatory colon diseases, and diverticulitis, which generally do not go along
with pain induced by defecation, must be ruled out.
Among 102 patients under 50 years of age suffering from rectal bleeding, Korkis
and McDougall (1995) found four patients with anal fissure, eleven patients with
polyps, five with diverticulosis, and six patients with colitis.
Conclusion
The second most common symptom of anal fissure disease is rectal bleeding caused
by defecation.
Table 6.1 Anal pain symptoms in 4047 anal fissure patients (in %)
Author (year)
Anal fissure patients Anal pain
(n) (%)
Willemsen (1963) 144 88.0
Mazier (1972) 1000 71.0
Böttcher (1977) 508 94.0
Gordon and Vasilevsky (1985) 133 100.0
Stürmlinger (1986) 153 90.0
Vafai and Mann (1987) 702 97.6
Jost (1989) 130 77.5
Eißer (1990) 131 46.0
Ali (1992) 82 90.0
Selvaggi et al. (1992) 28 83.5
Romano et al. (1994) 44 100.0
Hananel and Gordon (1997) 876 90.0
Schanne (1998) 56 87.5
Schwaner (2002) 60 98.0
Total 4047
Table 6.2 Anal bleeding in 4019 anal fissure patients (in %)
Author (year)
Anal fissure patients Rectal bleeding
(n) (n) %
Willemsen (1963) 144 86 59.7
Mazier (1972) 1000 770 77.0
Böttcher (1992) 508 320 63.0
Gordon and Vasilevsky (1985) 133 74 55.6
Stürmlinger (1986) 153 81 52.9
Vafai and Mann (1987) 702 579 82.5
Jost (1989) 130 84 64.6
Eißer (1990) 131 43 32.8
Ali (1992) 82 70 85.4
Romano et al. (1994) 44 32 72.7
Hananel and Gordon (1997) 876 622 71.0
Schanne (1998) 56 47 83.9
Schwaner (2002) 60 53 88.3
Total 4019 2861 71.2
6 Signs and Symptoms
69
6.3 Anal Pruritus
Occasionally, patients complain of secretion from exuding wounds, which leads to
anal pruritus without or with formation of an irritant toxic eczema in the perianal
region. Moreover, hypertrophied anal papillae and fistulae can develop, which cause
stool soiling. Sentinel tags complicate anal hygiene, and thus favor an anal eczema.
The analysis of 13 publications involving 3539 patients (Table 6.3) found pruri-
tus ani in 25.4% on average (6–75%) and secretion in 1–26% of patients.
Anal pruritus, however, is not alone induced by anal fissures. Next to rectal
bleeding, it is the most common symptom in proctology. Brühl and Schmauz
(1997/98) diagnosed pruritus in 42%, and Wienert (1973) in 62% of patients.
According to our experiences, pruritus ani has, with decreasing frequency, the fol-
lowing causes: hemorrhoidal disease with or without anal eczema (irritant-toxic),
anorectal prolapse, contact allergic anal eczema, a topic dermatitis (neurodermitis),
xerosis (dry skin due to excessive anal hygiene), incontinence (stool, urine), and
chronic diarrhea. These disorders must be excluded in differential diagnosis.
6.4 Constipation
An excessive stretching of the anal canal during the passage of stool either too hard
or too voluminous in case of constipation, for example, is supposed to lead to a fis-
sural lesion of the anoderm.
Upon review of the relevant medical literature, we found five publications deal-
ing with the role of constipation in connection with anal fissure.
Ali (1992) found constipation in 25% of 82 anal fissure patients, Selvaggi et al.
(1992) in 26.5% of 28 patients, Mazier (1972) in 26% of 1000 patients, Stürmlinger
Table 6.3 Anal pruritus and secretion in 3539 anal fissure patients (in %)
Author (year)
Anal fissure patients Anal pruritus Secretion
(n) (n) % (%)
Willemsen (1963) 144 0 11.0
Mazier (1972) 1000 340 34.0 3.0
Gordon and Vasilevsky (1985) 133 11 8.3 3.0
Stürmlinger (1986) 153 12 8.0 16.0
Vafai and Mann (1987) 702 279 39.7 n/a
Jost (1989) 130 51 39.2 26.5
Eißer (1990) 131 11 8.0 4.0
Ali (1992) 82 41 50.0 20.0
Selvaggi et al. (1992) 28 15 53.5 16.5
Romano et al. (1994) 44 15 34.0 9.0
Hananel and Gordon (1997) 876 53 6.0 1.0
Schanne (1998) 56 27 48.2 17.9
Schwaner (2002) 60 45 75.0 n/a
Total 3539 900 25.4
6.4 Constipation
70
(1986) in 30% of 153 patients, Schwaner (2002) in 60% of 60 patients, Prohm
(1993) found constipation in 20.7%, and Rosa et al. (2005) in 75% of patients.
However, all these studies do not refer to a uniform definition of constipation.
On average, constipation in these five studies with 1323 patients was found in
only 27.9% of the cases, with a range between 25 and 60% (Table 6.4). The esti-
mated prevalence of constipation in the general population of the United States is
given within a range between 1.9 and 27.2% (Higgins and Johanson, 2004).
Therefore, constipation is apparently not the trigger but rather the result of anal
fissure.
Conclusion
It is unlikely that chronic constipation is the cause of anal fissure disease.
References
Anorectal Pain
Ali J (1992) Die chirurgische Behandlung der akuten und chronischen Analfissur [dissertation].
Universität Münster
Böttcher KJ (1977) Die operative Behandlung der Analfissur [dissertation]. Universität
Erlangen-Nürnberg
Eißer H (1990) Die chirurgische Behandlung der chronischen und akuten Analfissur [dissertation].
Universität Münster
Table 6.4 Synopsis of symptoms in 4047 anal fissure patients (in %)
Author (year)
Anal fissure
patients
Anal
pain
Rectal
bleeding
Anal
pruritus Secretion Constipation
(n) (%) (%) (%) (%) (%)
Willemsen (1963) 144 88.0 60.0 11.0
Mazier (1972) 1000 71.0 77.0 34.0 3.0 26.0
Böttcher (1977) 508 94.0 63.0
Gordon and
Vasilevsky (1985)
133 100.0 55.6 8.3 3.0
Stürmlinger (1986) 153 90.0 53.0 8.0 16.0 30.0
Vafai and Mann
(1987)
702 97.6 82.5 39.7
Jost (1989) 130 77.5 64.7 39.2 26.5
Eißer (1990) 131 46.0 33.0 8.0 4.0
Ali (1992) 82 90.0 85.0 50.0 20.0 25.0
Selvaggi et al.
(1992)
28 83.5 83.5 53.5 16.5 26.5
Romano et al.
(1994)
44 100.0 72.7 34.0 9.0
Hananel and Gordon
(1997)
876 90.0 71.0 6.0 1.0
Schanne (1998) 56 87.5 83.9 48.2 17.9
Schwaner (2002) 60 98.0 88.0 75.0 60.0
Total 4047
6 Signs and Symptoms
71
Gordon PH, Vasilevsky CA (1985) Lateral internal sphincterotomy: rationale, technique and anes-
thesia. Can J Surg 28:228–230
Hananel N, Gordon PH (1997) Re-examination of clinical manifestation and response to therapy
of fissure in ano. Dis Colon Rectum 40:229–233
Jost WH (1989) Langzeitergebnisse nach operativer Behandlung der Analfissur [dissertation].
Universität Mainz
Mazier WP (1972) An evaluation of the surgical treatment of anal fissure. Dis Colon Rectum
15:222–227
Romano G, Rotondano G, Santangelo M et al (1994) A critical appraisal of pathogenesis and mor-
bidity of surgical treatment of chronic anal fissure. J Am Coll Surg 178:600–604
Schanne S (1998) Therapeutischer Einsatz von Botulinumtoxin bei der unkomplizierten chro-
nischen Analfissur [dissertation]. Universität Saarbrücken
Schwaner S (2002) Operative Behandlung der Analfissur: Ergebnisse, Rezidive, Kontinenzleistung
nach Fissurektomie bzw. Fissurektomie und lateraler Sphinkterotomie [dissertation].
Universität Mainz
Selvaggi F, di Carlo S, Silvestri A et al (1992) Prospektive Untersuchung der lateralen sukutanen
Sphinkterotomie in Allgemein- oder Lokalanästhesie bei der Behandlung von Analfissuren.
Coloproctology 14:348–350
Stürmlinger M (1986) Funktionelle Ergebnisse der lateralen Sphinkterotomie im Rahmen der
Behandlung der chronischen Analfissur [dissertation]. Universität Düsseldorf
Vafai M, Mann CV (1987) Ambulante geschlossene laterale Sphinkterotomie in der Behandlung
von Analfissuren. Coloproctology 9:49–53
Willemsen C (1963) Ursache von Analfissuren [dissertation]. Universität Düsseldorf
Anal Bleeding
Ali J (1992) Die chirurgische Behandlung der akuten und chronischen Analfissur. [dissertation].
Universität Münster
Böttcher KJ (1992) Die operative Behandlung der Analfissur. [dissertation]. Universität
Erlangen-Nürnberg
Eißer H (1990) Die chirurgische Behandlung der chronischen und akuten Analfissur. [disserta-
tion]. Universität Münster
Gordon PH, Vasilevsky CA (1985) Lateral internal sphincterotomy: rationale, technique and anes-
thesia. Can J Surg 28:228–230
Hananel N, Gordon PH (1997) Re-examination of clinical manifestation and response to therapy
of fissure in ano. Dis Colon Rectum 40:229–233
Jost WH (1989) Langzeitergebnisse nach operativer Behandlung der Analfissur. [dissertation].
Universität Mainz
Korkis AM, McDougall CJ (1995) Rectal bleeding in patients less than 50 years age. Dig Dis Sci
40:1520–1523
Mazier WP (1972) An evaluation of the surgical treatment of anal fissure. Dis Colon Rectum
15:222–227
Romano G, Rotondano G, Santangelo M et al (1994) A critical appraisal of pathogenesis and mor-
bidity of surgical treatment of chronic anal fissure. J Am Coll Surg 178:600–604
Schanne S (1998) Therapeutischer Einsatz von Botulinumtoxin bei der unkomplizierten chro-
nischen Analfissur. [dissertation]. Universität Saarbrücken
Schwaner S (2002) Operative Behandlung der chronischen Analfissur: Ergebnisse, Rezidive,
Kontinenzleistung nach Fissurektomie bzw. Fissurektomie und lateraler Sphinkterotomie. [dis-
sertation]. Universität Mainz
Stürmlinger M (1986) Funktionelle Ergebnisse der lateralen Sphinkterotomie im Rahmen der
Behandlung der chronischen Analfissur. [dissertation]. Universität Düsseldorf
Vafai M, Mann CV (1987) Ambulante geschlossene laterale Sphinkterotomie in der Behandlung
von Analfissuren. Coloproctology 9:49–53
Willemsen C (1963) Ursache von Analfissuren. [dissertation]. Universität Düsseldorf
References
72
Anal Pruritus
Ali J (1992) Die chirurgische Behandlung der akuten und chronischen Analfissur [dissertation].
Universität Münster
Brühl W, Schmauz R (1997/98) Analhygiene bei perianalen Hauterkrankungen. Zentralbl Hyg
Umweltmed 200:562–570
Eißer H (1990) Die chirurgische Behandlung der chronischen und akuten Analfissur [dissertation].
Universität Münster
Gordon PH, Vasilevsky CA (1985) Lateral internal sphincterotomy: rationale, technique and anes-
thesia. Can J Surg 28:228–230
Hananel N, Gordon PH (1997) Re-examination of clinical manifestation and response to therapy
of fissure in ano. Dis Colon Rectum 40:229–233
Jost WH (1989) Langzeitergebnisse nach operativer Behandlung der Analfissur [dissertation].
Universität Mainz
Mazier WP (1972) An evaluation of the surgical treatment of anal fissure. Dis Colon Rectum
15:222–227
Romano G, Rotondano G, Santangelo M et al (1994) A critical appraisal of pathogenesis and mor-
bidity of surgical treatment of chronic anal fissure. J Am Coll Surg 178:600–604
Schanne S (1998) Therapeutischer Einsatz von Botulinumtoxin bei der unkomplizierten chro-
nischen Analfissur [dissertation]. Universität Saarbrücken
Schwaner S (2002) Operative Behandlung der chronischen Analfissur: Ergebnisse, Rezidive,
Kontinenzleistung nach Fissurektomie bzw. Fissurektomie und lateraler Sphinkterotomie [dis-
sertation]. Universität Mainz
Selvaggi F, di Carlo S, Silvestri A et al (1992) Prospektive Untersuchung der lateralen sukutanen
Sphinkterotomie in Allgemein- oder Lokalanästhesie bei der Behandlung von Analfissuren.
Coloproctology 14:348–350
Stürmlinger M (1986) Funktionelle Ergebnisse der lateralen Sphinkterotomie im Rahmen der
Behandlung der chronischen Analfissur [dissertation]. Universität Düsseldorf
Vafai M, Mann CV (1987) Ambulante geschlossene laterale Sphinkterotomie in der Behandlung
von Analfissuren. Coloproctology 9:49–53
Wienert V (1973) Häufigkeitsverteilung von anorektalen Beschwerden und Befunden. Z Hautkr
48:147–151
Willemsen C (1963) Ursachen von Analfissuren [dissertation]. Universität Düsseldorf
Constipation
Ali J (1992) Die chirurgische Behandlung der akuten und chronischen Analfissur [dissertation].
Universität Münster
Böttcher KJ (1977) Die operative Behandlung der Analfissur [dissertation]. Universität
Erlangen-Nürnberg
Eißer H (1990) Die chirurgische Behandlung der chronischen und akuten Analfissur [dissertation].
Universität Münster
Gordon PH, Vasilevsky CA (1985) Lateral internal sphincterotomy: rationale, technique and anes-
thesia. Can J Surg 28:228–230
Hananel N, Gordon PH (1997) Re-examination of clinical manifestation and response to therapy
of fissure in ano. Dis Colon Rectum 40:229–233
Higgins PD, Johanson JF (2004) Epidemiology of constipation in the United States: a systematic
review. Am J Gastroenterol 99:750–759
Jost WH (1989) Langzeitergebnisse nach operativer Behandlung der Analfissur [dissertation].
Universität Mainz
Mazier WF (1972) An evaluation of the surgical treatment of anal fissure. Dis Colon Rectum
15:222–227
6 Signs and Symptoms
73
Prohm P (1993) Analyse der prä- und postoperativen Kontinenzfunktion nach lateraler
Sphinkterotomie am Beispiel der chronischen Analfissur. Kontinenz 2:120–124
Romano G, Rotondano G, Santangelo M et al (1994) A critical appraisal of pathogenesis and mor-
bidity of surgical treatment of chronic anal fissure. J Am Coll Surg 178:600–604
Rosa G, Lolli P, Piccinelli D et al (2005) Calibrated lateral internal sphincterotomy for chronic anal
fissure. Tech Coloproctol 9:127–132
Schanne S (1998) Therapeutischer Einsatz von Botulinumtoxin bei der unkomplizierten chro-
nischen Analfissur [dissertation]. Universität Saarbrücken
Schwaner S (2002) Operative Behandlung der Analfissur:Ergebnisse, Rezidive, Kontinenzleistung
nach Fissurektomie bzw. Fissurektomie und lateraler Sphinkterotomie [dissertation].
Universität Mainz
Selvaggi F, di Carlo S, Silvestri A et al (1992) Prospektive Untersuchung der lateralen sukutanen
Sphinkterotomie in Allgemein- oder Lokalanästhesie bei der Behandlung von Analfissuren.
Coloproctology 14:348–350
Stürmlinger M (1986) Funktionelle Ergebnisse der lateralen Sphinkterotomie im Rahmen der
Behandlung der chronischen Analfissur [dissertation]. Universität Düsseldorf
Vafai M, Mann CV (1987) Ambulante geschlossene laterale Sphinkterotomie in der Behandlung
von Analfissuren. Coloproctology 9:49–53
Willemsen C (1963) Ursachen von Analfissuren [dissertation]. Universität Düsseldorf
References
75
© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5_7
7
Anal Fissure Disease: Prevention
and Quality of Life
7.1 Prevention
Anal fissures have a tendency for recurrence or chronicity. Katsinelos et al. (2006)
observed 16% recurrences, and Jensen (1987) 25%. Therefore, strategies to avoid
such developments should be designed. In a double-blind, placebo-controlled study
concerning 90 patients with acute anal fissure, Jensen (1987) was able to prove that
after the administration of 5 g of unprocessed bran (three times daily over a year), a
recurrence affected only 16% of the cases. The placebo group, however, showed
68% recurrences. Bran absorbs four times its weight in water, and thus effects a
voluminous stool which leads to a physiological dilatation of the anus during its
passage. Contrary to bran, Plantago ovata (flee seed husks; Mucofalk
®
) increases
substantially in volume, so that its administration promises an even better therapeu-
tic effect.
Moreover, Katsinelos et al. (2006) were able to show that 0.5% nifedepine oint-
ment significantly reduced the tendency for recurrence of acute anal fissure or its
transition to a chronic anal fissure.
7.2 Anal Fissure Disease and Quality of Life
Quality of Life (QOL) is a complex health-related concept which still lacks a uni-
versally binding definition. In medicine, this term has been gaining increasing
importance for some years now, especially under therapeutic aspects, for instance,
in palliative cancer therapy. However, this concept does not guarantee survival, but
it can improve or at least maintain more or less the quality of life until death.
Quality of life can be quantified on the basis of data drawn from three different
health questionnaires:
• The GastroIntestinal Quality of Life Index (GIQLI, Eypasch et al. 1995),
• The Fecal Incontinence Quality of Life Scale (FIQLS, Rockwood et al. 2000),
• The Short Form (36) Health Survey (SF-36, Bensoussan et al. 2001).