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76
In 1995, Eypasch and coworkers developed the GastroIntestinal Quality of Life
Index (GIQLI). The questionnaire lists symptoms and factual as well as emotional
and social dysfunctions which are associated with a gastrointestinal disorder or are
related to a corresponding treatment.
Points between 0 and 4 are allotted to each of the 36 questions. The quality of life
status is equivalent to the sum of points scored, that is, 144 points in the best and 0
points in the worst case.
The FIQLS asks 29 questions assigned to the following four subscales:
Lifestyle (10 items), coping behavior (9 items), depression (7 items), embar-
rassment (3 items).
The SF-36 comprises 36 questions assigned to eight sections: vitality, physical
functioning, bodily pain, general health perceptions, physical role functioning,
emotional role functioning, social role functioning, and mental health. The answers
are entered on a linear scale from 0 to 100 (optimum).
Applying the GIQLI questionnaire to 38 anal fissure patients, Sailer et al. (1998)
found an average score of 104 points (optimum 144). In comparison, the quality of
life of hemorrhoidal disease patients was less affected (120 GIQLI).
Mentes et al. (2006) could establish a mean value of 118.34 ± 6.33 (FIQLS)
among their 244 patients. After lateral sphincterotomy, this value rose to 140.74 ±
2.38. Twelve months later, the FIQLS value of three patients (1.22%) deteriorated.
Griffin et al. (2004) used the SF-36 questionnaire to evaluate the effect of local
therapy for chronic anal fissure with 0.2% GTN or 2% diltiazem. A follow-up
examination for 39 of 54 patients was possible. The sections vitality, general health
perception, bodily pain, and physical role functioning significantly improved after
therapy.
After lateral sphincterotomy in 108 patients, Ortiz et al. (2005) could notice a
significant improvement in six sections (SF-36) 6 months later: bodily pain, physi-
cal role functioning, vitality, social role functioning, mental health, and physical
functioning.
Conclusion
Anal fissure disease leads to a marked decline in the quality of life.
References
Prevention
Jensen SL (1987) Maintenance therapy with unprocessed bran in the prevention of acute anal fis-
sure recurrence. J R Soc Med 80:296–298
Katsinelos P, Koutouras J, Paroutoglou G et al (2006) Aggressive treatment of acute anal fissure
with 0.5% nifedipine ointment prevents its evaluation to chronicity. World J Gastroenterol
12:6203–6206
7 Anal Fissure Disease: Prevention and Quality of Life
77
Anal Fissure Disease and Quality of Life
Bensoussan A, Chang SW, Menzies RG et al (2001) Application of the general health status ques-
tionnaire SF-36 to patients with gastrointestinal dysfunction: initial validation and validation as
a measure of change. N Z J Public Health 25:71–77
Eypasch E, Williams JJ, Wood-Dauphinee S et al (1995) Gastrointestinal quality of life index:
development, validation and application of a new instrument. Br J Surg 82:216–222
Griffin N, Acheson AG, Tung P et al (2004) Quality of life in patients with chronic anal fissure.
Colorectal Dis 6:39–44
Mentes BB, Tezcaner T, Yilmaz U et al (2006) Results of lateral internal sphincterotomy for
chronic anal fissure with particular reference to quality of life. Dis Colon Rectum
49:1045–1051
Ortiz H, Marzo J, Armendariz P et al (2005) Quality of life assessment in patients with chronic anal
fissure after lateral internal sphincterotomy. Br J Surg 92:881–885
Rockwood TH, Church JM, Fleshman JW et al (2000) Fecal incontinence quality of life scale. Dis
Colon Rectum 43:9–17
Sailer M, Bussen D, Debus ES et al (1998) Quality of life in patients with benign anorectal disor-
ders. Br J Surg 85:1716–1719
References
79
© Springer International Publishing AG 2017
V. Wienert et al., Anal Fissure, DOI 10.1007/978-3-319-49244-5_8
8
Diagnostics and Differential Diagnostics
8.1 Diagnostics
8.1.1 Anamnesis
A tentative diagnosis is often confirmed by a typical anamnesis: strong pain during
and/or after defecation as well as a blood strip on the stool column and/or traces of
blood on toilet paper.
Many patients are afraid of the next bowel movement. Therefore, they some-
times reduce food intake to delay defecation.
Latency between the first occurrence of complaints and the presentation at the
doctor’s office shows an astonishing range (see Chap. 2.5).
8.1.2 Medical Examination
Generally, an anal fissure becomes visible already when the buttocks are parted
and the patient exerts pressure at the same time. The ensuing digital examina-
tion should be carried out with caution. If it is too painful, the fissure can be
injected subcutaneously with a local anesthetic, for example, 2 ml 2% lidocaine.
The exact location of the fissure can be identified using a cotton swab. Imbued
with a topical anesthetic preparation, the swab is gently introduced into the anal
canal. After its removal, a blood strip on the cotton carrier shows the location of
the fissure (Fig. 8.1).
A complete proctological examination at an early stage using anal speculum,
probe, proctoscope, and rectoscope is advised to detect possible secondary changes
and to rule out other disorders.
80
8.2 Differential Diagnosis
8.2.1 Preliminary Note
Under the aspect of rectal pain, pain syndromes like proctalgia fugax, coccygo-
dynia, anogenital syndrome abscesses due to periproctitis, anal thrombosis, and
proctitides have to be excluded in differential diagnosis. With regard to morphol-
ogy, distinctions have to be made in particular between erosion, rhagades, anal
ulcerations, and anal carcinoma. For differential diagnostic and therapeutic rea-
sons, a chronic fissure must be distinguished from secondary fissures as described
in Chap. 3.
8.2.1.1 Erosions
If the lining of the anal canal is inflamed (anitis), occurrence of erosions can be soli-
tary or multifocal. Erosions are superficial as well as exuding tissue defects which
heal without scarring. In this case, the epithelium in the anal canal is edematous,
exuding, and hyperemic. The causes can be multiple: anal eczema, hemorrhoidal
disease, herpes simplex, gonorrhea, syphilis, chlamydia infection, papillitis, crypti-
tis, prolapse disorders, and also chronic diarrhea. Excessive anal hygiene can also
lead to erosions.
Patients complain of secretion, often with an addition of mucus and/or blood,
intra-anal burning, persistent pruritus ani, and soiling.
Therapy must not be aimed at the symptoms, but has to be directed at the causes
(Figs. 8.2, 8.3 and 8.4).
Fig. 8.1 Location of anal fissure by use of a cotton carrier
8 Diagnostics and Differential Diagnostics
81
Epidermis
Dermis
Epidermis
Dermis
Rhagade
Erosion
Fig. 8.2 Differential diagnosis: erosion versus rhagades (schematic)
Fig. 8.3 Perianal erosions
8.2 Differential Diagnosis
82
8.2.1.2 Rhagades
Rhagades are solitary, slit-like, deep skin cracks which can be caused by excessive
stretching of the anoderm and the perianal skin when the elasticity of the anal canal
is reduced. They heal without scarring, and they are found particularly in patients
with a narrow anal canal. In most cases, they cause a slightly burning pain. But if
pain is felt, it will not be as violent and cramp-like as the pain caused by an anal
fissure. Rhagades heal quickly when silver nitrate solution (AgNO
3
, 1%) is applied.
8.2.1.3 Anal Ulcers
Anal fissures can also result traumatically after anal intercourse (Pradel et al. 1985;
Marino 1964; Nzimbala and Bruynin 2007; Pierce 2004). However, a variety of
other anal and perianal ulcers must be excluded in differential diagnosis: those
induced by infections (syphilis, chlamydia, haemophilus ducreyi, cytomegalovirus,
herpes simplex virus, tuberculosis, HIV), and also neoplasia such as the squamous
epithelium carcinoma, lymphomas, leukemia, Kaposi sarcoma (Marino 1964;
Pierce 2004; Pradel et al. 1985).
8.2.1.4 Anal Carcinoma
Under differential diagnostic aspects, the exclusion of a malign finding is extremely
important. A suspicion should already be nourished during the clinical examination.
On palpation, the carcinoma of the anal verge appears distinctly firmer than a fis-
sure, and the infiltration of subcutaneous tissue can also be felt. The carcinoma of
the anal canal shows the same palpatory criteria, and during proctoscopy of advanced
tumors, one can often sense its growth below the covering epithelium. The tumor is
felt to be significantly more extended in the deep than near the surface, and it
Fig. 8.4 Rhagades at 6 o’clock
8 Diagnostics and Differential Diagnostics
83
infiltrates the deeper layers of the wall of the anal canal (NCCN Clinical Practice
Guidelines in Oncology 2008) (Fig. 8.5).
The histological structure of the malignomas (squamous epithelial carcinoma
and its variant, the verrucous carcinoma, adenocarcinoma, basalioma, and melano-
mas as well as malign lymphomas) is different and does not convey a macromorho-
logically typical picture.
It is difficult to macroscopically evaluate the tumor entities without the forma-
tion of tumor mass, like, for instance, the forms of anal Morbus Paget which imitate
rather an eczema, or the bowenoid papulosis or the Morbus Bowen, as it was for-
merly known. The last-mentioned tumors of various grades of malignancy are now-
adays defined as anal intraepithelial neoplasia (AIN) with its grading scheme AIN
1, 2, and 3 (Hartschuh et al. 2012). Malign lesions of the anal edge and the anal
canal do not show the same preference for the central location as the anal fissure, but
can nevertheless be situated at 6 or 12 o’clock.
Yet, tissue which is supposedly scarred or altered by inflammation is excised as
“anal fissure” again and again, but subsequent histological preparation and analysis
disclose very surprisingly a carcinoma or AIN. This underlines the necessity of a
histological examination of all excision preparations taken from the anus. Inversely,
this means that a biopsy must be taken into consideration after every clinically
unclear finding of a chronic eczema or a therapy-refractory anal fissure or unclear
knotty alterations (Jehle et al. 2003; Roelofsen 2002).
8.2.1.5 Anorectal Pain Syndromes
The disorders described below are characterized by suddenly occurring, permanent,
or recurring pain, without the evidence of a lesion in the anal canal.
Proctalgia Fugax
Proctalgia fugax is defined as an extremely painful disease without a discernible
pathomorphological substrate. It can only be diagnosed on the basis of the intermit-
tent symptoms which the afflicted patients describe during the anamnesis. Their
Fig. 8.5 Anal carcinoma at 12 o’clock
8.2 Differential Diagnosis
84
account is almost always the same and limited only by their command of language.
Proctalgia fugax was first described by A. S. Myrtle in 1883. The term “proctalgia
fugax” goes back to the Danish physician T. E. H. Thaysen (1935) who published an
exact description of the characteristic symptoms in 1935. The following synonyms
are today obsolete: perineal neuralgia, perineal cramp, cramp of the anal sphincter
muscle, nervous rectalgia, neuralgia pudendo-analis, or paroxysmal proctalgia.
Prevalence
Proctalgia fugax is by no means uncommon. Its prevalence is given within a range
between 2 and 21% of the respective collectives (Ibrahim 1961; Mlitz 2003; de
Parades et al. 2007; Boyce et al. 2006; Thompson and Heaton 1980; Schmulson
et al. 2006). It occurs mainly in patients between 40 and 50 years of age (Boisson
et al. 1966) and lasts for more than 11 years on average (Pilling et al. 1965).
Women are twice as often afflicted as men (Bensaude 1966; Mlitz 2003).
Referring to their systematic review, Jeyarajah et al. (2010) stated a prevalence
rate between 4 and 18% in the general population. Various causes are discussed to
trigger the disease (Table 8.1).
Symptoms
A distinction is made between diurnal and nocturnal attacks, the latter occurring
mostly in the early hours of the morning and rudely awakening the patient (Wienert
1980). The duration of the attacks varies between some minutes and 1 h or more
(Mlitz 2003). In the case of severe attacks, the circulatory system occasionally reacts
with vertigo, excessive perspiration, nausea, or even physical collapse. Contrary to
anal fissure pain, proctalgia fugax induced pain is not connected with defecation.
Anogenital Syndrome (AGS)
Various conditions of pain in the area of the pelvic organs which concern the sub-
ject areas of proctology and urology are subsumed under the term “anogenital
Table 8.1 Synopsis of 13 studies on the causes of proctalgia fugax
Author Assumed causes
Guy et al. (1997) Hypertrophy of internal anal sphincter muscle
Rao and Hatfield (1996) Hyperkinesis of musculature
Harvey (1979) Increased contractions in rectosigmoid
Marti (1992) Stenosing edema of colonic mucosa
Kamm et al. (1991)
Celik et al. (1995)
Martin et al. (1990)
König et al. (2000)
Hereditary myopathy of internal anal sphincter muscle
Eckhardt et al. (1996) Spasm of internal anal sphincter muscle
Takano (2005) Pudendal neuropathy
Lans (1994) Concurrent symptom of hemorrhoidal disease
Mlitz (2003) Rare symptom of hemorrhoidal disease
Pilling et al. (1965) Psychosomatic disorder
8 Diagnostics and Differential Diagnostics
85
syndrome (AGS).” But a sufficiently precise definition of AGS is not found in the
respective medical literature. In the case of prostatic complaints without a tangible
correlate, the only recommendation in differential diagnosis is to consider the ano-
rectal symptom complex (hemorrhoidal disease, anal fissure, cryptitis, etc.).
Synonyms of AGS (Brühl and Hansen 1986; Persson-Jüneman and Alken 1995;
Müller 1975) are anourogenital syndrome (Becker 1995), prostatitis-like syndrome
(Ikeuchi et al. 1991), prostatoanal syndrome (Puigvert 1975), and urogenital syn-
drome (Persson- Jüneman and Alken 1995). The authors emphasize the interdisci-
plinary character of the signs and symptoms of AGS. In the differential diagnosis
of anal fissure, AGS must be taken into consideration and, if necessary, a urological
clarification should follow.
Proctological diseases were found in a range between 8.4 and 35% of
patients with unclear prostatic complaints (Pavone et al. 2000; Schnierstein
1965; Vogt 1974, 1983).
The causal pathological relationship can be explained anatomically by the
relative neighborhood of both organs as well as by their common sensomotoric
supply through the pudendal nerve. Moreover, venous and lymphatic connec-
tions between prostate and rectum must be considered as paths of infection,
either lymphogenically or per continuitatem. In the case of proctological disor-
ders, for example, hemorrhoidal disease, cryptitis, or anal fissure, an increased
tone of the internal anal sphincter muscle may exist, which might cause a venous
congestion also in the prostate. On the other hand, it might be conceivable that
pain in the case of prostatitis could reactively lead to sphincter hypertonia, which
could in turn trigger an anal fissure (Ikeuchi et al. 1991; Akande and Esho 1989;
Becker 1995).
Coccygodynia
Definition
Coccygodynia is defined by a pulling or stabbing, sometimes a long-lasting pain
in the coccyx itself or in its immediate neighborhood (Buchmann 1964). The
pain intensifies when sitting down, while sitting, when getting up, or during def-
ecation. That means, pain occurs mostly when forces are exerted upon the coc-
cyx. The causes of coccygodynia seem to be rather complex. As it is not defined
by a pathognomonic substrate, Buchmann (1964) warns against speaking of a
disease. The first description of coccygodynia was published in 1859 by James
Y. Simpson (Buchmann 1964; Stein 2002). The term coccygeal neuralgia is also
used (Baciu et al. 1966). A distinction is made between the so-called idiopathic
coccygodynia and the traumatic coccygodynia. Under certain circumstances,
radiology reveals pathomorphological alterations like subluxation, luxation, and
fracture (Buchmann 1964; Maigne et al. 1992, 1994, Maigne and Tamalet 1996).
Coccygodynia is relatively rare. Particularly women are afflicted (Buchmann
1964; Kim and Suk 1999; Tilscher et al. 1986), mostly in their middle age (Stein
2002; Winkler and Otto 1997). Only Grosso and van Dam (1995) report a male
to female ratio of 2:1 in a small number of cases. Traumatic coccygodynia seems
8.2 Differential Diagnosis
86
to be more common than idiopathic coccygodynia (Buchmann 1964; Kim and
Suk 1999).
All too often, it is impossible to pinpoint a cause for idiopathic coccygodynia
(Kim and Suk 1999; Postacchini and Massobrio 1983). Table 8.2 shows various
authors and their suspected causes.
Symptoms
Patients complain of pulling, stabbing, and also burning pain in the coccyx
region, which radiates into the anal, lumbar, and/or hip bone area (Winkler and
Otto 1997). This pain can last for some days or up to several weeks. It mostly
appears when sitting (Baciu et al. 1966; Maigne et al. 1992, 1994; Maigne and
Tamalet 1996; Polkinghorn and Colloca 1999), when standing up from a sitting
position (Baciu et al. 1966; Kim and Suk 1999), and during defecation (Baciu
et al. 1966; Kim and Suk 1999; Winkler and Otto 1997), particularly in associa-
tion with idiopathic coccygodynia, and also during sexual intercourse (Baciu
et al. 1966).
Diagnosis
Diagnosis is based on pain triggered by palpation, particularly from outside or
trans rectally, and when moving the coccyx (Buchmann 1964; Stein 2002; Winkler
and Otto 1997). With idiopathic coccygodynia, X-ray examinations of the coccyx,
especially in the lateral ray path, can yield unexpected pathological findings. So,
Buchmann (1964) found in 11 of 47 cases of supposed idiopathic coccygodynia
unmistakable consequences of traumata, such as subluxation, luxation, and fracture-
like changes, without the patients remembering such an incidence. In 8 of 30
patients with idopathic coccygodynia, Maigne et al. (1992) could show a posterior
subluxation of the coccyx, which was visible in the sitting position, but not in the
lying position. The procedure of measuring the mobility of the coccyx and the inter-
coccygeal angle is long known, but does not yet belong to routine diagnostic proce-
dures. The intercoccygeal angle – measured between the first and last coccygeal
segment – is larger in patients with idiopathic coccygodynia than in patients with
traumatic coccygodynia and also in patients of a normal control group (Kim and
Suk 1999). The wealth of coccyx variants complicates X-ray diagnosis consider-
ably. Trivial alterations might therefore be misinterpreted as a fracture.
Table 8.2 Synopsis of eight studies on the causes of coccygodynia
Authors Assumed causes
Kepski and Rudnicki (1978) Arachnoid cyst
Ziegler and Batnitzky (1984) Perineural cyst
Buchmann (1964) Dermoid cyst
Duncan et al. (1991) Glomus tumors
Nutz and Stelzner (1985) Glomus tumors
Kim and Suk (1999) Enlarged intercoccygeal angle
Postacchini and Massobrio (1983) Fusion of the sacrococcygeal transition
Maigne and Tamalet (1996) Hypermobility of coccyx
8 Diagnostics and Differential Diagnostics