Practice parameters for the management of anal fissure. The Standards Task Force American Society of Colon and Rectal Surgeons

Topical diltiazem ointment in post-hemorrhoidectomy pain relief: A meta-analysis of randomized controlled trials

BACKGROUND

Hemorrhoidectomy is commonly associated with postoperative pain. Calcium channel blockers are known to cause relaxation of gastrointestinal smooth muscle and oral diltiazem has also been shown to reduce the resting anal pressure.

OBJECTIVE

We attempted to analyze efficacy and side effects of topical diltiazem oint. in post-operative pain control.

METHODS

This is a meta-analysis of patients who underwent hemorrhoidectomy using topical diltiazem oint. versus placebo (Vaseline) for pain control. Patients with third or fourth degree hemorrhoids undergoing traditional hemorrhoidectomy were included. Procedures took place in the colorectal division of a hospital in 5 countries. Five randomized control trials (RCTs) published between 2005 and 2016 including 227 patients were included our meta-analysis (Diltiazem (calcium channel block) group = 137; Placebo (Vaseline) group = 90). Pain assessment was performed using a standardized Visual Analogue Scale. Any side effects of surgery or medication use, which were noted by the patient or the surgeon, also were recorded.

RESULTS

A total of 227 patients were included in the meta-analysis. The results revealed that Diltiazem ointment was statistically significant in reducing pain within 48 h, at 72 h, and more than 96 h after operation compared to the placebo group. Regarding overall complications (including headache), there was no statistical significance between diltiazem and placebo group.

CONCLUSIONS

Topical application of diltiazem effectively relieves pain after hemorrhoidectomy with minimal side effects. Further large studies are needed to substantiate its value in clinical practice.

Clinical, manometric, and ultrasonographic results of pneumatic balloon dilatation vs. lateral internal sphincterotomy for chronic anal fissure: a prospective, randomized, controlled trial

PURPOSE

This prospective, randomized, controlled trial was designed to compare the clinical, functional, and morphologic results of pneumatic balloon dilatation with lateral internal sphincterotomy for the treatment of chronic anal fissure.

METHODS

All patients with symptomatic chronic anal fissure were randomly assigned to pneumatic balloon dilatation or lateral internal sphincterotomy and invited to complete a standardized questionnaire inquiring about their symptoms. Anal ultrasonography and anal manometry were performed before and six months after surgery. A proctologic examination was performed between the fifth and sixth postoperative weeks. Anal continence, scored by using a validated continence grading scale, was evaluated preoperatively at 1 and 6 weeks and at 12 and 24 months.

RESULTS

Fifty-three patients, who satisfied selection criteria, were enrolled in the trial. Four patients (7.5 percent) were lost to follow-up. Twenty-four patients (11 males; mean age, 42 +/- 8.2 years) underwent pneumatic balloon dilatation and 25 patients (10 males; mean age, 44 +/- 7.3 years) underwent lateral internal sphincterotomy. Fissure-healing rates were 83.3 percent in the pneumatic balloon dilatation and 92 percent in the lateral internal sphincterotomy group. Recurrent anal fissure was observed in one patient (4 percent) after lateral internal sphincterotomy. At anal manometry, mean resting pressure decrements obtained after pneumatic balloon dilatation and lateral internal sphincterotomy were 30.5 and 34.3 percent, respectively. After pneumatic balloon dilatation, anal ultrasonography did not show any significant sphincter damage. At 24-month follow-up, the incidence of incontinence, irrespective of severity, was 0 percent in the pneumatic balloon dilatation group and 16 percent in the lateral internal sphincterotomy group (P < 0.0001).

CONCLUSIONS

As lateral internal sphincterotomy, pneumatic balloon dilatation grants a high anal fissure-healing rate but with a statistically significant reduction in postoperative anal incontinence.

A review of chronic anal fissure management

Anal fissure management has rapidly progressed in the last 15 years as our understanding of fissure pathophysiology has developed. All methods of treatment aim to reduce the anal sphincter spasm associated with chronic anal fissures. Surgical techniques have been used for over 100 years with success. Lateral internal sphincterotomy remains the surgical treatment of choice for many practitioners. Postoperative impairment of continence remains controversial. Recently, less invasive methods of treatment have been explored. Topical nitrates, calcium channel blockers and botulinum toxin are established treatments. These and other non-surgical treatments are described in this review. Various guidelines and treatment algorithms for anal fissure are also discussed.

Randomized clinical trial comparing botulinum toxin injections with 0.2 per cent nitroglycerin ointment for chronic anal fissure

BACKGROUND

In recent years treatment of chronic anal fissure has shifted from surgical to medical. This study compared the ability of two non-surgical treatments-botulinum toxin injections and nitroglycerin ointment-to induce healing in patients with idiopathic anal fissure.

METHODS

One hundred adults were assigned randomly to receive treatment with either type A botulinum toxin (30 units Botox or 90 units Dysport) injected into the internal anal sphincter or 0.2 per cent nitroglycerin ointment applied three times daily for 8 weeks.

RESULTS

After 2 months, the fissures were healed in 46 (92 per cent) of 50 patients in the botulinum toxin group and in 35 (70 per cent) of 50 in the nitroglycerin group (P=0.009). Three patients in the botulinum toxin group and 17 in the nitroglycerin group reported adverse effects (P<0.001). Those treated with botulinum toxin had mild incontinence to flatus that lasted 3 weeks after treatment but disappeared spontaneously, whereas nitroglycerin treatment was associated with transient, moderate-to-severe headaches. Nineteen patients who did not have a response to the assigned treatment crossed over to the other therapy.

CONCLUSION

Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective option.

Efficacy of botulinum toxin in chronic anal fissure

BACKGROUND

Chronic anal fissures (CAF) are caused by anal sphincter hypertonia leading to an ischaemic ulcer. By inducing temporary sphincter relaxation, botulinum toxin (Botox) injection has been shown to heal CAF in approximately 73-96% of cases in clinical trials.

AIM

This study looks at the efficacy of Botox clinical practice.

METHODS

The medical charts were reviewed of all patients with CAF treated with Botox (30iu injected into the sphincter complex in three 10iu aliquots) in the Ulster Hospital, Dundonald, Northern Ireland between March 1999 and November 2001.

RESULTS

Fifty-one charts were identified. Four patients failed to attend for review and were excluded from the study. Of the remaining 47 patients, 37 (78.7%) were healed following Botox injection. 10 out of 37 (27.0%) developed a recurrent CAF after a median time of 16.0 months (IQR 3.8-20 months). Eight of these patients opted for repeat Botox injection, which was successful in 7 (87.5%) cases. No adverse effects were reported.

CONCLUSION

Botox injection for the treatment of CAF is as effective in clinical practice as reported in clinical trials from specialist centres.

Topical nitroglycerin versus lateral internal sphincterotomy for chronic anal fissure: prospective, randomized trial

INTRODUCTION

Topical nitroglycerin (GTN) is one of the medical treatments of choice in chronic anal fissure. The present prospective, randomized, clinical trial was conducted to study the symptomatic relief, healing, and changes in the maximum anal resting pressure (MARP) in patients with chronic anal fissure comparing topical GTN and lateral sphincterotomy.

METHODS

Forty consecutive patients with chronic anal fissure were randomized for treatment with either topical GTN or internal sphincterotomy (20 patients in each group). Anal manometry was done before treatment in all patients, and 1 h after application of GTN or sphincterotomy. Patients were followed at 2-weekly intervals for 6 weeks for symptomatic relief and healing.

RESULTS

Both GTN and sphincterotomy brought about a highly significant, but comparable drop in the MARP after treatment (P < 0.0001 in both groups). Sphincterotomy relieved pain much earlier compared to GTN (70% vs 40% at 2 weeks, P = 0.0032); but after 4 weeks of treatment, pain relief in both groups was comparable. Healing in the sphincterotomy group was also earlier than with GTN (55% vs 0% at 2 weeks, P < 0.0001; and 85% vs 30% at 4 weeks, P < 0.0001); but after 6 weeks, healing in both groups was comparable. Sphincterotomy had a significant incidence of minor, short-term complications; it also required surgical expertise, theatre time, and day-care beds. Nitroglycerin is safe, with mild and tolerable side-effects of headache and local burning sensation.

CONCLUSION

Topical GTN should be the initial treatment in chronic anal fissure. Lateral sphincterotomy should be reserved for patients with severe disabling pain (because pain relief is much faster), and for patients not responding to at least 4 weeks of GTN therapy.

Controlled lateral sphincterotomy for chronic anal fissure

PURPOSE

This study assessed the usefulness of "controlled" lateral sphincterotomy for chronic anal fissures.

METHODS

Of 225 patients with chronic anal fissure, 110 underwent traditional sphincterotomy to the level of the dentate line, and 115 underwent controlled sphincterotomy in three steps according to the degree of anal stenosis. In Step 1, the internal sphincter was divided to the proximal level of the fissure. If the anal canal was still stenosed, the division was extended to the level of the dentate line in Step 2. Step 3 was a bilateral internal sphincterotomy. The anal stenosis was evaluated under anesthesia using a new conical calibrator scaled in 1-mm diameter increments. Forty adults without anorectal disease were examined as controls. In a telephone follow-up, 102 patients in the traditional sphincterotomy group and 106 patients in the controlled sphincterotomy group responded.

RESULTS

The normal group measured 34.6 +/- 1.4 mm (mean +/- standard deviation). Confounding effects of age, gender, body weight, and height were not significant. Based on the anal caliber measured in the normal group, anal stenosis is present with values of 31 mm and below (mean--2SD of the control value). Of 115 patients in the controlled sphincterotomy group, 90 (78 percent) underwent sphincterotomy below the level of the dentate line, 18 (16 percent) underwent sphincterotomy to the level of the dentate line, and 7 (6 percent) underwent bilateral sphincterotomy. None had incontinence of feces or leakage of stool. Ten of 102 patients (10 percent) in the traditional sphincterotomy group and 2 of 106 patients (2 percent) in the controlled sphincterotomy group complained of minor incontinence, such as gas incontinence, minor staining, or urgency (P = 0.017). There was one recurrence in the traditional sphincterotomy group.

CONCLUSION

Controlled lateral sphincterotomy could be a way of overcoming the risk of incontinence with lateral internal sphincterotomy for chronic anal fissure.

Pneumatic balloon dilatation for chronic anal fissure: a prospective, clinical, endosonographic, and manometric study

PURPOSE

Pneumatic balloon dilation has been shown to be effective in the management of chronic anal fissure, but its effect on the anal sphincter has not been fully investigated. The aim of this study was to evaluate prospectively the clinical, anatomic, and functional pattern in a group of patients treated by pneumatic balloon dilation.

METHODS

A series of 33 consecutive patients suffering from chronic anal fissure underwent pneumatic balloon dilation. Anal manometry and ultrasonography were performed prior to and 6 to 12 months after the treatment. Manometry was accomplished by means of an endoanal 40-mm balloon inflated with a pressure of 1.4 atmospheres that was left in situ for six minutes under local anesthesia. All patients were interviewed daily for three days after surgery and then clinically evaluated between the third and fifth postoperative weeks. Most patients were interviewed after 25.7 +/- 8.4 months (mean +/- standard deviation). Anal incontinence was evaluated by means of a validated score of 1 to 6.

RESULTS

The chronic anal fissure healed between the third and fifth weeks in 31 patients (94 percent), who became asymptomatic 2.5 +/- 1.4 days after pneumatic balloon dilation. None of them reported anal pain two years after the treatment (n = 20). The first post-pneumatic balloon dilation defecation was painless in 27 cases (82 percent). Two multiparous females (6 percent of the patients) complained of minor transient anal incontinence (score, 3). Chronic anal fissure recurred in one case (3 percent) after treatment. At manometry, the preoperative anal resting pressure decreased from 91 +/- 11.2 to 70.5 +/- 5.6 and to 78 +/- 5.7 mmHg, 6 and 12 months after pneumatic balloon dilation, respectively (P < 0.0001). Anal ultrasonography did not show any significant sphincter defect.

CONCLUSIONS

Pneumatic balloon dilation seems to be an effective, safe, easy procedure that decreases anal resting pressure without endosonographically detectable significant sphincter damage.

[Botulinum toxin A in the treatment of anal fissure]

BACKGROUND

This paper presents our first experience in the treatment of primary anal fissure by injection of botulinum A toxin into the internal sphincter.

METHODS

The study group of the retrospective study included 12 outpatients (8 females and 4 males), mean age 42 (range 18-60). During the period 2000-2003, after unsuccessful conservative treatment, patients were treated with the injections of botulinum A toxin, 100 units on both sides of the anal fissure laterally into the internal anal sphincter (50 units on either side). The patients were clinically evaluated 3, 7, and 30 days, and 3 and 6 months after the treatment.

RESULTS

Three fissures had healed after a month, and seven after 3 months. Two remained unhealed, but asymptomatic. There was no incontinence of flatus or faeces after 3 months of the treatment. After temporary healing, two fissures relapsed after 6 months, and these patients had the adequate tonus of the anal sphincter muscles. Except for the temporary incontinence, there were neither other side-effects, nor serious complications.

CONCLUSION

Injection of botulinum A toxin achieved good results in the treatment of anal fissure. The appropriate use makes this method safe as an alternative to surgical treatment of anal fissure.

[Lateral, partial sphincter myotomy as therapy of chronic anal fissue. Long-term outcome of an epidemiological cohort study]

AIM

We observed a relatively high rate of severe forms of anal incontinence in patients who had undergone lateral, partial, internal, open sphincterotomy for chronic fissure in ano years ago in our clinic. An explicit investigation of pre- and postoperative data for a representative patient group was undertaken to find out whether this incidental finding proved to be meaningful.

PATIENTS AND METHODS

The perioperative data from 523 patients who underwent sphincterotomy (Parks) between 1986 and 1997 were analyzed by uni- and multivariate analysis.

RESULTS

Of 209 patients included in the study, 94.7% could be considered healed after operation. Up until the 12th postoperative week, 14.8% of patients were incontinent in stage I and II (Parks). This increased up to 21% at the time of follow-up, mainly in stage II and III, which significantly differed from a healthy control group.

CONCLUSION

Lateral sphincterotomy leads in most cases to quick healing of the chronic fissure in ano with a low recurrence rate. The added effect of degenerative changes was observed to be linked, however, with a higher long-term rate of anal incontinence.

Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: a two-year follow-up

PURPOSE

The aim of this trial was to compare lateral internal sphincterotomy with local 0.2 percent isosorbide dinitrate in the treatment of chronic anal fissure to minimize surgical complications such as minor fecal incontinence.

METHODS

Fifty-four patients with chronic anal fissure were randomized in a prospective trial to either sphincterotomy or local 0.2 percent isosorbide dinitrate. All patients had anal function tests before and 5 weeks after treatment.

RESULTS

In the ointment group, 18 patients (67 percent) healed at 5 weeks and 24 (89 percent) healed at 10 weeks of treatment. Maximum resting anal pressure was reduced 30 percent. Eight patients (30 percent) had minor side effects. In the surgical group, 26 patients (96 percent) healed at 5 weeks and 100 percent healed at 10 weeks after treatment, with 33 percent reduction in maximum resting anal pressure. Forty-four percent of patients had minor fecal incontinence, which remained in 15 percent after 24 months follow-up. No statistical difference in maximum resting anal pressure was found between groups ( P = 0.16), but the percentage of healing at 5 weeks was greater in the surgical group ( P < 0.001).

CONCLUSIONS

Isosorbide dinitrate ointment must be considered as the first choice of treatment in patients with chronic anal fissure. Surgery should be indicated if chemical sphincterotomy fails.

Attitudes to the treatment of chronic anal fissure in ano after failed medical treatment

OBJECTIVE

The treatment of chronic fissure may be medical or surgical. Indications for assessment, which is the better treatment and under what circumstances, are vital for the appropriate management. The aim of the study was to assess the management of this condition by an expert group of surgeons.

METHODS

Consultant members of the Association of Coloproctology of Great Britain and Ireland (n=452) were approached and requested to answer a preset multiple-choice questionnaire. The questionnaire was designed to assess their management strategy and their approach to investigation and treatment under different clinical situations.

RESULTS

The overall response was 78% (n = 356). Medical treatment was the first line treatment in 95% of the responders. Lateral anal sphincterotomy without pre-operative endoanal ultrasound and/or anorectal physiology was performed by 57%. Anal dilatation was performed selectively by 36% but only 35% of these would perform a pre-operative endoanal ultrasound or anorectal physiology.

CONCLUSION

In the selected group of clinicians lateral anal sphincterotomy remains the procedure of choice in both sexes. Pre-operative assessment using endoanal ultrasound and anorectal physiology is used selectively especially in postpartum women. Anal dilatation remains a subjective procedure and though used selectively, is performed without pre-operative endoanal ultrasound and/or anorectal physiology in majority of cases.

A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures

PURPOSE

The aim of this study was to determine the optimal dose and dosing interval of nitroglycerin ointment to heal chronic anal fissures.

METHOD

A randomized, double-blind study of intra-anally applied nitroglycerin ointment (Anogesic) was conducted in 17 centers in 304 patients with chronic anal fissures. The patients were randomly assigned to one of eight treatment regimens (0.0, 0.1, 0.2, 0.4 percent nitroglycerin ointment applied twice or three times per day), for up to eight weeks. A dose-measuring device standardized the delivery of 374 mg ointment. Healing of fissures (complete reepithelialization) was assessed by physical examination using an observer unaware of treatment allocation. The subjects assessed pain intensity daily by completing a diary containing a visual analog scale for average pain intensity for the day, the worst pain intensity for the day, and pain intensity at the last defecation.

RESULTS

There were no significant differences in fissure healing among any of the treatment groups; all groups, including placebo had a healing rate of approximately 50 percent. This rate of placebo response was inexplicably higher than previously reported in the literature. Treatment with 0.4 percent (1.5 mg) nitroglycerin ointment was associated with a significant (P < 0.0002) decrease in average pain intensity compared with vehicle as assessed by patients with a visual analog scale. The decreases were observed by Day 4 of treatment. At 8 weeks the magnitude of the difference between 0.4 percent nitroglycerin and control was a 21 percent reduction in average pain. Treatment was well tolerated, with only 3.29 percent of patients discontinuing treatment because of headache. Headaches were the primary adverse event and were dose related.

CONCLUSION

Nitroglycerin ointment did not alter healing but significantly and rapidly reduced the pain associated with chronic anal fissures.

Progress in the understanding and treatment of chronic anal fissure

BACKGROUND

Chronic anal fissure is a common and painful condition associated with internal anal sphincter hypertonia. Reduction of this hypertonia improves the local blood supply, encouraging fissure healing. Surgical sphincterotomy is very successful at healing these fissures but requires an operation with associated morbidity. Temporary reduction in sphincter tone can be achieved on an outpatient basis by applying a topical nitric oxide donor (for example, glyceryl trinitrate) or injecting botulinum toxin into the anal sphincter.

METHODS

A Medline database was used to perform a literature search for articles relating to the non-surgical treatment of chronic anal fissure.

RESULTS

Review of the literature shows botulinum toxin injection to be more effective at healing chronic anal fissures than topical glyceryl trinitrate. Topical isosorbide dinitrate has not been directly compared with either of these two agents but has a healing rate approaching that of botulinum toxin injection. The main side effect of botulinum toxin injection is temporary faecal incontinence in approximately 2% of cases, whereas topical nitrates cause headaches in 20%-100% of cases. No long term side effects were identified with any of the medical treatments.

CONCLUSION

Chemical sphincterotomy is an effective treatment for chronic anal fissure and has the advantages over surgical treatment of avoiding long term complications (notably incontinence) and not requiring hospitalisation.

Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects

PURPOSE

Topical glyceryl trinitrate heals anal fissures, but a majority of patients experience headache. Topical gels of the calcium channel blocker diltiazem and the cholinomimetic bethanechol significantly lower anal sphincter pressure in volunteers. This study investigated the use of these two new pharmacologic agents in the treatment of patients with chronic anal fissure.

METHODS

Two studies were conducted, each involving 15 patients with chronic anal fissure. In each study patients underwent anal manometry and laser doppler flowmetry before treatment. They were treated with either 2 percent diltiazem gel or 0.1 percent bethanechol gel three times daily for eight weeks. Assessment every two weeks was by clinical examination, repeat anal manometry, and laser doppler flowmetry. Daily pain was assessed by linear analog charts.

RESULTS

Fissures healed in 10 of 15 (67 percent) patients treated with 2 percent diltiazem gel and in 9 (60 percent) patients treated with 0.1 percent bethanechol gel. There was no significant difference in the pretreatment maximum resting sphincter pressure (MRP) between responders and nonresponders in either group. There was significant reduction in the pain score after treatment with diltiazem (P = 0.002) and bethanechol (P = 0.005) compared with that before treatment. MRP was significantly lower after diltiazem (P = 0.0001) and bethanechol (P = 0.02) compared with pretreatment MRP. No headaches or side effects were reported.

CONCLUSIONS

Both topical diltiazem and bethanechol substantially reduce anal sphincter pressure and achieve fissure healing to a similar degree reported with topical nitrates, but without side effects.

Glyceryl trinitrate for chronic anal fissure--healing or headache? Results of a multicenter, randomized, placebo-controled, double-blind trial

PURPOSE

Internal anal sphincterotomy for treating chronic anal fissure can irreversibly damage anal continence. Reversible chemical sphincterotomy may be achieved by anal application of glyceryl trinitrate ointment (nitric oxide donor), which has been reported to heal the majority of patients with anal fissure by inducing sphincter relaxation and improving anodermal blood flow. This trial aimed to further clarify the role of glyceryl trinitrate in the treatment of chronic anal fissure.

METHODS

A total of 132 consecutive patients from nine centers were randomly assigned to receive 0.2 percent glyceryl trinitrate ointment or placebo twice daily for at least four weeks. The severity of pain and maximum anal resting pressure were measured before and after one week of treatment. Anodermal blood flow was measured before and after application of glyceryl trinitrate or placebo in ten patients.

RESULTS

The study was completed by 119 patients (59 glyceryl trinitrate and 60 placebo), matched for gender, age, duration of symptoms, duration of treatment, site of fissure, previous attempts to treat, pain score, and maximum anal resting pressure. Twenty-nine patients (49.2 percent) healed after glyceryl trinitrate and 31 patients (51.7 percent) healed after placebo (P = not significant). Pain score fell significantly in both groups, in addition to maximum anal resting pressure. Anodermal blood flow improved significantly in seven patients receiving glyceryl trinitrate, but not in the three receiving placebo. Twenty-three patients (33.8 percent) experienced headache and 4 (5.9 percent), orthostatic hypotension after glyceryl trinitrate.

CONCLUSION

This trial fails to demonstrate any superiority of topical 0.2 percent glyceryl trinitrate treatment vs. a placebo, although the effects of glyceryl trinitrate on anodermal blood flow and sphincter pressure are confirmed. This finding, together with the high incidence of side-effects, should discourage the use of this treatment as a substitute for surgery in chronic anal fissure.

Topical ketanserin gel for anal fissure: an open-label, prospective study

This open-label, prospective study assessed the efficacy and safety of topical ketanserin gel in 63 patients with symptomatic anal fissure. The efficacy outcome was total clinical healing of the fissure. Topical ketanserin gel was 90% effective (fissure healed) and 100% safe (no adverse events) in the primary nonsurgical treatment of anal fissure.

A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure

BACKGROUND AND METHODS

Lateral internal sphincterotomy, the most common treatment for chronic anal fissure, may cause permanent injury to the anal sphincter, which can lead to fecal incontinence. We compared two nonsurgical treatments that avert the risk of fecal incontinence. We randomly assigned 50 adults with symptomatic chronic posterior anal fissures to receive treatment with either a total of 20 U of botulinum toxin injected into the internal anal sphincter on each side of the anterior midline or 0.2 percent nitroglycerin ointment applied twice daily for six weeks.

RESULTS

After two months, the fissures were healed in 24 of the 25 patients (96 percent) in the botulinum-toxin group and in 15 of the 25 (60 percent) in the nitroglycerin group (P=0.005). No patient in either group had fecal incontinence. At some time during treatment, five patients in the nitroglycerin group had transient, moderate-to-severe headaches that were related to treatment. None of the patients in the botulinum-toxin group reported adverse effects. Ten patients who did not have a response to the assigned treatment - 1 in the botulinum-toxin group and 9 in the nitroglycerin group - crossed over to the other treatment; the fissures subsequently healed in all 10 patients. There were no relapses during an average of about 15 months of follow-up.

CONCLUSIONS

Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective nonsurgical treatment.

Nitroglycerin ointment for anal fissures: effective treatment or just a headache?

PURPOSE

Topical nitrates have been shown to cause nitric oxide-mediated relaxation of the internal anal sphincter. Previous reports have suggested initial efficacy in the treatment of anal fissures. The aim of this study was to assess the longer-term usefulness of this treatment.

METHODS

Thirty-three patients with an anal fissure were treated with topical 0.3% nitroglycerin ointment, applied to the anoderm three times per day and after bowel movements. Patients were followed up by office visits and telephone calls until symptoms were completely resolved or treatment was noted to be ineffective or intolerable.

RESULTS

Thirty-three patients were treated, 16 with acute fissures, and 17 with chronic fissures. Nitroglycerin was effective in 9 of 16 acute fissures (56%), and 7 of 17 chronic fissures (41%). Even when effective, 75% of patients reported an adverse reaction.

CONCLUSIONS

Topical nitroglycerin was only effective in approximately one-half of patients with an anal fissure. There was a very high incidence of adverse reactions. In our experience nitroglycerin more often causes a headache than treats the symptoms of anal fissure.

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.

Botulinum toxin injections in the internal anal sphincter for the treatment of chronic anal fissure: long-term results after two different dosage regimens

OBJECTIVE

To investigate the effects of two different dosage regimens of botulinum toxin to induce healing in patients with idiopathic anal fissure.

SUMMARY BACKGROUND DATA

Chronic anal fissure is maintained by contraction of the internal anal sphincter. Sphincterotomy, which is successful in 85% to 95% of patients, permanently weakens the sphincter and therefore might be associated with anal deformity and incontinence.

METHODS

Fifty-seven consecutive outpatients were evaluated. Type A botulinum toxin was injected into the internal anal sphincter.

RESULTS

Patients were divided into two treatment groups based on the number of botulinum toxin units injected. Patients in the first group were treated with 15 units and retreated with 20 units. Patients in the second group were treated with 20 units and retreated with 25 units. Two months after treatment, 10 patients in the first group and 23 patients in the second group had a healing scar. Symptomatic improvement was observed in 13 patients in the first group and in 24 patients in the second group. Statistical analysis showed that resting anal pressure varied from baseline values as a function of treatment; in contrast, the treatment had no effect on maximum voluntary pressure. Long-term healing was achieved in 13 patients in the first group and in all patients in the second group who underwent a complete treatment.

CONCLUSIONS

Botulinum toxin is safe and effective in the treatment of anal fissure. It is less expensive and easier to perform than surgical treatment. No adverse effects resulted from injections of the toxin. The higher dosage is effective in producing long-term healing without complications.

Anorectal disorders

Anorectal disorders are commonly encountered in the practice of emergency medicine. Most can be diagnosed and treated in the emergency department setting. Almost all anorectal disorders once diagnosed and treated in the emergency department need appropriate follow-up to ensure adequacy of treatment, for further possible diagnostic procedures (e.g., endoscopy, biopsy), or for definitive treatment. Hemorrhoids are the most prevalent anorectal disorder and are the most common cause of hematochezia. Treatment is dependent on the degree of hemorrhoid prolapse and symptoms. Most cases can be treated by conservative medical treatment (e.g., dietary changes, sitz baths) or nonsurgical procedures (e.g., rubber band liagation, infrared coagulation). Surgical excision of symptomatic thrombosed external hemorrhoids is indicated if within 48 to 72 hours of pain onset. Anal fissures are one of the most common causes of anorectal pain. They are most frequently idiopathic, and most are located in the posterior midline of the anal canal. Most anal fissures are adequately treated by a medical approach using sitz baths, stool softeners, and analgesics. If the anal fissure becomes chronic and is not responsive to medical therapy, a lateral sphincterotomy of the internal anal sphincter is the surgical procedure of choice. Pharmacologic treatment (botulinum toxin or nitroglycerin ointment) to decrease internal anal sphincter tone has shown promise in the treatment of anal fissure. Anorectal abscesses are categorized into four types: perianal, ischiorectal, intersphincteric, and supralevator. Most are idiopathic and contain mixed aerobic-anaerobic pathogens. Fistula formation varies from 25% to 50% and is much more common with gut-derived organisms (e.g., E. coli, B. fragilis). Definitive treatment for an anorectal abscess is timely surgical incision and drainage to prevent more serious complications (e.g., serious infection, extension of the abscess). Anal carcinomas are infrequent, the majority of them being squamous cell or epidermoid carcinomas. The emergency physician must maintain a high index of suspicion and obtain a biopsy of suspicious lesions in order not to miss the diagnosis of a cancer. The most common presenting complaint of anal tumors is rectal bleeding. Combination chemotherapy and radiotherapy have shown promising results in the treatment of anal canal tumors. Bacterial, viral, and protozoal infections can be transmitted to the anorectum via anoreceptive intercourse. Such infections must be considered when a patient presents with rectal pain or discharge, tenesmus, or rectal or perineal ulcers. Proctosigmoidoscopy and rectal cultures may be necessary to determine the cause. Potential rectal complications of HIV infection include infectious diarrhea, acyclovir-resistant strains of HSV2, Kaposi's sarcoma, lymphoma, and squamous cell carcinoma. Rectal injuries may result from penetrating or blunt trauma, iatrogenic injuries, or foreign bodies. Rectal injury should be suspected when a patient presents with low abdominal, pelvic, or perineal pain or blood per rectum after sustaining trauma or undergoing an endoscopic or surgical procedure. Tetanus prophylaxis, intravenous antibiotics, and surgical intervention are indicated in all but superficial rectal tears.

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.

Primary care office management of perianal and anal disease

Benign anorectal processes, hemorrhoids, fissures, abscesses, fistulas, and infections, as well as some functional disorders, are common. They generate significant patient discomfort and disability. Appropriate recognition of these processes allows for outpatient, office-based intervention. With the techniques and management described in this article, many patients' symptoms can be ameliorated expeditiously.

Treatment of benign anal disease with topical nitroglycerin

PURPOSE

Fissure-in-ano and acutely thrombosed external hemorrhoids are common, benign anal conditions, usually characterized by severe anal pain. Internal anal sphincter hypertonia appears to play a role in the etiology of this pain. Nitric oxide has recently been identified as the "novel biologic messenger" that mediates the anorectal inhibitory reflex in humans. This report documents a therapeutic role for nitroglycerin, a nitric oxide donor, in the treatment of acutely thrombosed external hemorrhoids and anal fissure.

METHODS

Five patients with thrombosed external hemorrhoids and fifteen patients with anal fissure or ulcer were identified. A treatment regimen that included 0.5 percent nitroglycerin ointment applied topically to the anus was instituted. After one week of therapy, all patients were re-examined and questioned regarding pain relief and side effects of treatment. Fissure patients were followed for eight weeks or until healing occurred.

RESULTS

All patients reported dramatic relief of anal pain following application of nitroglycerin. Pain relief lasted from two to six hours. Complete healing of fissures occurred within two weeks in ten patients and within one month in two patients. One patient, whose fissure had not healed completely within two weeks requested surgical sphincterotomy. Two patients remained with persistent anal ulcers despite two months of therapy. Both, however, were pain-free. Side effects were limited to transient headache in 7 of 20 patients.

CONCLUSION

Topically applied nitroglycerin ointment appears to have a therapeutic role in the treatment of thrombosed external hemorrhoids and anal fissure.

Fissure in ano

The present study documents a 15 year experience with anal dilatation in patients with fissure in ano. Patients who were unable to tolerate rectal examination were admitted urgently for anal dilatation. Patients in whom rectal examination and proctoscopy was possible were offered an anal dilator and were reviewed after 4 weeks. Patients who preferred not to use an anal dilator or who had not become asymptomatic were admitted for elective anal dilatation. Four finger anal dilatation was performed under general anaesthesia. Between 1975 and 1990 104 patients underwent 111 procedures. The male to female ratio was 1.3:1. Five patients were re-operated because of failure of resolution of symptoms. Three patients with anal fissures and Crohn's disease were successfully managed by anal dilatation. Nine patients had excision of a 'sentinel pile' in addition to anal dilatation. Ten patients were admitted acutely. One patient developed a perineal haematoma. Seventy-four procedures were performed as day cases. There was no mortality associated with the procedure. At the time of discharge from the clinic no patient complained of problems with continence. These results support our policy of gentle anal dilatation as first management choice in the treatment of anal fissure.

'Reversible chemical sphincterotomy' by local application of glyceryl trinitrate

Nitric oxide has emerged as one of the most important neurotransmitters mediating internal anal sphincter relaxation. The effect of glyceryl trinitrate, a nitric oxide donor, on anal tone was examined. Maximum resting pressure, predominantly a function of the smooth muscle internal anal sphincter, was measured before and 20 min after application of 0.2 per cent glyceryl trinitrate ointment in ten patients. Pressure decreased by a mean of 27 per cent (95 per cent confidence interval 18-36 per cent) (P = 0.0004) after administration of the drug. A further 20 patients were then randomized to either active or placebo ointment. Anal pressure was significantly decreased (P = 0.002) in those who received 0.2 per cent glyceryl trinitrate, but there was no significant reduction in the control patients. Mild headache occurred in two patients who were given the active preparation and in one who received placebo. Manometry was repeated 9h after application of glyceryl trinitrate and showed a sustained decrease in pressure in two patients. Topical glyceryl trinitrate may have a role in the treatment of anal fissure, haemorrhoids, certain types of constipation and anal pain. It may also reduce injury to the internal sphincter during peranal operations.