Currently, the most common surgical problem that I see Israelis suffering from is – anal fissures. I never saw so many cases of this very painful condition in the USA, compared to what I see here in Israel. Thus, I feel compelled to educate the public as to the Evidence Based Medicine (EBM) standards of care for this painful condition. A topic for further discussion, is the long waiting time (many months) that Israelis need to wait in the “kuppa” system for their urgent operations.
An anal fissure (fissure-in-ano) is a small, oval shaped tear in skin that lines the opening of the anus. Fissures typically cause severe pain and bleeding with bowel movements. Fissures are quite common in the general population, but are often confused with other causes of pain and bleeding, such as hemorrhoids.
The typical symptoms of an anal fissure include severe pain during, and especially after, a bowel movement, lasting from several minutes to a few hours. Patients may also notice bright red blood from the anus that can be seen on the toilet paper or on the stool. Between bowel movements, patients with anal fissures are often relatively symptom-free. Many patients are fearful of having a bowel movement and may try to avoid defecation secondary to the pain.
Fissures are usually caused by trauma to the inner lining of the anus. Patients with tight anal sphincter muscles (i.e. increased muscle tone) are more prone to developing anal fissures. A hard, dry bowel movement is typically responsible, but diarrhea can also be the cause. Following a bowel movement, severe anal pain can produce spasm of the anal sphincter muscle, resulting in a decrease in blood flow to the site of the injury, thus impairing healing of the wound. The next bowel movement results in more pain, anal spasm, decreased blood flow to the area, and the cycle continues. Treatments are aimed at interrupting this cycle by relaxing the anal sphincter muscle and anal blood vessels, to promote healing of the fissure.
Other, less common, causes include inflammatory conditions and certain anal infections or tumors. Anal fissures may be acute or chronic. Chronic anal fissures are defined by symptoms lasting more than 12 weeks. Chronic fissures may be more difficult to treat, and may also have an external lump associated with the tear, called a sentinel pile or skin tag; as well as extra tissue just inside the anal canal called a hypertrophied papilla, not to be confused with a polyp.
Acute fissures have the appearance of a tear in the anoderm. In 90% of cases fissures are identified in the posterior midline, however, a fissure can also occur in the anterior midline in 25% of women and 8% of men. Chronic fissures manifest as a sentinel skin tag at the distal fissure margin and a hypertrophied anal papilla proximal to the fissure in the anal canal. Fibers of the internal anal sphincter are often visible at the base of the fissure. The clinical hallmark of an anal fissure is severe sharp pain during or after defecation. The presence of bright red rectal bleeding is common.
There is high quality evidence to begin treatment with non-operative therapy. 50% of patients with an acute anal fissure will heal with conservative therapy which includes: psyllium fiber, sitz baths and stool softeners such as polyethylene glycol. Patients should be cautious prior to using mineral oil since common since is can cause severe anal itching; if aspirated it can cause a severe lung inflammation, called lipoid pneumonitis.
The most common treatment for an acute anal fissure consists of making the stool more formed and bulky with a diet high in fiber, totaling 20-30 grams of fiber per day. Taking stool softeners and increasing water intake may be necessary to promote soft bowel movements and aid in the healing process. Topical anesthetics for pain and warm tub baths (sitz baths) for 20 minutes several times a day (especially after bowel movements) are soothing and promote relaxation of the anal muscles, which may help the healing process.
Medications (such as 0.4% Nitroglycerin or 0.2% Nifedipine) may be prescribed that cause dilatation of the anal blood vessels and thus increased blood flow to the area. Chronic fissures are generally more difficult to treat. High quality evidence supports medical treatment of anal fissures with topical nitrates (nitroglycerine). 50% healing has been demonstrated for chronic anal fissures. Pain is decreased during this treatment. However, the Cochrane EBM (Evidence Based Medicine) review has concluded that topical nitroglycerin is only marginally better than placebo in healing fissures. The typical recommend dose of Rectogesic or Rectiv is 0.4% 2 times daily for 8 weeks. Increased dosage or duration of treatment does not improve healing rates. Headache is very common with topical nitrate treatment. The main limiting factor in this treatment is headache which occurs in up to 30% of patients. Fissure recurrence after medical therapy is higher than after surgical therapy.
Anal fissures may be treated with a topical calcium channel blocker cream with a lower incidence of headaches, based on moderate quality evidence. Nifedipine 0.2% or 0.3% applied 2 times daily for 8 weeks has been associated with healing of chronic anal fissures in 65% of patients. Headache is a very rare complaint; personally I don’t recall any patients’ complaints of this nature. However, some reports in the literature state that headache may occur in up to 25% of cases. Due to lack of efficacy and decreased blood pressure, oral calcium channel blockers, for treatment of fissures is not recommended.
Fissures can recur easily, and it is quite common for a fully healed fissure to recur after a hard bowel movement or other trauma. Even when the pain and bleeding have subsided, it is very important to continue good bowel habits and a diet high in fiber as a lifestyle change.
A fissure that fails to respond to conservative measures should be re-examined. Persistent hard or loose bowel movements, scarring, or spasm of the internal anal muscle all contribute to delayed healing. Other medical problems such as inflammatory bowel disease (Crohn’s disease), infections (HIV, syphilis, tuberculosis), or anal tumors (SCC, leukemia) can cause symptoms similar to anal fissures. Patients suffering from persistent anal pain or one who has a fissure located in the lateral location, should be examined to exclude these diseases. This may include a colonoscopy or an exam in the operating room under anesthesia. A biopsy should be performed on any fissure that fails to heal after surgical treatment.
Another medical option described is the injection into the anal sphincter of Botulinum toxin (Botox®). Botox® injection treatments have reported healing rates of 50% to 80%, while surgical sphincterotomy success is reported to be over 90%. The patient must be aware of the risk that temporary incontinence to flatus can occur in 20% of cases and temporary incontinence of stool occurs in 5% of cases after Botox treatment.
One of the practical limitations of Botulinum toxin is the prohibitive cost of the medication itself. It is not covered by most insurance plans and is too costly for most patients to afford. The cost of treatment has been reported to be more than $5,000 per treatment, which is prohibitive for most patients. There is very low quality evidence supporting the use of Botulinum toxin injections as a treatment modality. There is inadequate consensus on dosage, precise site of administration, number of injections and efficacy. Recurrence occurs in 40% of patients which require re-treatment and more cost.
Surgical options for treating anal fissure include lateral internal sphincteroromy (LIS) or subcutaneous fissurotomy. The goal of these surgical options is to promote relaxation of the anal sphincter, thereby decreasing anal pain and spasm, thereby allowing the fissure to heal. If a sentinel pile is present, it may be removed to promote healing of the fissure. Both of these are performed typically as outpatient, same-day procedures. All surgical procedures carry some risk, and a sphincterotomy can rarely interfere with one’s ability to control gas and stool, when surgery is performed by a colorectal surgeon.
Lateral internal sphincterotomy (LIS) is the surgical treatment of choice for refractory anal fissures based on high quality evidence. Manual dilatation (Lord Procedure) is not recommended due to uncontrolled tearing of the anal sphincter resulting in fecal incontinence. This is in contrast to the LIS procedure, which is a controlled cutting of the internal sphincter only, in the lateral location. Similarly, posterior sphincterotomy or fissurectomy is not currently recommended.
There is a fear among patients to have the LIS procedure due to reported fecal incontinence rates as high as 15%. These results maybe the difference between the outcomes of a fellowship trained board certified colorectal surgeon and a general surgeon. In my experience the risk of incontinence after LIS is very low. I quote my patients a risk of 1% based on personal experience. However there is another surgical option which may further eliminate or decrease the risk of incontinence. This procedure is known as the Subcutaneous Fissurotomy, described by A. Pelta and D. Armstrong in 2007. In this article published in the Diseases of the Colon and Rectum (DCR), we evaluated 109 patients after subcutaneous fissurotomy. In this operation, only skin is cut and no muscles are harmed. A 98% cure rate was reported with no fecal incontinence; however there was post-operative pain. Larger trials are needed to improve the quality of this evidence. However it is still a viable alternative to LIS based on patient preference.
Anal advancement flap and subcutaneous fissurotomy are surgical alternatives to LIS. The advantage of these techniques is that they do not divide the internal anal sphincter and yet allow good healing rates. This is especially attractive especially to patients with preexisting continence problems.
Surgery is consistently superior to medical therapy and may be offered without a pharmacological treatment failure based on high quality 1A evidence. LIS is superior to any topical or injected agent with low rates of incontinence. My personal bias is to always start with medical therapy and only proceed with surgery if pain is not tolerable after a trial of nifedipine cream with stool softeners. Even better is to wait 2-3 months, if possible, to allow medical treatment to work. At that point a persistent fissure will only heal with surgery and medical therapy has clearly failed.
It is important to note that complete healing with both medical and surgical treatments can take up to approximately 6-10 weeks. However, acute pain after surgery often disappears after a few days. Most patients will be able to return to work and resume daily activities in a few short days after the surgery.
There has been a recent interest in small case studies using laser therapy treatment for anal fissures. Due to very low quality of evidence, none of these studies are conclusive or within the accepted standard of care for the treatment of anal fissures. Laser therapy cannot be recommended as an acceptable treatment for anal fissures at this time.
Any patient who suffers from anal pain or fissures is recommended to seek the guidance and care from a fellowship trained colon and rectal surgeon (CRS).
To become a board certified CRS one must first complete a 5 year general surgery residency program, and then pass the written and oral General Surgery boards. The next step is completing another year of advanced residency training called a fellowship. After the fellowship one must pass a very comprehensive written exam in Colon and Rectal Surgery followed by an oral exam a year later. Once the surgeon is in an active surgical practice and is able to demonstrate competency and has the acceptance of his colleagues; then he is eligible to be inducted as a Fellow of the American Society of Colon and Rectal Surgeons (FASCRS).
Arie E. Pelta, MD FACS FASCRS