Quality of life in patients with chronic anal fissure after topical treatment with diltiazem

Enhanced Approach to Treating Chronic Anal Fissures: Fissurectomy with Vertical Non-full-thickness Midline Sphincterotomy and Mucosal Advancement Flap

Objectives

Lateral internal sphincterotomy is a conventional surgical intervention for chronic anal fissures, yet the potential for postoperative anal incontinence underscores the need for an alternative approach. This study aimed to evaluate the outcomes of patients with chronic fissures who underwent a combination of fissurectomy, vertical non-full thickness midline sphincterotomy (VNMS), and mucosal advancement flap (MAF), as a means of mitigating the risk of incontinence.

Methods

This retrospective analysis included forty-six consecutive patients with chronic anal fissures, unresponsive to topical diltiazem, who underwent fissurectomy combined with VNMS and MAF between April 2018 and May 2023. Primary outcome measures encompassed fissure healing rates. Continence was assessed using the Fecal Incontinence Severity Index (FISI), and manometric assessments were conducted before the procedure and three months postoperatively.

Results

With a median follow-up of 27 months, there were no postoperative complications, and the overall fissure healing rate reached 96% (44/46). At three months post-procedure, FISI scores were reduced to 0, with no instances of fecal soiling. Anal resting pressure exhibited a significant reduction at 3 months [pre-op: 133 (95% CI, 128-150) vs. 3 mo: 109 (95% CI, 100-117) cmH2O; p = 0.01]. Similarly, maximum anal squeeze pressure showed a significant decrease three months post-surgery [pre-op: 317 cmH2O (95% CI, 294-380) vs. 3 mo: 291 cmH2O (95% CI, 276-359), p = 0.03].

Conclusions

The combination of fissurectomy, VNMS, and MAF proved to be an effective approach for chronic anal fissures, yielding favorable medium-term outcomes without postoperative anal incontinence.

Assessment of Quality of Life in Patients with Chronic Anal Fissures: A 1-Year Follow-Up Study before and after Botulinum Toxin (Botox) Injection

This longitudinal study aimed to assess the quality of life in patients with anal fissures treated with botulinum toxin (Botox) injections over a one-year period. The study hypothesized that Botox injections would significantly improve quality of life and that these improvements would be sustained over a year. Conducted as a cross-sectional study, it assessed adults diagnosed with chronic anal fissures unresponsive to conventional treatments. Participants received 25 U of Botox in two sessions and their quality of life was assessed using the WHOQOL-BREF, COPE-60, Hospital Anxiety and Depression Scale (HADS), and SF-36 surveys. Data were collected at baseline six months and one year post-treatment. The study involved 113 patients, with a mean age of 38.1 years. Significant improvements were observed in the WHOQOL-BREF scores across all domains from baseline to 12 months (physical domain: 49.4 ± 10.5 to 70.2 ± 10.6, p < 0.001; mental domain: 34.8 ± 11.2 to 61.9 ± 11.5, p < 0.001). SF-36 scores also showed significant enhancements in physical and mental health components (physical: 44.3 ± 7.5 to 56.9 ± 5.9, p < 0.001; mental: 41.1 ± 7.2 to 54.4 ± 6.3, p < 0.001). Additionally, significant improvements were noted in patient perception on quality of life from the perspective of various aspects including physical discomfort, pain management, and mood and emotional well-being. The study demonstrated that Botox injections significantly improved the quality of life in patients with chronic anal fissures, with sustained benefits observed over a year. These findings suggest Botox as an effective treatment modality for enhancing life quality in patients with this condition, highlighting the potential for broader applications in managing chronic anal fissures.

L-Arginine is a feasible supplement to heal chronic anal fissure via reducing internal anal sphincter pressure: a randomized clinical trial study

The hypertonicity of internal anal sphincter resting pressure is one of the main causes of chronic anal fissure. Therefore, the aim of this study was to assess the effect of oral administration of L-arginine on the improvement of the anal fissures by relaxing the internal anal sphincter. Seventy-six chronic anal fissure patients (aged 18-65 years) who were referred to Rasoul-e-Akram Hospital, Tehran, Iran from February 2019 to October 2020 participated in this randomized, double-blind, placebo-controlled trial. Participants were allocated into treatment (L-arginine) and placebo groups. They took a 1000 mg capsule three times a day for 1 month, and then we followed them at the end of the first and third months after the intervention. Clinical symptoms, anal sphincter resting pressure, and quality of life (QoL) were completed at baseline and the end of the study. The analysis of data showed a significant decrease in bleeding, fissure size, and pain for each group; however, in the L-arginine group was more than the control group at the end of the study (P values < 0.001). Following that, a significant increase in QoL was seen just in patients treated with L-arginine (P value = 0.006). In addition, the comparison of anal pressures at baseline and, between groups at the end of the study showed a significant reduction in sphincter pressure in patients treated with L-arginine (P value < 0.001, = 0.049; respectively). The oral administration of 3000 mg L-arginine can heal chronic anal fissures by reducing internal anal sphincter pressure with more negligible side effects. However, we recommend long-term study with more extended follow-up.Clinical trial registry: IRCT20190712044182N1 at Iranian clinical trials, date: 2019-08-27.

Pelvic floor physical therapy in the treatment of chronic anal fissure (PAF trial): quality of life outcome

BACKGROUND

Chronic anal fissure is one of the most common anorectal diseases and is associated with reduced quality of life. The aim of this study was to investigate the effects of pelvic floor physical therapy on quality of life in patients with chronic anal fissure using the Short-Form 36 Health Survey (RAND-36).

METHODS

Adult patients, with chronic anal fissure and concomitant pelvic floor dysfunction, such as dyssynergia and increased pelvic floor muscle tone, were recruited at the Proctos Clinic in the Netherlands, between December 2018 and July 2021 and randomly assigned to an intervention group, receiving 8 weeks of pelvic floor physical therapy or assigned to a control group receiving postponed pelvic floor physical therapy (PAF trial). Quality of life and pain ratings were outcomes of the study and were measured at 8- and 20-week follow-up.

RESULTS

One hundred patients (50 women and 50 men, median age 44.6 years [range 19-68 years]), completed the RAND-36 questionnaire and visual analog (VAS) pain scale score at admission. A significant improvement was found at 20-week follow-up in all domains of the RAND-36; physical functioning, pain, health change (p < 0.001); physical role, vitality, general health, social functioning, emotional role, mental health (p < 0.05). VAS pain was significantly reduced at 8 weeks (mean estimated difference 1.98; 95% CI 1.55-2.42, p < 0.001) and remained significant at 20-week follow-up (p < 0.001). The difference between the groups as regards change in the mean pain intensity scores at 8 weeks was 2.48 (95% CI - 3.20 to - 1.75; p < 0.001). Compared to the reference values of the general Dutch population, the patients in our study with a chronic anal fissure and pelvic floor dysfunction reported an impaired quality of life in 8 of 9 domains of the RAND-36. After treatment, significant lower scores were found in 2 out of 9 domains.

CONCLUSIONS

The results of this study provide evidence that treatment by pelvic floor physical therapy improves quality of life and reduces pain, making it an important tool in management of chronic anal fissure and concomitant pelvic floor dysfunction.

Efficacy of posterior median anal incision with incision and drainage of the anal sinus on chronic anal fissure

BACKGROUND

To explore the efficacy of posterior median anal incision plus incision and drainage of anal sinus on chronic anal fissure (CAF), and its influence on incidence and recurrence of postoperative infection.

METHODS

Altogether 130 patients with CAF treated during January 2017 and January 2021 were included and divided into a research group (RG) and control group (CG). Among them, 80 patients in the RG were treated with posterior median anal incision and expansion plus anal sinus incision and drainage, while 50 in the CG were treated with lateral internal sphincterotomy. Clinical indexes (wound healing time, recovery time of bowel sounds, intraoperative blood loss, length of stay), levels of inflammatory factors (IL-6, IL-8, CRP) before and one week after treatment, changes of psychological and emotional scores (SAS, SDS scores) before and 6 months after treatment, sleep and scores of daily activities after admission and 6 months after treatment, VAS scores at 1 day, 1 week and 2 weeks after operation, compliance, total effective rate, and incidence and recurrence rate of postoperative incision infection were compared between the groups.

RESULTS

Compared with the CG, the wound healing time, recovery time of bowel sounds and length of stay were shorter, and intraoperative blood loss was lower in the RG; the levels of IL-6, IL-8 and CRP were lower in RG one week after treatment. Six months after treatment, the SAS, SDS and PSQI scores were lower, the ADL scores were higher, the compliance and total effective rate were higher, and the incidence and recurrence rate of postoperative incision infection were lower in the RG.

CONCLUSION

Posterior median anal incision plus incision drainage of the anal sinus has better efficacy on CAF, and can effectively reduce the incidence of postoperative infection and recurrence.

Sexuality, Quality of Life, Anxiety, Depression, and Anger in Patients with Anal Fissure. A Case-Control Study

Anal fissures (AFs) are lesions located in the lower anal canal. They can be primary (chronic or acute) or secondary to a basic disease. There is high comorbidity of depression and anxiety in patients with chronic AF, with poorer quality of life (QoL) and sexual function. This is a case–control study carried out in the San Juan Hospital (Alicante, Spain). Sixty-seven participants were included in the study, including 35 cases and 32 controls: 36 males and 31 females. This study aims to investigate the association of presenting AFs with sexuality, quality of life, anxiety, depression, and anger. The instruments used were the Spanish validated versions of the validated original selected questionnaires. These instruments were used to assess health-related quality of life, anxiety, anger, depression, and sexual function. Results show higher values in cases than in controls with statistical significance in anxiety state and trait; anxiety and depression; bodily pain, general health, and vitality; and 10 of the 12 anger factors. Higher values in controls than in cases with statistical significance in sexuality and many of the QoL factors were found. Addressing these issues in AF surgical patients would be beneficial for their clinical assessment and intervention.

Comparison of the Effects of Diltiazem Gel with Lidocaine Gel on Reducing Pain and Discomfort in Patients Undergoing Rectosigmoidoscopy: A Randomized Double-blinded Clinical Trial

Background:

Flexible rectosigmoidoscopy is an easy and accessible exam to diagnose distal colon diseases, although many patients refuse to undergo it due to pain and discomfort during the procedure. Studies show that the application of local lidocaine, as an analgesic has no effect on pain relief in patients undergoing rectosigmoidoscopy. The current study aims at comparing the effects of diltiazem gel, an antispasmoic drug with local pain-reducing effects, with lidocaine gel in patients undergoing flexible rectosigmoidoscopy.

Materials and Methods:

The current double-blinded, randomized, clinical trial was performed to compare the effect of two topical drugs, lidocaine and diltiazem, on pain relief in patients undergoing rectosigmoidoscopy. A total of 80 patients who were potential candidates for rectosigmoidoscopy were enrolled in the study after obtaining the informed consent and then randomly assigned to one of the lidocaine gel (2 mL) or diltiazem gel (2 mL) group, 10 minutes prior to rectosigmoidoscopy. The level of pain in the patients during the procedure was measured using the visual analogue scale (VAS) and the results were recorded. The data were analyzed using paired samples ttest and independent t-test as well as analysis of covariance (ANOVA) with SPSS version 18. P-value <0.05 was considered the level of significance.

Results:

Of 80 patients, 35 (43.75%) were male and 45 (56.25%) female. The mean age and body mass index (BMI) of the patients were 51.45 ± 15.21 years and 25.95 ± 7.47 kg/m2, respectively, and there was no significant difference between the groups. The most frequent indications for rectosigmoidoscopy were abdominal pain (46.3%) and rectorrhagia (31.3%). The mean VAS score for pain reported by the patients in the lidocaine and diltiazem groups was 3.97 ± 2.89 and 2.60 ± 2.36, respectively. The VAS score for pain in the diltiazem group was significantly lower than lidocaine group (P = 0.023).

Conclusion:

The application of local diltiazem gel around the anus, in spite of no side effects, can effectively reduce the pain and discomfort in patients during rectosigmoidoscopy. Iranian Registry of Clinical Trials (Reg. No 31055).

Analgesic Effectiveness and Improvement in Quality of Life after Using Topical Sevoflurane for an Extremely Painful Anal Fissure

Painful anal fissures could be distressing conditions that severely impair the patients' quality of life. The analgesic effectiveness of topical drugs, such as calcium-antagonists and nitrates is quite variable. The inhalational anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds. We report a pioneer experience treating a painful chronic anal fissure with topical sevoflurane. A young adult male was suffering from an extremely painful chronic anal fissure, which severely affected his quality of life. The topical treatment with nitroglycerine and diltiazem gels failed. The patient agreed to the treatement with topical sevoflurane as an off-label medication, and it produced an immediate, intense, and long-lasting analgesic effect. An intense but rapidly transient burning sensation, as well as persistent but well-tolerated flatulence were the only adverse effects. The quality of life was greatly improved, and the cost of the treatment was affordable. Therefore, the off-label use of topical sevoflurane appears to be an effective alternative for the symptomatic treatment of painful anal fissures.

MEBO versus topical Diltiazem versus a combination of both ointments in the treatment of acute anal fissure: a randomized clinical trial protocol

Background

Anal fissure is a common complication of the anorectal region and one of the most reported causes of anal pain. Acute anal fissure can be cured by surgery or medical treatment. There is an increase in the use of topical therapy for the treatment of anal fissures. A common topical drug used is Diltiazem (DTZ), a calcium-channel blocker, which relaxes the anal sphincter and thus promotes healing of the anal fissure. Moist exposed burn ointment (MEBO) is an ointment that is effective for the treatment of burns and wound healing and is becoming popular in the treatment of anal fissures.

Methods

This is a 1:1:1 randomized, controlled, parallel design, with endpoint measures of change in pain score, wound healing, defecation strain score and patient’s global impression of improvement. The study will be conducted at AUBMC over a 10-week period. Patients will be randomized to three treatment arms: MEBO, Diltiazem, and a combination of MEBO and Diltiazem ointments.

Discussion

The results of this study will allow physicians to assess the efficacy and safety of MEBO in the treatment of acute anal fissure, and also in comparison to Diltiazem. This trial will generate evidence-based conclusions regarding the use of a herbal/natural-based product (MEBO ointment) for the treatment of anal fissures.

Trial registration

ClinicalTrials.gov Identifier NCT04153032. Clinical Trial Registration Date: 06-NOVEMBER-2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03227-z.

Health and quality of life among a cohort of patients having lateral internal sphincterotomy for anal fissures

AIM

The aim of this study is to report changes in health-related quality of life attributable to lateral internal sphincterotomy for treatment of anal fissure. There is very little evidence on whether the overall health-related quality of life of patients is detrimentally affected by the condition, or which aspects of self-perceived health status improve after lateral internal sphincterotomy. This study will articulate which aspects of health tend to improve and guide postoperative expectations appropriately. Knowledge gained from this study may also identify gaps in an individual patient's episode of care.

METHOD

Patients were prospectively identified when they consented to surgical treatment of their anal fissure and were contacted by phone to participate. Participants completed a number of patient-reported outcomes preoperatively and 6 months postoperatively. Faecal incontinence-related quality of life, pain and depression were measured at both time points. The severity of faecal incontinence was measured at both times.

RESULTS

Participants reported high levels of pain preoperatively. Postoperatively, improvement in pain exceeded the threshold of clinical relevance (P < 0.01). Thirty-five per cent of participants reported significant effects of faecal incontinence preoperatively, while 26% did so postoperatively. Participants with multiple comorbidities were more likely to report faecal incontinence postoperatively than preoperatively.

CONCLUSION

This study reports that lateral internal sphincterotomy improved pain symptoms without adverse effects on continence. Not all domains of health-related quality of life were similarly positively affected by anal fissure repair.

Potential combination topical therapy of anal fissure: development, evaluation, and clinical study†

To treat anal fissure, internal anal sphincterotomy may be associated with surgical risks and incidence of incontinence. Botulinum toxin injection into the anal sphincter is invasive and expensive. Headache and hypotension hindered topical treatment with glyceryl trinitrate. Greater patient compliance, potentiated efficacy, reduced side effects, and lower cost are the major advantages offered by the combination therapy. Therefore, combination topical gels of nifedipine (NIF), lidocaine hydrochloride (LDH) and betamethasone valerate (BMV) were prepared and evaluated regarding viscosity, pH, drug content, and in vitro release. Compatibility study of drug-drug and drug-excipient mixtures preceded the formulation. Stability study was performed. A prospective randomized clinical trial was conducted for six weeks to assess the efficacy of the optimized formula in the treatment of anal fissure either acute (AAF, 37 patients) or chronic (CAF, 34 patients) in comparison with three single drug market products. The compatibility was indicated except in case of LDH with each of poloxamer 407 (P407), methylparaben, and propylparaben as well as BMV with P407. The gels showed acceptable viscosity ranges, tolerated pH values, and drugs content limits complying with the pharmacopeial limit. The gel containing 10% Transcutol^® (F2) was selected as optimized formula due to the significant (p < 0.05) enhancement in NIF release. The recommended storage temperature was 8 °C. In comparison with the market products, the optimized gel can be represented as a potential combination therapy of acute and chronic anal fissures as suggested by significantly increased healing% and significantly reduced pain, bleeding, anal discharge and itching without side effects.

Effects of subjective sleep quality on the quality of life in patients with chronic anorectal disorder

OBJECTIVE

The aim of the present study was to evaluate the subjective sleep quality in patients with anorectal disorder, to determine the factors associated with subjective sleep quality, and to explore the relationship between subjective sleep quality and quality of life.

MATERIAL AND METHODS

This descriptive study was conducted between April 8, 2015 and April 12, 2016. The research population consisted of 284 patients who attended the general surgery outpatient clinics of Konya Military Hospital and were subsequently diagnosed with one of the four most common anorectal disorders (hemorrhoidal disease, anal fissure, anorectal abscess/fistula, and sacrococcygeal pilonidal disease). Data were collected from 114 patients who volunteered to participate in the study. After establishment of the diagnosis based on proctological anamnesis and physical examination, the Pittsburgh Sleep Quality Index, Short-Form Health Survey, Beck Anxiety Inventory, and Beck Depression Inventory were administered to the patients, along with a questionnaire on sociodemographic data, via a face-to-face interview technique.

RESULTS

Ninety-six (84.2%) patients had poor sleep quality, whereas 18 (15.8%) patients had good sleep quality. Among the patients with poor sleep quality, 16 were diagnosed with anorectal abscess and fistula (100.0%), 40 with hemorrhoidal disease (90.9%), 16 with sacrococcygeal pilonidal disease (80.0%), and 24 with anal fissure (70.6%). Overall, all patients with poor sleep quality (n=96) had low scores in all subcomponents of the quality of life scale.

CONCLUSION

The sleep quality in patients with chronic anorectal disorder is significantly impaired, thus negatively affecting quality of life. Therefore, improvement in quality of life by improving sleep quality should be one of the main objectives in treating chronic anorectal disorders.

Quality of life following fistulotomy - short term follow-up

AIM

Anal fistula causes pain and discharge of pus and blood. Treatment by fistulotomy has the highest success, but can risk continence; treatment needs to balance cure with continence. This study assessed the impact of fistulotomy on quality of life (QOL) and continence.

METHOD

Patients selected for fistulotomy prospectively completed the St Mark's Continence Score (full incontinence = 24) and Short Form-36 questionnaires preoperatively at two institutions with an interest in anal fistula. Patients were reassessed 3 months' postoperatively.

RESULTS

There were 52 patients with a median age of 44 (range 19-82) years; 10 were women. Preoperative continence scores were median 0 (range 0-23) and there was no significant difference compared with postoperative scores (median 1, range 0-24). Following fistulotomy QOL was significantly improved in four of eight domains - Bodily Pain (P < 0.001), Vitality (P < 0.01), Social Functioning (P < 0.05) and Mental Health (P < 0.001) - and returned to that of the general population. QOL for patients with intersphincteric fistula improved postfistulotomy, and for those with trans-sphincteric fistula it remained the same. Data were further examined in two groups, with and without deterioration in continence score. Where continence improved postoperatively, QOL improved in three domains; where continence deteriorated QOL improved in two domains (P < 0.05). Patients with postoperative continence scores of < 5 had worse QOL than those scoring 4 or less.

CONCLUSION

QOL significantly improved at 3 months' follow-up after fistulotomy where continence was maintained or a small reduction occurred.

Stress and psychopathology and its impact on quality of life in chronic anal fissure (CAF) patients

BACKGROUND

Chronic anal fissure (CAF) onset, exacerbation, and impact on quality of life are influenced by a host of psychological, physiological, and social factors. We aimed to investigate the difference in psychopathology and stress between normal and CAF groups.

METHODS

Thirty CAF patients and 20 age-sex matched healthy controls were evaluated for Axis I psychopathology, depression, anxiety, and stress with Hamilton and Hospital Depression-Anxiety Scales, Perceived Stress Scale, and SF-36.

RESULTS

With a mean age of 39.47, 83.3% of CAF patients were female. Anxiety-depression and stress scores were all significantly higher and functionality was lower in the CAF group compared to controls (p < 0.001); 36.7% of the patients had a triggering stress factor and 56.6% had an exacerbating stress factor; 56.7% of the patients had an ongoing Axis I psychopathology while 50% had a previous psychopathology. Pain (96.7% had pain (VAS = 6.55)) and bleeding (83.3% had bleeding (VAS = 4.14)) severity showed a negative impact on bodily pain and role limitations emotional subscales of SF36.

CONCLUSION

There is a high comorbidity of psychopathology in the CAF patients and depression and anxiety severities show a negative impact on the quality of life. Stress acts as both a triggering and an exacerbating factor in CAF.

Increasing efficacy and reducing side effects in treatment of chronic anal fissures: A study of topical diazepam therapy

This is a single institution nonexperimental study intended to analyze the therapeutic efficacy of topical diazepam in treating symptoms of chronic anal fissures.Anal fissures are a common cause of anal pain. Conventional treatments include nonsteroidal anti-inflammatory drugs, topical creams, such as nitroglycerin and nifedipine, and surgery. However, these treatments are usually suboptimally efficacious or have deterring side effects.Patients at an outpatient community center with a diagnosis of a chronic anal fissure were prescribed either topical 2% (n = 19) or 4% (n = 18) diazepam cream between January 2013 and February 2015. We retrospectively analyzed their responses to treatment.All 19 patients using 2% diazepam cream experienced a positive response in pain, whereas 47.4% experienced a complete response, with a numerical rating scale (NRS) score of 0 (0-10). Eighty-eight percent of patients using 4% dose had a positive response in pain, whereas 23.5% experienced a complete response. Ninety-four percent of patients using 2% dose had a positive response in anal bleeding, whereas 68.8% experienced a complete response with an anal bleeding score (ABS) of 2 (2-9). Ninety-four percent of patients using 4% dose had a positive response in anal bleeding, whereas 64.7% experienced a complete response. Only 1 patient reported a side effect from diazepam cream-perianal pruritus.Both 2% and 4% topical diazepam provided significant pain and bleeding relief from chronic anal fissures that were refractory to conventional therapies. There were insignificant differences when assessing independent comparisons for pain and bleeding between the doses.

Prospective multicenter observational trial on the safety and efficacy of LEVORAG® Emulgel in the treatment of acute and chronic anal fissure

Background

Anal fissure (AF) is a common cause of anal pain with a tendency not to heal spontaneously because of ischemia of the anoderm caused by sphincter spasm. Lateral internal sphincterotomy, while very effective, can cause fecal incontinence and chemical sphincterotomy by application of cream may have discouraging side effects and/or low efficacy. The aim of this prospective multicenter study was to evaluate the safety and effectiveness of a new medical treatment based on Emulgel cream, with emollient, soothing and protective agents, on AF healing.

Methods

Consecutive patients with AF treated in nine coloproctology units during 6 months entered the study on topical treatment with Levorag^® Emulgel (THD S.p.A Correggio (RE), Italy). Before treatment, they had a proctologic examination and pain was measured using a visual analog scale. THD Levorag^® Emulgel was applied every 12 h for 40 days. Monitoring was scheduled at 10, 20 and 40 days. At time 0 and at the end of treatment, patients underwent anorectal manometry, if possible.

Results

Two hundred eighty-four AF patients were recruited (171 acute fissures). Complete healing was achieved in 47.9 % of the cases, an improvement in 31.0 % (global efficacy 78.9 %). In patients with acute fissure, the rate of efficacy was 89.4 % (complete healing: 64.3 %, improvement: 25.1 %), in those with chronic fissure the rate of efficacy was 62.8 % (complete healing: 23 %, improvement: 39.8 %), p < 0.001. Pain and resting anal pressure decreased significantly after treatment.

Conclusions

Treatment with THD Levorag^® Emulgel proved to be effective for the reepithelization of AF and the reduction of pain in the short term in about 80 % of patients.

Partial lateral internal sphincterotomy versus combined botulinum toxin A injection and topical diltiazem in the treatment of chronic anal fissure: a randomized clinical trial

OBJECTIVES

The aim of this study is to evaluate the effectiveness and complications associated with combined topical diltiazem cream and botulinum toxin A injection versus partial lateral internal sphincterotomy in chronic anal fissure.

DESIGN

This study is a parallel, randomized controlled trial (using the block randomization method).

SETTING

This study was performed at a university hospital in Iran.

PARTICIPANTS

Ninety-nine patients who had chronic anal fissures were included.

INTERVENTION

A total of 99 patients were randomly assigned to 2 groups; the first group received combined topical diltiazem ointment (for 6 weeks) and botulinum toxin A injection (once) (n = 49), and the second group received partial lateral internal sphincterotomy (n = 50). All the patients were followed up for 1 year.

MAIN OUTCOME MEASURES

The primary outcomes measured were the healing of the anal fissure and the development of incontinence as the major adverse event during the 1-year follow-up period.

RESULTS

The overall healing rate was 65% and 94% in the botulinum toxin A-diltiazem and partial lateral internal sphincterotomy groups (p < 0.001). The patients in the partial lateral internal sphincterotomy group experienced significantly higher incontinence scores (p = 0.04) according to the Cleveland Clinic Florida-Fecal Incontinence scoring system. In patients who had chronic anal fissure for ≤12 months, no statistical difference was observed in the healing rate between the botulinum toxin A-diltiazem and partial lateral internal sphincterotomy groups (100% vs 100%). However, in the patients with longer chronic fissures, the healing rate was significantly higher in the partial lateral internal sphincterotomy group (86% [18/21] vs 23% [5/21], p < 0.001).

LIMITATIONS

The 1-year follow-up period, subjective definitions of itching, and lack of anorectal manometry examinations and data regarding the effect of each treatment on anal sphincter pressure at rest and contraction are the key limitations of this study.

CONCLUSION

Combined botulinum toxin A injection with a topical application of diltiazem could be as effective as partial lateral internal sphincterotomy in the treatment of chronic anal fissure in patients who have chronic anal fissure for ≤12 months. However, in chronic anal fissures of longer duration, partial lateral internal sphincterotomy is associated with a significantly higher cure rate.

Cost considerations in the treatment of anal fissures

Anal fissure is a split in the lining of the distal anal canal. Lateral internal sphincterotomy remains the gold standard for treatment of anal fissure. Although technique is simple and effective, a drawback of this surgical procedure is its potential to cause minor but some times permanent alteration in rectal continence. Conservative approaches (such as topical application of ointment or botulinum toxin injections) have been proposed in order to treat this condition without any risk of permanent injury of the internal anal sphincter. These treatments are effective in a large number of patients. Furthermore, with the ready availability of medical therapies to induce healing of anal fissure, the risk of a first-line surgical approach is difficult to justify. The conservative treatments have a lower cost than surgery. Moreover, evaluation of the actual costs of each therapeutic option is important especially in times of economic crisis and downsizing of health spending.

Quality of compounded topical 2% diltiazem hydrochloride formulations for anal fissure

AIM: To investigate the quality of topical 2% diltiazem formulations extemporaneously compounded by retail pharmacies openly offering drug-compounding services.

METHODS: A participating healthcare professional wrote 12 prescriptions for compounded 2% diltiazem cream, with 2 refills allowed per prescription. The 12 sets of prescriptions were filled, at intervals of 1-2 wk between refills, at 12 different independent retail pharmacies that openly offer drug-compounding services in a major metropolitan region. The 36 resultant preparations, provided as jars or tubes, were shipped, as soon as each was filled, at ambient temperature to the study core laboratory for high-performance liquid chromatography (HPLC) analysis, within 10 d of receipt. For the HPLC analysis, 8 different samples of the topical diltiazem, each approximately 1 g in weight, were taken from prespecified locations within each container. To initiate the HPLC analysis, each sample was transferred to a 100 mL volumetric flask, to which methanol was added. The HPLC analysis was conducted in accordance with the laboratory-validated method for diltiazem in cream, ointment, and gel formulations. The main outcome measures were potency (percentage of label claim) and content uniformity of the compounded topical 2% diltiazem formulations.

RESULTS: Of the 36 prescriptions filled, 30 were packaged in jars and 6 were packaged as tubes. The prescriptions were specifically for cream formulations, but 6 of the 12 pharmacies compounded 2% diltiazem as an ointment; for another pharmacy, which had inadequate labeling, the dosage form was unknown. The United States Pharmacopoeia (USP) standard for potency is 90%-115% of label claim. Of the 36 preparations, 5 (13.89%) were suprapotent and 13 (36.11%) were subpotent. The suprapotent prescriptions ranged in potency from 117.2% to 128.5% of label claim, and the subpotent prescriptions ranged in potency from 34.8% to 89.8% of label claim. Fourteen (38.9%) preparations lacked content uniformity according to the USP standard of 90%-110% potency and < 6% relative standard deviation. Of the 30 formulations packaged in jars, 12 (40%) lacked content uniformity, while of the 6 formulations packaged in tubes, 2 (33.3%) lacked content uniformity. Nine of the 12 pharmacies (75%) failed USP potency or content-uniformity specifications for at least 1 of the 3 prescription fills. For 5 of the 12 pharmacies (41.7%), the mean potency across all three prescription fills was < 90% of label claim.

CONCLUSION: Patients prescribed topical 2% diltiazem for treatment of anal fissure frequently receive compounded formulations that are misbranded with respect to potency and that lack content uniformity.