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Anal Fissure

Anal fissure is a small break or tear in the skin of the anal canal , which typically runs from below the dentate line to the anal verge and is usually situated in the posterior midline( Zaghiyan KN et al 2011 , Madalinski MH et al 2011 )

 

Most common cause of severe anal pain Mostly affect young people 2nd and 4th decades of life Most papers report an equal distribution between men and women Lifetime risk has been reported between
7.8 % to 11.1 % ie
Anal Fissure ( AF ) is a common problem but it is now very well known exactly how widespread this problem is Studies have shown association with pregnancy
- in a prospective study of 165 women , 2 had AF before delivery but 25 % ( 15 ) had AF afterwards with half occurring more than 2 weeks after delivery ( Abramowitz L et al 2002 ) It can cause significant morbidity in otherwise young and healthy population

 

Etiology remains unclear Trauma from passing a large bowel / hard stool or diarrhoe can also cause initial trauma Increased anal sphincter tone – possible play a role in persistence Fewer anal tone relaxations have been shown in people with chronic fissures Decreased blood flow 
- prevents healing
- relative ischaemia of the posterior anal canal as fissure can happen without trauma or constipation and may be even present in patients with diarrhoea symptoms no theory comprehensively explains the pathogenesis

 

duration varies in laterature generally of 4 to 6 weeks duration American Society of Colorectal Surgeons
( 2016 ) describe acute as symptoms present for fewer than 8 weeks

 

Failure to heal – chronic fissure Anorectal fistula Infection and / or abscess Faecal impaction.

 

Pain often provoked by defecation ( worst with and after bowel movement ) Pain can persist for 1-2 hrs after bowel movement Pain is sharp and described as passing a glass or razor blades Bright red blood either streaking the stool or when wiping Patient may also report constipation Periodic episodes may indicate chronicity A combination of anal pain and bleeding will cause most people to present with significant worry to the medical practitioner Often misdiagnosed as haemorrhoids due to presence of bright red bleeding

 

Examination of perineum would be normal Most fissures ( 90 % ) are on the posterior midline of the anus 8 % may occur both posteriorly and anteriorly Anterior-midline in as many as 25 % of female patients Gentle traction of the buttocks will show fissure on most people DRE / Anoscopy in surgery may be painful on initial presentation- avoid Sphincter spam is a common finding A fissure may not be always visible on examination- if so an examination under anaesthetic should be advised.

 

clean longitudinal tear in the anoderm with little surrounding inflammation.

 

Chronic fissures are characterized by
- fissure is deeper with exposed internal sphincter fibres at its base
- edema, fibrosis or heaped up granulation tissues at the edges
- a sentinel piles at the base of the fissure leading to a permanent skin tag
- enlargement of the anal papillae ( hypertrophy )

 

off midline fissure /morphologically unusual / multiple these may happen in people with Crohn’s disease , STIs ( particularly HIV ) syphilis and herpes simplex ) , anal cancer , local trauma ( anal intercourse ) , TB or receving chemotherapy

 

Spontaneous resolution is reported in literature between 33-50 % within 6 weeks First line is bowel management programme which can include
-sitz bath
- use of psyllium fibers or other bulking agents , stool softeners ( e.g docusate sodium )
- increased fluid intake
- maintenance therapy with fibers Topical anaesthetic or topical steroids correct anal hygiene – keep the area dry These interventions are well tolerated , minimal or no SEs.

 

Will help in resolution of symptoms in many patients
 It is worth trying medical management even in patients with chronic fissure
 Medical management aims to achieve relaxation of the internal anal sphincter tone and increasing the blood flow
 A trial of conservative management of 3-6 weeks is often recommended before a trial of medical management

 

Topical nitrates for e,g 0.2 % GTN-work by releasing nitric oxide causing relaxation of anal sphincter tone and promotes healing can lead to healing of about 50 % of chronic anal fissures the improvement appears independent of the dose and dose escalation doesn not improve healing rates but are associated with increased incidence of medication SEs compliance is reduced due to headache – main SE ( in up to 25-30 % ) patient should use it 3 times / day by inserting the ointment into the anal canal Rectogesic is commercially available GTN 0.4 % recurrence rates can be high ( up to 50 % ) – a repeat of treatment can be considered or refer for botulinum toxin / surgery

 

Calcium channel blockerse.g topical diltiazem or nifedipine –topical diltiazem ( 2 % tds ) has been reported to be as efficacious as GTN but with fewer SEs relaxes the anal sphincter and improves blood flow good healing rates have been reported of up to 65-95 % SEs like headache are less when compared to GTN Clear data to prove a clear advantage is lacking hence literature may often quote that this is unapproved use ( oral calcium channel blockers may also be used but are associated with systemic SEs )

 

Botulinumtoxin-Chemodenervation-acts on presynaptic nerve at the neuromuscular junction to prevent the release of acetylcholine this paralyzes the internal anal sphincter – induces a relative hypotonia reducing anal canal pressure. This effect can last for 2- months efficacy similar to GTN but more expensive effect does not seem to vary with dose

 

Surgical – Lateral internal sphincterectomy is considered the gold standard surgical treatment Surgical treatment is more effective than medical The risk of significant continent disturbance is the main deterrence in offering this measure to all The overall incidence of disturbed continence after LIS is reported to be about 14 % ASCRS quotes anorectal seepage and incontinence has been reported in 8-30 % of patients Other studies have shown that
- 30 % may encounter difficulty in controlling flatus
- 20 % may suffer with soiling
- 3 to 10 % may suffer with episodes of leakage which depends on the choice of surgical intervention
the disturbances may be transient Other procedures may include – fissurectomy , advancement flaps.

Patient Information

Printable information from Imperial NHS https://www.imperial.nhs.uk/~/media/website/patient-information-leaflets/surgery/colorectal-surgery/treating-anal-fissure.pdf

A useful explanation with video from the American Society of Colon and Rectal Surgeons https://fascrs.org/patients/diseases-and-conditions/a-z/anal-fissure-expanded-information

BUPA has a nice summary on anal fissure for patients https://www.bupa.co.uk/health-information/digestive-gut-health/anal-fissure

NICE has produced some further information about 0.2 % topical glyceryl trinitrate treatment https://www.nice.org.uk/advice/esuom7/ifp/chapter/About-topical-glyceryl-trinitrate

Rectogesic patient information from Medicine compendium https://www.medicines.org.uk/emc/files/pil.3933.pdf

Information from Everest Pharmacy is quite comprehensive https://www.everestpharmacy.co.uk/condition/anal-fissure/

Better health channel ( Australia ) has a good detailed section on anal fissure https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/anal-fissure

 

References

  1. The Management of Anal Fissure: ACPGBI Position Statement K. L. R. Cross, E. J. D. Massey, A. L. Fowler, J. R. T. Monson The Association of Coloproctology of Great Britain and Ireland. Colorectal Disease, 10 (Suppl. 3), 1–7
  2. Anal Fissure Emily Steinhagen, M.D.
    Division of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio Dis Colon Rectum 2018; 61: 293–295 DOI: 10.1097/DCR.0000000000001042
  3. Nitroglycerine: A Paradigm in Treatment of Chronic Anal Fissure Varsha SB1* and Jagadish H2
    1Resident, Department of Surgery, Government Medical College, India 2Associate Professor, Department of Surgery, Government Medical College, IndiaMedical Journal of Clinical Trials & Case Studies ISSN: 2578-4838 Med J Clin Trials Case Stu
  4. A quick guide to managing anal fissures BPJ Issue 52
  5. The epidemiology and treatment of anal fissures
    in a population-based cohort Douglas W Mapel*
    , Michael Schum and Ann Von Worley Mapel et al. BMC Gastroenterology 2014, 14:129
    http://www.biomedcentral.com/1471-230X/14/129
  6. Clinical Practice Guideline for the Management of
    Anal Fissures David B. Stewart, Sr., M.D. • Wolfgang Gaertner, M.D. • Sean Glasgow, M.D.
    John Migaly, M.D. • Daniel Feingold, M.D. • Scott R. Steele, M.D. Dis Colon Rectum 2017; 60: 7–14
    DOI: 10.1097/DCR.0000000000000735
  7. Anal Fissure Daniel O. Herzig, MD*, Kim C. Lu, MD Surg Clin N Am 90 (2010) 33–44
    doi:10.1016/j.suc.2009.09.002

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