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Anal Fissure

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Abstract

An anal fissure is a tear in the anoderm, typically in the posterior midline. In the first 6 weeks, they will likely resolve with increased fiber and water, laxatives, and topical lidocaine. Chronic anal fissures, however, heal only 35.5 % of the time without further management. Nearly all treatments seek to relax the hypertonic internal anal sphincter. Perianal topical nitroglycerin, perianal topical diltiazem, and intramuscular (internal anal sphincter) injection of botulinum toxin are slightly more effective than placebo in healing anal fissures. Lateral internal anal sphincterotomy is far more effective (>90 %) in healing anal fissure. There is no difference between closed vs. open sphincterotomy techniques. Atypical anal fissures may require biopsy to rule out infectious disease, inflammatory bowel disease, or malignancy. For patients with hypotonic anal sphincters, dermal advancement flap to close the anal fissure should be considered. This chapter will cover the diagnosis, medical, and surgical management of anal fissures.

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References

  1. Herzig DO, Lu KC. Anal fissure. Surg Clin North Am. 2010;90:33–44.

    PubMed  Google Scholar 

  2. Ricciardi R, Dykes S, Madoff R. Anal fissure. In: Beck DE, Roberts P, Saclarides TK, Senagore AJ, Stamos MJ, Wexner SD, editors. The ASCRS textbook of colon and rectal surgery. 2nd ed. New York, NY: Springer; 2011. p. 203–18.

    Google Scholar 

  3. Hoexter B. Anal fissure. In: Fazio VW, Church J, Delaney CP, editors. Current therapy in colon and rectal surgery. 2nd ed. Philadelphia, PA: Elsevier Mosby; 2005. p. 19–22.

    Google Scholar 

  4. Perry GG. Fissure in ano--a complication of anusitis. South Med J. 1962;55:955–7.

    CAS  PubMed  Google Scholar 

  5. Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum. 1994;37:424–9.

    CAS  PubMed  Google Scholar 

  6. Nothmann BJ, Schuster MM. Internal anal sphincter derangement with anal fissures. Gastroenterology. 1974;67:216–20.

    CAS  PubMed  Google Scholar 

  7. Gibbons CP, Read NW. Anal hypertonia in fissures: cause or effect? Br J Surg. 1986;73:443–5.

    CAS  PubMed  Google Scholar 

  8. Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989;32:43–52.

    CAS  PubMed  Google Scholar 

  9. Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996;83:63–5.

    CAS  PubMed  Google Scholar 

  10. Perry WB, Dykes SL, Buie WD, Rafferty JF. Standards Practice Task Force of the American Society of C, Rectal S. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum. 2010;53:1110–5.

    PubMed  Google Scholar 

  11. Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Br Med J. 1986;292:1167–9.

    CAS  Google Scholar 

  12. Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012; (2): CD003431.

    Google Scholar 

  13. O’Kelly T, Brading A, Mortensen N. Nerve mediated relaxation of the human internal anal sphincter: the role of nitric oxide. Gut. 1993;34:689–93.

    PubMed  PubMed Central  Google Scholar 

  14. Loder PB, Kamm MA, Nicholls RJ, Phillips RK. ‘Reversible chemical sphincterotomy’ by local application of glyceryl trinitrate. Br J Surg. 1994;81:1386–9.

    CAS  PubMed  Google Scholar 

  15. Lund JN, Scholefield JH. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet. 1997;349:11–4.

    CAS  PubMed  Google Scholar 

  16. Jonas M, Barrett DA, Shaw PN, Scholefield JH. Systemic levels of glyceryl trinitrate following topical application to the anoderm do not correlate with the measured reduction in anal pressure. Br J Surg. 2001;88:1613–6.

    CAS  PubMed  Google Scholar 

  17. Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med. 1999;341:65–9.

    CAS  PubMed  Google Scholar 

  18. Lund JN, Armitage NC, Scholefield JH. Use of glyceryl trinitrate ointment in the treatment of anal fissure. Br J Surg. 1996;83:776–7.

    CAS  PubMed  Google Scholar 

  19. Watson SJ, Kamm MA, Nicholls RJ, Phillips RK. Topical glyceryl trinitrate in the treatment of chronic anal fissure. Br J Surg. 1996;83:771–5.

    CAS  PubMed  Google Scholar 

  20. Perez-Legaz J, Arroyo A, Moya P, Ruiz-Tovar J, Frangi A, Candela F, et al. Perianal versus endoanal application of glyceryl trinitrate 0.4% ointment in the treatment of chronic anal fissure: results of a randomized controlled trial. Is this the solution to the headaches? Dis Colon Rectum. 2012;55:893–9.

    PubMed  Google Scholar 

  21. Chrysos E, Xynos E, Tzovaras G, Zoras OJ, Tsiaoussis J, Vassilakis SJ. Effect of nifedipine on rectoanal motility. Dis Colon Rectum. 1996;39:212–6.

    CAS  PubMed  Google Scholar 

  22. Carapeti EA, Kamm MA, Phillips RK. Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum. 2000;43:1359–62.

    CAS  PubMed  Google Scholar 

  23. Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum. 2001;44:1074–8.

    CAS  PubMed  Google Scholar 

  24. Bielecki K, Kolodziejczak M. A prospective randomized trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. Colorectal Dis. 2003;5:256–7.

    CAS  PubMed  Google Scholar 

  25. Kocher HM, Steward M, Leather AJ, Cullen PT. Randomized clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure. Br J Surg. 2002;89:413–7.

    CAS  PubMed  Google Scholar 

  26. Cheng CM, Chen JS, Patel RP. Unlabeled uses of botulinum toxins: a review, part 1. Am J Health Syst Pharm. 2006;63:145–52.

    CAS  PubMed  Google Scholar 

  27. Tjandra JJ. Ambulatory haemorrhoidectomy - has the time come? ANZ J Surg. 2005;75:183.

    PubMed  Google Scholar 

  28. Gui D, Cassetta E, Anastasio G, Bentivoglio AR, Maria G, Albanese A. Botulinum toxin for chronic anal fissure. Lancet. 1994;344:1127–8.

    CAS  PubMed  Google Scholar 

  29. Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. Influence of botulinum toxin site of injections on healing rate in patients with chronic anal fissure. Am J Surg. 2000;179:46–50.

    CAS  PubMed  Google Scholar 

  30. Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med. 1998;338:217–20.

    CAS  PubMed  Google Scholar 

  31. Arroyo A, Perez F, Serrano P, Candela F, Lacueva J, Calpena R. Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study. Am J Surg. 2005;189:429–34.

    CAS  PubMed  Google Scholar 

  32. Iswariah H, Stephens J, Rieger N, Rodda D, Hewett P. Randomized prospective controlled trial of lateral internal sphincterotomy versus injection of botulinum toxin for the treatment of idiopathic fissure in ano. ANZ J Surg. 2005;75:553–5.

    PubMed  Google Scholar 

  33. Mentes BB, Irkorucu O, Akin M, Leventoglu S, Tatlicioglu E. Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum. 2003;46:232–7.

    PubMed  Google Scholar 

  34. Chen HL, Woo XB, Wang HS, Lin YJ, Luo HX, Chen YH, et al. Botulinum toxin injection versus lateral internal sphincterotomy for chronic anal fissure: a meta-analysis of randomized control trials. Tech Coloproctol. 2014;18:693–8.

    PubMed  Google Scholar 

  35. Gandomkar H, Zeinoddini A, Heidari R, Amoli HA. Partial lateral internal sphincterotomy versus combined botulinum toxin A injection and topical diltiazem in the treatment of chronic anal fissure: a randomized clinical trial. Dis Colon Rectum. 2015;58:228–34.

    Google Scholar 

  36. Saad AM, Omer A. Surgical treatment of chronic fissure-in-ano: a prospective randomised study. East Afr Med J. 1992;69:613–5.

    CAS  PubMed  Google Scholar 

  37. Steele SR, Madoff RD. Systematic review: the treatment of anal fissure. Aliment Pharmacol Ther. 2006;24:247–57.

    CAS  PubMed  Google Scholar 

  38. Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S. Operative procedures for fissure in ano. Cochrane Database Syst Rev. 2011; (11): CD002199.

    Google Scholar 

  39. Renzi A, Izzo D, Di Sarno G, Talento P, Torelli F, Izzo G, et al. Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial. Dis Colon Rectum. 2008;51:121–7.

    PubMed  Google Scholar 

  40. Eisenhammer S. The evaluation of the internal anal sphincterotomy operation with special reference to anal fissure. Surg Gynecol Obstet. 1959;109:583–90.

    CAS  PubMed  Google Scholar 

  41. Notaras MJ. Lateral subcutaneous sphincterotomy for anal fissure--a new technique. Proc R Soc Med. 1969;62:713.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. Arroyo A, Perez F, Serrano P, Candela F, Calpena R. Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: prospective randomized study of clinical and manometric longterm results. J Am Coll Surg. 2004;199:361–7.

    PubMed  Google Scholar 

  43. Filingeri V, Gravante G. A prospective randomized trial between subcutaneous lateral internal sphincterotomy with radiofrequency bistoury and conventional parks’ operation in the treatment of anal fissures. Eur Rev Med Pharmacol Sci. 2005;9:175–8.

    CAS  PubMed  Google Scholar 

  44. Boulos PB, Araujo JG. Adequate internal sphincterotomy for chronic anal fissure: subcutaneous or open technique? Br J Surg. 1984;71:360–2.

    CAS  PubMed  Google Scholar 

  45. Kortbeek JB, Langevin JM, Khoo RE, Heine JA. Chronic fissure-in-ano: a randomized study comparing open and subcutaneous lateral internal sphincterotomy. Dis Colon Rectum. 1992;35:835–7.

    CAS  PubMed  Google Scholar 

  46. Wiley M, Day P, Rieger N, Stephens J, Moore J. Open vs. closed lateral internal sphincterotomy for idiopathic fissure-in-ano: a prospective, randomized, controlled trial. Dis Colon Rectum. 2004;47:847–52.

    CAS  PubMed  Google Scholar 

  47. Garcia-Granero E, Sanahuja A, Garcia-Botello SA, Faiz O, Esclapez P, Espi A, et al. The ideal lateral internal sphincterotomy: clinical and endosonographic evaluation following open and closed internal anal sphincterotomy. Colorectal Dis. 2009;11:502–7.

    CAS  PubMed  Google Scholar 

  48. Mentes BB, Ege B, Leventoglu S, Oguz M, Karadag A. Extent of lateral internal sphincterotomy: up to the dentate line or up to the fissure apex? Dis Colon Rectum. 2005;48:365–70.

    PubMed  Google Scholar 

  49. Elsebae MM. A study of fecal incontinence in patients with chronic anal fissure: prospective, randomized, controlled trial of the extent of internal anal sphincter division during lateral sphincterotomy. World J Surg. 2007;31:2052–7.

    PubMed  Google Scholar 

  50. Magdy A, El Nakeeb A, el Fouda Y, Youssef M, Farid M. Comparative study of conventional lateral internal sphincterotomy, V-Y anoplasty, and tailored lateral internal sphincterotomy with V-Y anoplasty in the treatment of chronic anal fissure. J Gastrointest Surg. 2012;16:1955–62.

    PubMed  Google Scholar 

  51. Mentes BB, Guner MK, Leventoglu S, Akyurek N. Fine-tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs. up to the fissure apex. Dis Colon Rectum. 2008;51:128–33.

    PubMed  Google Scholar 

  52. Pelta AE, Davis KG, Armstrong DN. Subcutaneous fissurotomy: a novel procedure for chronic fissure-in-ano. a review of 109 cases. Dis Colon Rectum. 2007;50:1662–7.

    PubMed  Google Scholar 

  53. Garcia-Aguilar J, Belmonte C, Wong WD, Lowry AC, Madoff RD. Open vs. closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum. 1996;39:440–3.

    CAS  PubMed  Google Scholar 

  54. Madoff RD, Fleshman JW. AGA technical review on the diagnosis and care of patients with anal fissure. Gastroenterology. 2003;124:235–45.

    PubMed  Google Scholar 

  55. Floyd ND, Kondylis L, Kondylis PD, Reilly JC. Chronic anal fissure: 1994 and a decade later--are we doing better? Am J Surg. 2006;191:344–8.

    PubMed  Google Scholar 

  56. Lysy J, Israeli E, Levy S, Rozentzweig G, Strauss-Liviatan N, Goldin E. Long-term results of “chemical sphincterotomy” for chronic anal fissure: a prospective study. Dis Colon Rectum. 2006;49:858–64.

    PubMed  Google Scholar 

  57. Giordano P, Gravante G, Grondona P, Ruggiero B, Porrett T, Lunniss PJ. Simple cutaneous advancement flap anoplasty for resistant chronic anal fissure: a prospective study. World J Surg. 2009;33:1058–63.

    PubMed  Google Scholar 

  58. Nyam DC, Wilson RG, Stewart KJ, Farouk R, Bartolo DC. Island advancement flaps in the management of anal fissures. Br J Surg. 1995;82:326–8.

    CAS  PubMed  Google Scholar 

  59. Kenefick NJ, Gee AS, Durdey P. Treatment of resistant anal fissure with advancement anoplasty. Colorectal Dis. 2002;4:463–6.

    CAS  PubMed  Google Scholar 

  60. Sangwan YP, Schoetz Jr DJ, Murray JJ, Roberts PL, Coller JA. Perianal Crohn’s disease. Results of local surgical treatment. Dis Colon Rectum. 1996;39:529–35.

    CAS  PubMed  Google Scholar 

  61. Platell C, Mackay J, Collopy B, Fink R, Ryan P, Woods R. Anal pathology in patients with Crohn’s disease. ANZ J Surg. 1996;66:5–9.

    CAS  Google Scholar 

  62. Wolkomir AF, Luchtefeld MA. Surgery for symptomatic hemorrhoids and anal fissures in Crohn’s disease. Dis Colon Rectum. 1993;36:545–7.

    CAS  PubMed  Google Scholar 

  63. Fleshner PR, Schoetz Jr DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Anal fissure in Crohn’s disease: a plea for aggressive management. Dis Colon Rectum. 1995;38:1137–43.

    CAS  PubMed  Google Scholar 

  64. Ouraghi A, Nieuviarts S, Mougenel JL, Allez M, Barthet M, Carbonnel F, et al. Infliximab therapy for Crohn’s disease anoperineal lesions. Gastroenterol Clin Biol. 2001;25:949–56.

    CAS  PubMed  Google Scholar 

  65. Sweeney JL, Ritchie JK, Nicholls RJ. Anal fissure in Crohn’s disease. Br J Surg. 1988;75:56–7.

    CAS  PubMed  Google Scholar 

  66. Viamonte M, Dailey TH, Gottesman L. Ulcerative disease of the anorectum in the HIV+ patient. Dis Colon Rectum. 1993;36:801–5.

    CAS  PubMed  Google Scholar 

  67. Weiss EG, Wexner SD. Surgery for anal lesions in HIV-infected patients. Ann Med. 1995;27:467–75.

    CAS  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L-223A, Portland, OR, 97239, USA

    Kim C. Lu MD, FACS, FASCRS & Daniel O. Herzig MD, FACS, FASCRS

Authors
  1. Kim C. Lu MD, FACS, FASCRS
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  2. Daniel O. Herzig MD, FACS, FASCRS
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Corresponding author

Correspondence to Kim C. Lu MD, FACS, FASCRS .

Editor information

Editors and Affiliations

  1. Division of Colorectal Surgery, University Hospitals Case Medical Center Case Western Reserve University, Cleveland, OH, USA

    Scott R. Steele

  2. Cleveland Clinic, Cleveland, OH, USA

    Tracy L. Hull

  3. Tufts University School of Medicine, Lahey Hospital & Medical Center, Burlington, MA, USA

    Thomas E. Read

  4. Ambrose and Gladys Bowyer, Loyola University, Chicago, IL, USA

    Theodore J. Saclarides

  5. University of Texas Medical Branch at Galveston, Galveston, TX, USA

    Anthony J. Senagore

  6. Ochsner Medical Center, New Orleans, LA, USA

    Charles B. Whitlow

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Anoplasty for anal stenosis. Courtesy of ASCRS (MP4 100,338 kb)

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Lu, K.C., Herzig, D.O. (2016). Anal Fissure. In: Steele, S.R., Hull, T.L., Read, T.E., Saclarides, T.J., Senagore, A.J., Whitlow, C.B. (eds) The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-25970-3_13

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  • DOI: https://doi.org/10.1007/978-3-319-25970-3_13

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