Gastroenterology
Volume 124, Issue 1 , Pages 235-245 , January 2003

AGA technical review on the diagnosis and care of patients with anal fissure

References 

  1. Nothmann BJ, Schuster MM. Internal anal sphincter derangement with anal fissures. Gastroenterology. 1974;67:216–220
  2. Hancock BD. The internal sphincter and anal fissure. Br J Surg. 1977;64:92–95
  3. Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum. 1994;37:424–429
  4. Gibbons CP, Read NW. Anal hypertonia in fissures: cause or effect?. Br J Surg. 1986;73:443–445
  5. Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989;32:43–52
  6. Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum. 1994;37:664–669
  7. Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996;83:63–65
  8. Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg. 1996;83:1335–1344
  9. Hananel N, Gordon PH. Re-examination of clinical manifestations and response to therapy of fissure-in-ano. Dis Colon Rectum. 1997;40:229–233
  10. Shub HA, Salvati EP, Rubin RJ. Conservative treatment of anal fissure: an unselected, retrospective and continuous study. Dis Colon Rectum. 1978;21:582–583
  11. Jensen SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Br Med J (Clin Res Ed). 1986;292:1167–1169
  12. Jensen SL. Maintenance therapy with unprocessed bran in the prevention of acute anal fissure recurrence. J R Soc Med. 1987;80:296–298
  13. McDonald P, Driscoll AM, Nicholls RJ. The anal dilator in the conservative management of acute anal fissures. Br J Surg. 1983;70:25–26
  14. Gough MJ, Lewis A. The conservative treatment of fissure-in-ano. Br J Surg. 1983;70:175–176
  15. Bhardwaj R, Vaizey CJ, Boulos PB, Hoyle CH. Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures. Gut. 2000;46:861–868
  16. Frenckner B, Ihre T. Influence of autonomic nerves on the internal anal sphincter in man. Gut. 1976;17:306–312
  17. Frenckner B. Function of the anal sphincters in spinal man. Gut. 1975;16:638–644
  18. O'Kelly T, Brading A, Mortensen N. Nerve mediated relaxation of the human internal anal sphincter: the role of nitric oxide. Gut. 1993;34:689–693
  19. Rattan S, Chakder S. Role of nitric oxide as a mediator of internal anal sphincter relaxation. Am J Physiol. 1992;262(1 Pt 1):G107–G112
  20. Cook TA, Humphreys MM, Mortensen NJ. Oral nifedipine reduces resting anal pressure and heals chronic anal fissure. Br J Surg. 1999;86:1269–1273
  21. Loder PB, Kamm MA, Nicholls RJ, Phillips RK. ‘Reversible chemical sphincterotomy’ by local application of glyceryl trinitrate. Br J Surg. 1994;81:1386–1389
  22. Gorfine SR. Topical nitroglycerin therapy for anal fissures and ulcers [letter]. N Engl J Med. 1995;333:1156–1157
  23. Lund JN, Armitage NC, Scholefield JH. Use of glyceryl trinitrate ointment in the treatment of anal fissure. Br J Surg. 1996;83:776–777
  24. Lund JN, Scholefield JH. Internal sphincter spasm in anal fissure. Br J Surg. 1997;84:1723–1724
  25. Lund JN, Scholefield JH. Glyceryl trinitrate is an effective treatment for anal fissure. Dis Colon Rectum. 1997;40:468–470
  26. Lund JN, Scholefield JH. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure [published erratum appears in Lancet 1997;349:656]. Lancet. 1997;349:11–14
  27. Kennedy ML, Sowter S, Nguyen H, Lubowski DZ. Glyceryl trinitrate ointment for the treatment of chronic anal fissure: results of a placebo-controlled trial and long-term follow-up. Dis Colon Rectum. 1999;42:1000–1006
  28. Bacher H, Mischinger HJ, Werkgartner G, Cerwenka H, El-Shabrawi A, Pfeifer J, et al. Local nitroglycerin for treatment of anal fissures: an alternative to lateral sphincterotomy?. Dis Colon Rectum. 1997;40:840–845
  29. Carapeti EA, Kamm MA, McDonald PJ, Chadwick SJ, Melville D, Phillips RK. Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate. Gut. 1999;44:727–730
  30. Schouten WR, Briel JW, Boerma MO, Auwerda JJ, Wilms EB, Graatsma BH. Pathophysiological aspects and clinical outcome of intra-anal application of isosorbide dinitrate in patients with chronic anal fissure. Gut. 1996;39:465–469
  31. Lysy J, Israelit-Yatzkan Y, Sestiere-Ittah M, Keret D, Goldin E. Treatment of chronic anal fissure with isosorbide dinitrate: long-term results and dose determination. Dis Colon Rectum. 1998;41:1406–1410
  32. Lund JN, Scholefield JH. Follow-up of patients with chronic anal fissure treated with topical glyceryl trinitrate [letter]. Lancet. 1998;352:1681
  33. Dorfman G, Levitt M, Platell C. Treatment of chronic anal fissure with topical glyceryl trinitrate. Dis Colon Rectum. 1999;42:1007–1010
  34. Hyman NH, Cataldo PA. Nitroglycerin ointment for anal fissures: effective treatment or just a headache?. Dis Colon Rectum. 1999;42:383–385
  35. Altomare DF, Rinaldi M, Milito G, Arcana F, Spinelli F, Nardelli N, et al. Glyceryl trinitrate for chronic anal fissure—healing or headache? Results of a multicenter, randomized, placebo-controlled, double-blind trial. Dis Colon Rectum. 2000;43:174–179
  36. Richard CS, Gregoire R, Plewes EA, Silverman R, Burul C, Buie D, et al. Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: results of a randomized, controlled trial by the Canadian Colorectal Surgical Trials Group. Dis Colon Rectum. 2000;43:1048–1057 discussion 1057–1058
  37. Chrysos E, Xynos E, Tzovaras G, Zoras OJ, Tsiaoussis J, Vassilakis SJ. Effect of nifedipine on rectoanal motility. Dis Colon Rectum. 1996;39:212–216
  38. Cook TA, Humphreys MM, Mortensen NJ. Oral nifedipine reduces resting anal pressure and heals chronic anal fissure. Br J Surg. 1999;86:1269–1273
  39. Carapeti EA, Kamm MA, Evans BK, Phillips RK. Topical diltiazem and bethanechol decrease anal sphincter pressure without side effects. Gut. 1999;45:719–722
  40. Antropoli C, Perrotti P, Rubino M, Martino A, DeStefano G, Migliore G, et al. Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study. Dis Colon Rectum. 1999;42:1011–1015
  41. Carapeti EA, Kamm MA, Phillips RK. Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum. 2000;43:1359–1362
  42. Knight JS, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg. 2001;88:553–556
  43. Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum. 2001;44:1074–1078
  44. Pitt J, Craggs MM, Henry MM, Boulos PB. α1-adrenoreceptor blockade: potential new treatment for anal fissures. Dis Colon Rectum. 2000;43:800–803
  45. Pitt J. Double-blind randomized placebo-controlled trial of oral indoramin to treat chronic anal fissure. J Colorectal Dis. 2000;2(Suppl 1):61–62 (abstr)
  46. Ojo-Aromokudu O. A comparison of alpha and beta adreno-receptor function in the internal anal sphincter in people with and without chronic anal fissures (abstr). J Physiol. 1998;507:19
  47. Jankovic J, Brin MF. Therapeutic uses of botulinum toxin. N Engl J Med. 1991;324:1186–1194
  48. Pasricha PJ, Ravich WJ, Hendrix TR, Sostre S, Jones B, Kalloo AN. Intrasphincteric botulinum toxin for the treatment of achalasia [published erratum appears in N Engl J Med 1995;333:75]. N Engl J Med. 1995;332:774–778
  49. Dykstra DD, Sidi AA. Treatment of detrusor-sphincter dyssynergia with botulinum A toxin: a double-blind study. Arch Phys Med Rehabil. 1990;71:24–26
  50. Jost WH, Schimrigk K. Use of botulinum toxin in anal fissure [letter]. Dis Colon Rectum. 1993;36:974
  51. Jost WH. One hundred cases of anal fissure treated with botulin toxin: early and long-term results. Dis Colon Rectum. 1997;40:1029–1032
  52. Jost WH, Schrank B. Repeat botulin toxin injections in anal fissure: in patients with relapse and after insufficient effect of first treatment. Dig Dis Sci. 1999;44:1588–1589
  53. Maria G, Cassetta E, Gui D, Brisinda G, Bentivoglio AR, Albanese A. A comparison of botulinum toxin and saline for the treatment of chronic anal fissure. N Engl J Med. 1998;338:217–220
  54. Brisinda G, Maria G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure [published erratum appears in N Engl J Med 1999;341:624]. N Engl J Med. 1999;341:65–69
  55. Maria G, Brisinda G, Bentivoglio AR, Cassetta E, Gui D, Albanese A. Botulinum toxin injections in the internal anal sphincter for the treatment of chronic anal fissure: long-term results after two different dosage regimens. Ann Surg. 1998;228:664–669
  56. Minguez M, Melo F, Espi A, Garcia-Granero E, Mora F, Lledo S, et al. Therapeutic effects of different doses of botulinum toxin in chronic anal fissure. Dis Colon Rectum. 1999;42:1016–1021
  57. Watts JM, Bennett RC, Goligher JC. Stretching of anal sphincters in treatment of fissure-in-ano. BMJ. 1964;342–343
  58. Isbister WH, Prasad J. Fissure in ano. Aust N Z J Surg. 1995;65:107–108
  59. Marby M, Alexander-Williams J, Buchmann P, Arabi Y, Kappas A, Minervini S, et al. A randomized controlled trial to compare anal dilatation with lateral subcutaneous sphincterotomy for anal fissure. Dis Colon Rectum. 1979;22:308–311
  60. O'Connor JJ. Lord procedure for treatment of postpartum hemorrhoids and fissures. Obstet Gynecol. 1980;55:747–748
  61. Jensen SL, Lund F, Nielsen OV, Tange G. Lateral subcutaneous sphincterotomy versus anal dilatation in the treatment of fissure in ano in outpatients: a prospective randomised study. BMJ (Clin Res Ed). 1984;289:528–530
  62. Weaver RM, Ambrose NS, Alexander-Williams J, Keighley MR. Manual dilatation of the anus vs. lateral subcutaneous sphincterotomy in the treatment of chronic fissure-in-ano. Results of a prospective, randomized, clinical trial. Dis Colon Rectum. 1987;30:420–423
  63. MacDonald A, Smoth A, McNeill AD, Finlay IG. Manual dilatation of the anus. Br J Surg. 1992;79:1381–1382
  64. Sohn N, Weinstein MA. Anal dilatation for anal fissures. Semin Colon Rectal Surg. 1997;8:17–23
  65. Nielsen MB, Rasmussen OO, Pedersen JF, Christiansen J. Risk of sphincter damage and anal incontinence after anal dilatation for fissure-in-ano. An endosonographic study. Dis Colon Rectum. 1993;36:677–680
  66. Sohn N, Eisenberg MM, Weinstein MA, Lugo RN, Ader J. Precise anorectal sphincter dilatation—its role in the therapy of anal fissures. Dis Colon Rectum. 1992;35:322–327
  67. Eisenhammer S. The surgical correction of chronic internal anal (sphincteric) contracture. S Afr Med J. 1951;25:486–489
  68. Eisenhammer S. The evaluation of the internal anal sphincterotomy operation with special reference to anal fissure. Surg Gynecol Obstet. 1959;109:583–590
  69. Abcarian H. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy—midline sphincterotomy. Dis Colon Rectum. 1980;23:31–36
  70. Hawley PR. The treatment of chronic fissure-in-ano. A trial of methods. Br J Surg. 1969;56:915–918
  71. Nelson RL. Meta-analysis of operative techniques for fissure-in-ano. Dis Colon Rectum. 1999;42:1424–1431
  72. Garcia-Aguilar J, Belmonte C, Wong WD, Lowry AC, Madoff RD. Open vs. closed sphincterotomy for chronic anal fissure: long-term results. Dis Colon Rectum. 1996;39:440–443
  73. Khubchandani IT, Reed JF. Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg. 1989;76:431–434
  74. Pernikoff BJ, Eisenstat TE, Rubin RJ, Oliver GC, Salvati EP. Reappraisal of partial lateral internal sphincterotomy. Dis Colon Rectum. 1994;37:1291–1295
  75. Usatoff V, Polglase AL. The longer term results of internal anal sphincterotomy for anal fissure. Aust N Z J Surg. 1995;65:576–578
  76. Garcia-Granero E, Sanahuja A, Garcia-Armengol J, Jimenez E, Esclapez P, Minguez M, et al. Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy. Dis Colon Rectum. 1998;41:598–601
  77. Sultan AH, Kamm MA, Nicholls RJ, Bartram CI. Prospective study of the extent of internal anal sphincter division during lateral sphincterotomy. Dis Colon Rectum. 1994;37:1031–1033
  78. Corby H, O'Herlihy C. Anal canal pressures are low in women with postpartum anal fissure. Br J Surg. 1997;84:86–88
  79. Littlejohn DR, Newstead GL. Tailored lateral sphincterotomy for anal fissure. Dis Colon Rectum. 1997;40:1439–1442
  80. Notaras MJ. The treatment of anal fissure by lateral subcutaneous internal sphincterotomy—a technique and results. Br J Surg. 1971;58:96–100
  81. Lewis TH, Corman ML, Prager ED, Robertson WG. Long-term results of open and closed sphincterotomy for anal fissure. Dis Colon Rectum. 1988;31:368–371
  82. Kortbeek JB, Langevin JM, Khoo RE, Heine JA. Chronic fissure-in-ano: a randomized study comparing open and subcutaneous lateral internal sphincterotomy. Dis Colon Rectum. 1992;35:835–837
  83. Olsen J, Mortensen PE, Krogh Petersen I, Christiansen J. Anal sphincter function after treatment of fissure-in-ano by lateral subcutaneous sphincterotomy versus anal dilatation. A randomized study. Int J Colorectal Dis. 1987;2:155–157
  84. Platell C, Mackay J, Collopy B, Fink R, Ryan P, Woods R. Anal pathology in patients with Crohn's disease. Aust N Z J Surg. 1996;66:5–9
  85. Sangwan YP, Schoetz DJ, Murray JJ, Roberts PL, Coller JA. Perianal Crohn's disease. Results of local surgical treatment. Dis Colon Rectum. 1996;39:529–535
  86. Fleshner PR, Schoetz DJ, Roberts PL, Murray JJ, Coller JA, Veidenheimer MC. Anal fissure in Crohn's disease: a plea for aggressive management. Dis Colon Rectum. 1995;38:1137–1143
  87. Wolkomir AF, Luchtefeld MA. Surgery for symptomatic hemorrhoids and anal fissures in Crohn's disease. Dis Colon Rectum. 1993;36:545–547
  88. Allan A, Keighley MR. Management of perianal Crohn's disease. World J Surg. 1988;12:198–202
  89. Viamonte M, Dailey TH, Gottesman L. Ulcerative disease of the anorectum in the HIV+ patient. Dis Colon Rectum. 1993;36:801–805
  90. Weiss EG, Wexner SD. Surgery for anal lesions in HIV-infected patients. Ann Med. 1995;27:467–475
  91. Consten EC, Slors FJ, Noten HJ, Oosting H, Danner SA, van Lanschot JJ. Anorectal surgery in human immunodeficiency virus-infected patients. Clinical outcome in relation to immune status. Dis Colon Rectum. 1995;38:1169–1175
  92. Lord RV. Anorectal surgery in patients infected with human immunodeficiency virus: factors associated with delayed wound healing. Ann Surg. 1997;226:92–99
  93. Barrett WL, Callahan TD, Orkin BA. Perianal manifestations of human immunodeficiency virus infection: experience with 260 patients. Dis Colon Rectum. 1998;41:606–611
  94. Zuberi BF, Rajput MR, Abro H, Shaikh SA. A randomized trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures. Int J Colorectal Dis. 2000;15:243–245
  95. Werre AJ, Palamba HW, Bilgen EJ, Eggink WF. Isosorbide dinitrate in the treatment of anal fissure: a randomized, prospective, double blind, placebo-controlled trial. Eur J Surg. 2001;167:382–385
  96. Fleshman JW. Fissure-in-ano and anal stenosis. In: 2nd ed.  Beck DE,  Wexner SD editor. Fundamentals of anorectal surgery. London: Saunders; 1998;p. 215
  97. Keighley MR, Greca F, Nevah E, Hares M, Alexander-Williams J. Treatment of anal fissure by lateral subcutaneous sphincterotomy should be under general anaesthesia. Br J Surg. 1981;68:400–401
  98. Ravikumar TS, Sridhar S, Rao RN. Subcutaneous lateral internal sphincterotomy for chronic fissure-in-ano. Dis Colon Rectum. 1982;25:798–801
  99. Hsu TC, MacKeigan JM. Surgical treatment of chronic anal fissure. A retrospective study of 1753 cases. Dis Colon Rectum. 1984;27:475–478
  100. Walker WA, Rothenberger DA, Goldberg SM. Morbidity of internal sphincterotomy for anal fissure and stenosis. Dis Colon Rectum. 1985;28:832–835
  101. Gingold BS. Simple in-office sphincterotomy with partial fissurectomy for chronic anal fissure. Surg Gynecol Obstet. 1987;165:46–48
  102. Zinkin L. Left lateral internal sphincterotomy for anal fissure—as an office procedure. N J Med. 1988;85:43–45
  103. Romano G, Rotondano G, Santangelo M, Esercizio L. A critical appraisal of pathogenesis and morbidity of surgical treatment of chronic anal fissure. J Am Coll Surg. 1994;178:600–604
  104. Leong AF, Seow-Choen F. Lateral sphincterotomy compared with anal advancement flap for chronic anal fissure. Dis Colon Rectum. 1995;38:69–71
  105. Prohm P, Bonner C. Is manometry essential for surgery of chronic fissure-in-ano?. Dis Colon Rectum. 1995;38:735–738
  106. Hananel N, Gordon PH. Lateral internal sphincterotomy for fissure-in-ano—revisited. Dis Colon Rectum. 1997;40:597–602
  107. Nyam DC, Pemberton JH. Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence. Dis Colon Rectum. 1999;42:1306–1310

 This work has been supported by the American Gastroenterological Association.

☆☆ Address requests for reprints to: Chair, Clinical Practice Committee, AGA National Office, c/o Membership Department, 7910 Woodmont Avenue, 7th Floor, Bethesda, Maryland 20814. Fax: (301) 654-5920.

 This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice Committee. This paper was approved by the Committee on May 19, 2002 and by the AGA Governing Board on July 27, 2002.

PII: S0016-5085(03)50035-X

doi: 10.1053/gast.2003.50005

Gastroenterology
Volume 124, Issue 1 , Pages 235-245 , January 2003