Anorectal pain and irritation: anal fissure, levator syndrome, proctalgia fugax, and pruritus ani

Anal fissures, proctalgia fugax, levator ani syndrome, and pruritus ani are common causes of anorectal pain and irritation. The clinician who obtains a thorough history and performs a complete examination can accurately diagnose these disorders. Ancillary tests seldom are helpful and rarely are necessary. Most patients suffering from these conditions readily respond to conservative therapy provided in the primary care practitioner's office.

Pathophysiology of anorectal dysfunction

Anorectal disorders are the cause of significant discomfort and embarrassment in women. The onset typically follows childbirth and symptoms increase with age. Anal incontinence, rectovaginal fistula, rectal prolapse, anal fissure, and constipation are considered.

Intolerance of cow's milk and chronic constipation in children

BACKGROUND

Chronic diarrhea is the most common gastrointestinal symptom of intolerance of cow's milk among children. On the basis of a prior open study, we hypothesized that intolerance of cow's milk can also cause severe perianal lesions with pain on defecation and consequent constipation in young children.

METHODS

We performed a double-blind, crossover study comparing cow's milk with soy milk in 65 children (age range, 11 to 72 months) with chronic constipation (defined as having one bowel movement every 3 to 15 days). All had been referred to a pediatric gastroenterology clinic and had previously been treated with laxatives without success; 49 had anal fissures and perianal erythema or edema. After 15 days of observation, the patients received cow's milk or soy milk for two weeks. After a one-week washout period, the feedings were reversed. A response was defined as eight or more bowel movements during a treatment period.

RESULTS

Forty-four of the 65 children (68 percent) had a response while receiving soy milk. Anal fissures and pain with defecation resolved. None of the children who received cow's milk had a response. In all 44 children with a response, the response was confirmed with a double-blind challenge with cow's milk. Children with a response had a higher frequency of coexistent rhinitis, dermatitis, or bronchospasm than those with no response (11 of 44 children vs. 1 of 21, P=0.05); they were also more likely to have anal fissures and erythema or edema at base line (40 of 44 vs. 9 of 21, P<0.001), evidence of inflammation of the rectal mucosa on biopsy (26 of 44 vs. 5 of 21, P=0.008), and signs of hypersensitivity, such as specific IgE antibodies to cow's-milk antigens (31 of 44 vs. 4 of 21, P<0.001).

CONCLUSIONS

In young children, chronic constipation can be a manifestation of intolerance of cow's milk.

[Early postoperative morbidity after hemorrhoidectomy using the Milligan-Morgan technic. A retrospective studies of 1,134 cases]

Milligan and Morgan's procedure is commonly used for the surgical management of haemorrhoids. The aim of our study was to evaluate short term postoperative morbidity. Between 1975 and 1990, 1,134 patients were operated on. Two patients died after operation. The most frequent complications were pain (71%) and urinary retention (16.4%). Hemorrhages (7.6%) resulting in a re-operation occurred in 1% of cases. Other complications were rare and always cured by a specific treatment (stenosis: 2.9%, anal fissure: 0.5%, abscess: 0.6%, fistula in ano: 1.2%). Two patients had anal incontinence partially improved by biofeedback. Hemorrhoidal was 2%. Short term postoperative morbidity is generally low after Milligan and Morgan hemorrhoidectomy, with careful supervision in a surgical department and repeated postoperative care.

A nonsurgical approach to chronic anal fissure

Both dilatation and sphincterotomy are sometimes followed by impaired continence. Recent experience with topical application of glyceryl trinitrate to relax the internal anal sphincter and cause reversible chemical sphincterotomy has shown promise as a first-line treatment.

Anal canal pressures are low in women with postpartum anal fissure

BACKGROUND

Anal sphincter hypertenia is commonly thought to underlie development of anal fissure, yet anal fissure is particularly common after childbirth, a time when anal canal pressure may be reduced. This paradox was investigated by a prospective study of the effect of parturition on the pelvic floor.

METHODS

Anal manometry was performed 6 weeks before and after delivery in 209 primigravid women with no pre-existing history of anorectal disease. Postpartum studies only were performed on a further 104 primiparae. Anal fissure was diagnosed by history and direct examination.

RESULTS

Some 29 women (9 per cent) developed postpartum anal fissure. Antepartum anal canal resting and squeeze pressures were similar in women who did and those who did not develop fissure. Resting and squeeze anal canal pressures decreased post partum in both groups. Postpartum constipation was more common in those with fissure (62 per cent) than in those without (29 per cent) (chi 2 = 10.6, 1 d.f., P < 0.01). The mode of delivery or use of epidural analgesia did not affect the incidence of fissure.

CONCLUSION

Postpartum anal fissure is associated with reduced anal canal pressures, and surgical interference with the anal sphincter mechanism should be avoided.

Aetiology and treatment of anal fissure

Anal fissure is a common problem that causes significant morbidity in a young and otherwise healthy population. Treatment has remained largely unchanged for over 150 years and the pathogenesis of this condition is not yet fully explained. Acute fissure should be treated conservatively with dietary modification. Chronic fissures do not respond to conservative treatment. The current recommended surgical treatment for chronic fissure is lateral internal sphincterotomy. However, there is a disturbance of continence in a sizeable proportion of those undergoing this procedure. As yet there is no proven non-surgical treatment for chronic fissure. Although local injection of botulinum toxin and the topical application of nitrates show early promise, further controlled trials are needed.

[Fistula, fissure, abscess]

Anal fistulas, anal fissures and anal abscesses are common disorders of the anorectal region that can often only be cured durably by operation. The acute anal fissure can usually be treated successfully by conservative means, whereas the chronical anal fissure can be cured by local fissurectomy as a rule. Primary anal abscesses and anal fistulas are different phenomena resulting from an infection of the proctodeal glands. The acute form, the anal abscess, always requires wide opening and drainage. Caudal intersphincteric and -trans-sphincteric anal fistulas can be cured by the division method. Types of anal fistulas that occur higher can be treated effectively by a special operative technique developed on the basis of the method of Parks.

Ischaemic nature of anal fissure

Microvascular perfusion of the anoderm was assessed by laser Doppler flowmetry in 27 patients with anal fissure. Anal pressure was recorded simultaneously. Both measurements were repeated 6 weeks after lateral internal sphincterotomy and compared with those obtained from 27 controls. Means(s.d.) maximum anal resting pressure was significantly higher in those with a fissure than in controls (121.07(24.48) versus 68.78(16.97) mmHg, P < 0.001). Anodermal blood flow at the fissure site was significantly lower than at the posterior commissure of the controls (0.46(0.20) versus 0.76(0.28) V, P < 0.001). The fissure healed in 24 patients within 6 weeks of sphincterotomy. In these patients a significant pressure decrease was noted (35 per cent) which was accompanied by a consistent rise in blood flow (65 per cent) at the original fissure site. The increased internal sphincter tone in patients with a fissure reduces anodermal blood flow at the posterior midline. Reduction of anal pressure by sphincterotomy improves anodermal blood flow at the posterior midline, resulting in fissure healing. These findings provide evidence for the ischaemic nature of anal fissure.

Anal fissure in Crohn's disease: a plea for aggressive management

PURPOSE

This study was undertaken to identify clinical characteristics, natural history, and results of medical and surgical treatment of anal fissures in Crohn's disease.

METHODS

This is a retrospective review of patients with Crohn's disease and anal fissure.

RESULTS

Of the 56 study patients, 49 (84 percent) had symptomatic fissures. Fissures were most commonly (66 percent) located in the posterior midline, and 18 patients (32 percent) had multiple fissures. Fissures healed in one-half of patients treated medically. Factors predictive of successful medical treatment included male gender, painless fissure, and acute fissure. Of 15 patients, 10 (67 percent) treated surgically healed. Fissures in seven of eight patients (88 percent) who underwent anorectal procedures healed compared with fissures in only three of seven patients (43 percent) who underwent proximal intestinal resection. In the group of 50 patients with complete follow-up studies, an anal abscess or fistula from the base of an unhealed fissure developed in 13 patients (26 percent). More fissures healed after anorectal surgery (88 percent) than after medical treatment alone (49 percent; P = 0.05) or after abnormal surgery (29 percent; P = 0.03).

CONCLUSION

This series documents that unhealed fissures frequently progress to more ominous anal pathologic disease. Judicious use of internal sphincterotomy appears to be safe for fissures unresponsive to medical treatment.

Local excision and mucosal advancement for anorectal ulceration in patients infected with human immunodeficiency virus

In patients infected with human immunodeficiency virus (HIV) no effective surgical procedure has been described for anorectal ulceration that is resistant to medical therapy. This study was designed to determine the effectiveness of surgical excision of anorectal ulcers, with or without mucosal advancement. The medical records of patients with HIV and anorectal pathology diagnosed between 1984 and 1994 were reviewed. Patients with anorectal ulcers were divided into group A which was treated only with excision and group B in which excision was combined with mucosal advancement. Surgical treatment was considered successful if relief of symptoms was achieved within 4 weeks of the operation. Excision of anorectal ulcers was successful in seven of 16 patients (44 per cent) in group A. Relief of symptoms was achieved in 12 of 13 patients (92 per cent) in group B when surgical excision was combined with mucosal advancement, which is significantly better than the results in group A (P = 0.02). This non-randomized study indicates that after unsuccessful medical treatment persistent symptomatic ulcers should be treated operatively by excision with mucosal advancement.

Anal fissure. 20-year experience

PURPOSE

This study was designed to review a 20-year experience of the treatment of patients with anal fissure to identify possible etiologic factors and to explore effective preventative measures and the ideal treatment for this disease.

METHODS

From January 1972 to December 1991, 1,391 patients (700 males, 691 females; average age, 39 years) with chronic symptomatic anal fissures underwent surgical treatment using either open or closed techniques. The following procedures were performed: 1) internal sphincterotomy for 1,313 idiopathic fissures; 2) C-anoplasty for 36 cases of anal stricture; 3) debridement and sphincterotomy for 25 patients with postsurgical nonhealing wounds; 4) bilateral excision of the protruding internal sphincter for 17 patients with "subluxation." Acute superficial anal fissures were treated conservatively, with emphasis on anal hygiene.

RESULTS

Acute superficial and fissures responded well to conservative management. Over 95 percent of patients with chronic anal fissures treated by surgery had satisfactory relief of symptoms. Early complications included urinary retention (1.4 percent), bleeding (1.1 percent), and abscess and fistula formation (0.7 percent). Late complications manifested as flatus and liquid incontinence (1.5 percent), delayed wound healing (1.4 percent), recurrence of fissures (1.3 percent), and symptomatic itching and burning (1.1 percent). The complication rate was higher in the group that underwent closed sphincterotomy than in the group treated by open techniques.

CONCLUSIONS

Proper and hygiene is important in both prevention and initial conservative management of symptomatic anal fissures. For chronic intractable cases, open lateral internal sphincterotomy is strongly recommended. C-anoplasty should be done when strictures are present. Excision of the protruding internal sphincter is recommended in patients who present with an excessively elongated, tight anal canal with a partially protruding internal sphincter.

Hemorrhoids, fissures, and pruritus ani

The diagnosis and management of hemorrhoids, fissures, and pruritus ani probably accounts for more than 81% of the complaints centered on this part of the human anatomy. This brief treatise offers a safe and practical approach to the management of these three diseases.

Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures

PURPOSE

The aim of this study was to investigate the relationship between anal pressure and anodermal blood flow.

METHODS

We performed Doppler laser flowmetry of the anoderm combined with anorectal manometry in 178 subjects (87 males and 91 females; median age, 55 (range, 17-87) years). This group consisted of 31 healthy volunteers, 23 patients with fecal incontinence, 17 patients with hemorrhoids, and 9 patients with anal fissure. The remaining 98 patients had other colorectal disorders. In 16 controls we examined anodermal blood flow in the four quadrants of the anal canal.

RESULTS

Perfusion of the anoderm at the posterior midline was significantly lower than in the other three segments of the anal canal (posterior midline: 0.74 +/- 0.26 V; left lateral side: 1.68 +/- 0.81 V; right lateral side: 1.57 +/- 0.52 V; anterior midline: 1.48 +/- 0.69 V, P < 0.001). In the overall group, we found a significant correlation between maximum and resting pressure and anodermal blood flow at the posterior midline (r = -0.616, P < 0.001). In the nine patients with chronic anal fissure, the mean maximum anal resting pressure was 125 +/- 26 mmHg, which was significantly higher than in patients with hemorrhoids (82 +/- 15 mmHg), controls (66 +/- 19 mmHg), and patients with fecal incontinence (42 +/- 14 mmHg, P < 0.001), whereas the blood flow at the base of the fissure was significantly lower (0.43 +/- 0.10 V vs. 0.57 +/- 0.19 V vs. 0.75 +/- 0.26 vs. 1.03 +/- 0.34 V). In ten patients we also studied the influence of anesthesia on both anal pressure and anodermal blood flow. During the administration of anesthesia, anal pressure dropped from 63 +/- 21 mmHg to 32 +/- 15 mmHg (P < 0.001), whereas anodermal blood flow at the posterior midline increased from 0.79 +/- 0.22 V to 1.31 +/- 0.35 V (P < 0.001).

CONCLUSION

Anodermal blood flow at the posterior midline is less than in the other segments of the anal canal. The perfusion of the anoderm at the posterior commissure is strongly related to anal pressure. The higher the pressure, the lower the flow. Our findings support the hypothesis that anal fissures are ischemic ulcers.

A critical appraisal of pathogenesis and morbidity of surgical treatment of chronic anal fissure

Preoperative and postoperative manometric findings and the results of lateral internal sphincterotomy were analyzed in 44 consecutive patients affected with chronic anal fissure. Preoperatively, resting anal pressure was increased in 32 patients. At one month postoperatively, 23 patients showed normal pressures, whereas 14 were still hypertonic and seven, hypotonic. Only three patients still had a weak sphincter six months postoperatively. The overall morbidity rate was 31.8 percent. Minor complications occurred in 11 patients. Major complications affected three patients. Overall, impaired continence was recorded in eight patients, although only two complained of persistent, albeit lesser, defects of continence not requiring the use of pads. Nonoperative treatment should be reserved for few selected patients with recent, acute fissures. As for chronic and fissures, compared with other operative or nonoperative modalities of treatment, lateral internal sphincterotomy is a highly successful procedure and its minimal morbidity is well accepted by the patient.

Sustained internal sphincter hypertonia in patients with chronic anal fissure

PURPOSE

This study was designed to determine whether functional variations of internal sphincter activity occur in order to differentiate between patients with anal fissures from those with hemorrhoids.

METHODS

Thirty patients with chronic anal fissure (median age, 28 years; 12 females), 22 patients with hemorrhoids (median age, 37 years; 7 females), and 33 control volunteers (median age, 48.5 years; 21 females) underwent ambulatory anal sphincter fine-needle electromyography and anorectal manometry.

RESULTS

The median internal sphincter electromyography frequency was similar: fissure group, 0.49 Hz; hemorrhoid group, 0.46 Hz (P > 0.05), and control group, 0.44 Hz (P > 0.05). Median anal resting pressures were similar in the fissure group (132 cm. H2O) and the hemorrhoids group (116 cm of H2O) (P > 0.05), but significantly greater than those in the control group (94 cm. H2O) (P < 0.05). The median number of transient relaxations of the internal and sphincter with an associated rise in rectal pressure and fall in anal pressure was 1 (range, 0-4) per hour in the fissure group, 6 (range, 4-7) per hour in the hemorrhoid group, and 4 range, 3-6) per hour in the control group. Six patients with fissures were reassessed following lateral internal sphincterotomy. Median and pressure was 102 cm of H2O (P > 0.1 vs. controls) and the number of internal sphincter relaxations increased to 4 per hour (P < 0.01 vs. preoperative number).

CONCLUSIONS

Internal anal sphincter relaxation occurs on fewer occasions in patients with chronic anal fissures that have failed to heal in comparison to patients with hemorrhoids and normal controls. This evidence further supports the hypothesis that internal sphincter hypertonia may be relevant to the pathogenesis of this disorder.

Ulcerative disease of the anorectum in the HIV+ patient

Ulcerative processes are the most disabling of anal diseases in HIV+ patients. The spectrum ranges from "benign" fissures to invasive ulcerative processes. It is important to recognize their salient features in order to effectuate proper management. Since 1989, 74 HIV+ patients with ulcerative anal disease were evaluated. Of 33 patients with benign fissures, 13 had sphincterotomy, with symptomatic relief in 12 and healing in 11. Ten had improvement with standard conservative treatment, and 10 did not return for re-evaluation. Of 41 patients with "idiopathic" anal ulcers, 34 underwent operative evaluation, biopsy, viral culture, and debridement. Thirty had significant pain relief, and 17 showed variable evidence of healing. Four patients with intractable pain had injection of Depo-Medrol (The Upjohn Co., Kalamazoo, MI) into the bed of the ulcer with significant pain relief. One patient was diverted. We propose that anal ulcerative disease be classified as benign lesions and therefore treated as if the patient were HIV negative. In those patients with HIV-associated anal ulcers, evaluation under anesthesia, biopsy, culture, and debridement should be performed and therapy directed against any neoplastic or viral agents found. Those patients with no identifiable agents may be helped with aggressive debridement or intralesional steroid therapy. This approach allows safe and effective treatment in most patients.

Surgery for symptomatic hemorrhoids and anal fissures in Crohn's disease

This study was undertaken to determine the outcome of surgery for symptomatic hemorrhoids and anal fissures in patients with known Crohn's disease. Seventeen patients underwent surgery for symptomatic hemorrhoids. Fifteen of these 17 patients' wounds healed without complication. Twenty-five patients underwent 27 operations for anal fissures. Twenty-two of these patients had uncomplicated wound healing by two months. Long-term follow-up, which was at a mean of 11.5 years in the hemorrhoid patients and 7.5 years in the fissure patients, revealed that only three patients required proctectomy, none as a direct result of surgery. Patients with severe symptoms secondary to anal fissures and hemorrhoids, who are known to have Crohn's disease and who cannot be controlled with conservative medical management, may undergo surgery on a highly selective basis when the disease is in the quiescent state. Proctectomy is not an inevitable outcome.

ABC of colorectal diseases. Paediatric problems--I

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[Microbiology related to anal abscess complicated with fistula formation]

The results of operative treatment of anal abscesses with reviewed retrospectively for a period of three years with the object of correlating the microbiological findings on culture from the abscess with the presence of a fistula. Patients who had not been controlled postoperatively were requested to attend for anal examination. Fistula were demonstrated in 27 out of 83 patients. No fistulae nor recurrences of abscesses were found in patients in whom only bacteria not derived from the intestine were cultured. Culture from an anal abscesses is thus of considerable prognostic value.

Perianal appearances associated with constipation

The perianal appearances were studied prospectively of 136 constipated children (mean age 3.9 years, 67 boys, 69 girls). Anal dilatation, fissures, tags, warts, perianal oedema, redness, blueness, and veins were recorded. It was noted whether dilatation occurred immediately or at 30 and 60 seconds with the buttocks minimally separated, and on subsequent firm lateral traction of the buttocks. The degree of faecal loading was assessed in all children. Anal dilatation was found in 24 (18%) and first appeared on lateral traction in eight (6%). In three quarters of the children with dilatation faecal loading or perianal signs were present. Fissures were found in 35 (26%) children and tags in seven (5%). Perianal redness was more likely to be associated with fissures, and blueness with dilatation. We conclude that there are no pathognomonic perianal signs in childhood constipation and that the technique of anal examination should be standardised.

Non-condylomatous, perianal disease in homosexual men

This retrospective study details the findings and outcome in 34 homosexual men, out of a total of 177 patients, who underwent surgery for non-condylomatous perianal disease over a 2-year period. Of 34 homosexuals 20 presented with anorectal sepsis compared with 11 of 79 heterosexual male patients (X2 = 24.07, P less than 0.001). Lesions included chronic intersphincteric abscess (eight patients), anal fistula (seven patients) and chronic intersphincteric abscess and fistula (five patients). Anal fissure occurred in 15 patients, anal ulcer in three, skin tags in six, haemorrhoids in two and Kaposi's sarcoma in one. Eight patients were human immunodeficiency virus (HIV) antibody negative, four were asymptomatic HIV antibody positive, 12 had symptomatic HIV infection using the Centers for Disease Control classification and in ten patients HIV status was unknown. Irrespective of the type of surgery performed, healing occurred within 6 weeks of operation in all HIV antibody negative patients, all asymptomatic HIV antibody positive and in only one of nine patients with symptomatic HIV infection. Eight of nine patients with symptomatic HIV infection failed to heal by this time (X2 = 8.98, P less than 0.05). These findings suggest that the prevalence of anorectal sepsis in homosexual men is high and that symptomatic HIV infection is an important determinant of progress after surgery.

Anal manometric studies in hemorrhoids and anal fissures

Manometry study with the use of continuous water perfusion system was performed for 50 patients with Grade III or IV hemorrhoids and for 29 patients with chronic anal fissure. Another 36 patients who did not have any anorectal symptom or pathology were chosen as the control group. The maximal basal pressures for the control, the hemorrhoid, and the chronic anal fissure groups were 71.2 +/- 24.9, 85.3 +/- 27.7 and 87.4 +/- 38.8 mmHg respectively; the maximal contraction pressures for the control, the hemorrhoid and the fissure groups were 132.9 +/- 44.9, 158.8 +/- 58.0 and 162.1 +/- 64.5 mmHg; while the lengths of the functional sphincter of the three groups were 3.7 +/- 0.5, 3.8 +/- 0.8 and 3.9 +/- 0.6 cm respectively. The maximal basal pressures and the maximal contraction pressures of the hemorrhoid and fissure patients were significantly greater than those of the control group; whereas the functional sphincter lengths of the three groups did not show significant difference.

Diet and other risk factors for fissure-in-ano. Prospective case control study

The findings of a partly prospective case control study of chronic fissure-in-ano conducted in two Danish outpatient clinics are reported. One hundred seventy-four patients with chronic fissure-in-ano were matched by age and sex to outpatients from the same community suffering from benign skin tumors. All subjects were interviewed regarding diet, beverage consumption, occupational exposures, and medical and surgical history. Significantly decreased risks were associated with frequent consumption of raw fruits, vegetables, and whole-grain bread, and significantly increased risks were associated with frequent consumption of white bread, sauces thickened with roux, and bacon or sausages. Risk ratios for consumption of coffee, tea, and alcohol were not significantly different. No statistical associations were found with particular occupational exposures. However, a history of previous anal surgery was reported significantly more often for cases than for controls. Current evidence indicates that anal fissure is likely to result at least partly from an inappropriate diet and that dietary manipulations might reduce the incidence of fissure-in-ano.

[Anal and perianal operations in ulcerative colitis and Crohn's disease]

Inflammation in ulcerative colitis is concentrated in the mucous membrane. Therefore, increased frequency of perianal and anal lesions is not to be expected and therapy does not differ from that in patients without inflammatory bowel disease. This study concentrates mainly on Crohn's disease and provides an overview on skin disorders, skin tag, fissure in ano, fistulae and abscess, stenosis, incontinence and the management of these conditions. A decision is necessary between four approaches to treatment: 1. Wait and see regarding the natural course. 2. Treatment of intestinal manifestations. 3. Conservative therapy concentrating on the anal lesion. 4. Local or extensive surgery. The indications for surgery should not be aggressive (except for abscesses and fistulae causing pain and discharge). However, excessive complications need not be feared if an experienced surgical team is involved.

Anal fissures and fistulas

Thorough understanding of the pathophysiology of anal fissures and fistulas is essential for the physician treating these conditions. An acute fissure often heals in a month with conservative management; long-standing disease is relieved by lateral internal sphincterotomy. An acute fistulous abscess must be drained by unroofing the abscess rather than by simple incision, which fosters recurrence. Chronic fistula in ano requires fistulotomy, which can be done with a local anesthetic. Fistulas with multiple external orifices should be treated by a specialist in rectal surgery.

Anal hypertonia in fissures: cause or effect?

High sphincter pressures recorded in patients with fissure-in-ano have been attributed to sphincter spasm induced by wide recording assemblies. To investigate this hypothesis, anal sphincter pressure was measured using a series of perfused probes of 0.4-2 cm diameter in six men with chronic anal fissure in whom digital examination was easily tolerated. The results were compared with those from 14 normal men. The resting pressure within the anal canal exceeded the normal range in all six patients irrespective of probe size. With the smallest (0.4 cm) probe, the resting pressure was 114 +/- 17.1 cmH2O (mean +/- s.d.) in patients with fissure and 73.1 +/- 27.0 cmH2O (mean +/- s.d.) in control subjects (P less than 0.001) even 10 min after introduction of the device. The minimum residual pressure attained during inflation of a rectal balloon with 100 ml of air was higher in patients with anal fissure than controls, reaching statistical significance with the 1.0 cm probe (80.8 +/- 17.7 cmH2O versus 36.9 +/- 19.0 cmH2O, P less than 0.001). Maximum pressures recorded during a voluntary contraction of the sphincter were no higher than in control subjects. The results suggest that high resting pressures are recorded in patients with chronic anal fissures even when small probes are employed and are unlikely to be due to spasm, but probably represent a true increase in basal sphincter tone. It is proposed that elevated sphincter pressures may cause ischaemia of the anal lining and this may be responsible for the pain of anal fissures and their failure to heal.

Medical problems of the homosexual adolescent

Physicians treating adolescents should take a complete sexual history, including sexual orientation and practices, to determine whether their patients are homosexually active. Lesbians are at very low risk for sexually transmitted diseases, but they do have other health concerns. Four general groups of conditions may be encountered in homosexually active men: classical sexually transmitted diseases (gonorrhea, infections with Chlamydia trachomatis, syphilis, herpes simplex infections, genital warts, pubic lice, scabies); enteric diseases (infections with Shigella species, Campylobacter jejuni, Entamoeba histolytica, Giardia lamblia, hepatitis A, hepatitis B, hepatitis non-A, non-B, and cytomegalovirus); trauma (fecal incontinence, hemorrhoids, anal fissure, foreign bodies, rectosigmoid tears, allergic proctitis, penile edema, chemical sinusitis, inhaled nitrite burns, and sexual assault of the male patient); and the acquired immunodeficiency syndrome (AIDS). Clinicians can assist homosexual teenagers by understanding their special health needs, by counseling them about safe sexual practices, and by accepting their relationships nonjudgmentally.

[Anal fissure]

The symptoms and diagnosis of anal fissure are described. An acute fissure is treated by conservative therapy, but the chronic type requires surgical intervention.

Common anorectal disorders

Anorectal disorders include a diverse group of pathologic processes that are frequently encountered in general medical practice but are poorly understood. The optimal management of anal pain, itching, bleeding, and incontinence is based on sound anatomic and pathophysiologic principles. Advances have been made in understanding the pathogenesis and management of four anorectal disorders frequently encountered by internists: hemorrhoids, fissures, pruritus, and incontinence.

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. XV. Chronic anal fissure: a new theory of pathogenesis

Pathologic changes in chronic anal fissures were studied in 52 patients. In 40 patients, epithelial cells could be identified in the fissure floor superficial to the internal anal sphincter. The cells were rounded, oval, or columnar and were arranged in clumps or pseudoacinar formations. In 10 patients the anorectal sinus was detected in the fissure floor, whereas in 2 patients no epithelial cells could be found. It seems that chronic anal fissure results from disruption of the anal lining, which exposes epithelial cells or the anorectal sinus in the wound floor to repeated infection. It is believed that these epithelial cells are just anorectal sinus remnants that exist in the submucosa of the anal canal proper as epithelial debris or anorectal band. Epithelial cells act as multiple sequestra that harbor the infection and are responsible for fissure chronicity. These patients are predisposed to anal traumatization by feces, owing to the anorectal band's constricting effect on the anal canal proper. The exclusive fissure location in the anal canal proper and not in the rectal neck is due to the anorectal sinus remnants contained therein. The posterior and, rarely, anterior median fissure position is ascribed to the existence of two weak anal areas. The break commonly occurs posteriorly because the posterior anal wall lacks sufficient support. It is concluded that fissure excision, including anorectal bandotomy, at present, is the best treatment to achieve a radical cure.