ANAL FISSURE

A Comparison of Conservative Treatment Versus Surgical Methods

Manu G Nariani*, Rajeev Chaturvedi**, Jignesh Jatania**
*Assistant Prof. of General Surgery, Consultant Surgeon; **Resident, Gen. Surgery, Bombay
Hospital Institute of Medical Sciences.
INTRODUCTIONAnal fissure is the most common cause of severe anal pain. It is the most
common cause of bleeding per anus in infants and young children. The pain of anal ulcer is
intolerable and always disproportionate to the severity of the physical lesion. It may be so
severe that patients may avoid defaecation for days altogether until it becomes inevitable.
This leads to hardening of the stools, which further tear the anoderm during defaecation,
setting a vicious cycle.
It occurs as a superficial split in the anoderm, that may heal by itself or may progress to a
chronic fissure. The physical lesion extends from distal to the dentate line to the anal verge.
A well developed idiopathic anal fissure rests directly over the internal sphincter and the
circular fibers of this sphincter are visible on the floor of the fissure on naked eye inspection.
The internal sphincter undergoes a perpetual state of spasm due to irritation and
hypertrophies.[1] This characteristic can be clinically observed during examination of the
anal canal. The lower edge of the internal anal sphincter (IAS) is prominent and so is the
inter-sphincteric groove. If these are not present then other causes of anal fissure should be
suspected.
Secondary changes develop with persistence of the fissure over time - 1) there may be mild
induration of the lateral edges of the fissure, 2) on the proximal end of the fissure, an anal
papilla hypertrophies that may become as large as a polyp, 3) there may be a swelling at the
distal end of the fissure - a tag like swelling, the so called sentinel pile. It forms due to low
grade inflammation and lymphatic oedema. This tag may become acutely inflamed, tense
and oedematous, it may undergo fibrosis and persist as a permanent tag even after the anal
fissure has healed, or it may develop into a perianal abscess or a low and superficial fistula
when the abscess communicates with the anal lumen and has burst open in the perianal
skin, 4) a perianal fistula may also develop due to an acute suppuration of the fissure.
Surgical anatomy and pressures in anal canal
The anus functions as a continent mechanism for the GIT. The mechanism consists of the
internal and external anal sphincters, the puborectalis, and the levator ani muscles. The
puborectalis hooks the anal canal to the pubic bones. Anal canal passes through the pelvic
diaphragm, therefore, the process of defaecation has to function in close coordination with
the pelvic diaphragm - where the levator ani become important. The sphincter apparatus is
organized as two concentric muscular tubes, positioned one enclosing the other. The internal
anal sphincter (IAS) is the specialized continuation of the circular layer of the rectum. It also
has variable amount of longitudinal muscles on luminal as well as the external aspects. It
consists of smooth muscles and is supplied by parasympathetic autonomic nerves. The
external anal sphincter (EAS) is skeletal muscle under voluntary control.
The tonic resting state pressure of the IAS is called 'anal resting pressure'. It has been found
that this pressure is significantly increased in majority of patients with anal fissure. The IAS
pressure has been found to display an overshoot phenomenon in the patients with chronic
anal fissure; it overshoots the basal resting pressure after physiologic lowering in response
to the rectal dilation with balloons. This signifies the internal sphincteric spasm, so
characteristic of this condition. The external anal canal when made to contract maximally

under command gives the maximum squeeze pressure. It is an indicator of the continence
facility of the anus.
Reasons of predilection of the posterior midline of the anal canal for fissures
The anoderm is more adherent to the underlying tissue in the posterior midline. The
sphincter fibers form Y-shaped decussation in the posterior midline that is anchored to the
mucosa. A perfusion lower than the rest of the anal canal may be responsible for the
persistence of the fissure when there is continued constipation and trauma due to hard
stools. Angiographic post-mortem studies by Klosterhalfen et al have revealed that the small
branches of both inferior rectal arteries passing through the IAS has no or minimal contact at
the posterior midline in 85% of cases.[2] Blood supply to the anoderm at the posterior
midline was found to be significantly lower. Maria et al have reported that there was
deposition of anti-endothelial cell antibody (AECA) complexes on the intima of the small
branches of the rectal arteries in the patients with chronic anal fissure,[3] the event which
may further compromise the already marginal blood supply. Intense and prolonged internal
sphincter spasm further compromises the blood perfusion of the anoderm, which, at least, is
important in keeping the fissure from healing.[4-6]
Note that, the reduced blood supply to the lesion is indicated by the absence of granulation
tissue at the base of the fissure and a very slow growth of the anoderm even when the
traditional conservative treatment eases the trauma due to hard faeces.
Conservative treatment
1.Warm Water Sitz bath with boric powder, betadine solution, or potassium permanganate.
This treatment soothes the pain and relaxes the spasm of the IAS for some time.
2.Adequate analgesia is necessary to break the vicious cycle of pain - avoidance to
defaecation for prolonged periods - hard stools - further tearing of the anoderm - increased
pain.
3.Stool softeners; soft and formed stools negotiate the rectum and anal canal in nontraumatic physiologic manoeuvre. Plenty of oral fluids will also help to keep the stools soft.
4.High-fiber-diet[7] and bulk-forming agents such as Isaphgula: Green leafy vegetables
fibrous fruits were helpful. Five grams of bran per day has been studied in comparative
studies and found useful.[8]
5.Reassurance and encouragement for not resisting the urge for defaecation helps prevent
hard stools. Later the patient should be encouraged to acquire and maintain a regular bowel
habit of once or twice a day. Application of local anaesthetic cream or gel may help avoid the
torture experienced in passage of stools in the patients with acute fissures.
6.Topical creams, gels, ointments. A variety of topical preparations are commercially
available. The degree of benefit experienced by individual patient is greatly variable.
Xylocaine gel/ointment, allantoin creams, antibiotic creams, and hydrocortisone ointments
are only a few of them. Jensen studied the effect of xylocaine ointment and hydrocotisone
ointment.[8]
7.Chemical cauterization using silver nitrate or phenol-in-glycerine. This procedure may be
repeated a couple of times until healing occurs - till 4 to 8 weeks.

8.Nitroglycerine paste.[9]
Frequent topical application of 0.2% nitroglycerine paste on the anal canal epithelium has
been used to relieve the internal sphincteric spasm. Nitroglycerine release NO, a naturally
occurring smooth muscle relaxant. Long-term relaxation of the spasm allows the anoderm
time for healing. Prolonged use along with the WASH regimen will allow healing in about twothirds of the patients.[10]
9.Oral Nifedipine : reversible internal anal sphincterolysis.[11]
Nifedipine is an L-type calcium channel antagonist. L-type calcium channels are the principal
calcium channels in the GI smooth muscles. It has been used with variable effects in the
management of achalasia cardia. In the treatment of anal fissures 20 mg of Nifedipine is
given twice daily. Nifedipine relieves the sphincter spasm. It also increases the local blood
supply, by an independent mechanism, to allow faster healing.
10.Botulinum toxin type A : Chemical denervation of internal anal sphincter. Injection of 20
Units of type A botulinum toxin diluted to 50 U/mL into the internal anal sphincter ensures a
reduction of the internal anal resting pressure for at least 4 months. This allows the fissure
time for healing. The toxin exerts its effects on the acetylcholine releasing parasympathetic
peripheral nerve endings as well as the ganglionic nerve endings, thereby leading to flaccid
paralysis of the internal sphincter.[12]
Surgical approaches
1.Anal dilation was described by Recamier in 1838. It has undergone several variations and
modifications. It is performed under general anaesthesia or local anaesthesia. A gradual
insertion and dilation to four to eight fingers lubricated with paraffin, lignocaine jelly, or K-Y
jelly achieves reduction of internal sphincteric pressure.[13]
2.Fissurectomy involves excision of the fissure from the anal canal. The wound is left open
without suturing.
3.Internal sphincterotomy[14],[15]
The internal sphincter is divided completely in its lower part from the dentate line to the
lower margin. The objective of the procedure is to relieve the pressure in the anal canal; the
part of the sphincter above the dentate line is left intact. It should be noted that the spasm
of the internal sphincter is taken as the key pathogenetic mechanism in the initiation and at
least maintaining the fissure.[15-18] There are various approaches to the internal
sphincterology; (a) Posterior midline, anterior, or lateral sphincterotomy - based on the site
of division of the sphincter, (b) open or closed sphincterotomy - based on whether anoderm
is incised or not during the procedure, (c) submucosal or the inter-sphincteric approaches.
4.Carbon dioxide laser surgery involves laser vaporization of the fissure locally. The internal
sphincter can be incised using this laser. In long-standing fissures anal stenosis is present. It
can be used to give relieving incisions in the three quadrants other than the fissure before
the fissure is attended. Cryo-analgesia with liquid nitrogen is given to all wounds distal to
the anorectal line.
Comparative criticism of various methods of treatment of anal fissures

A 'W-A-S-H' was a popular non-surgical treatment, which used Warm water Sitz baths +
Analgesics + Stool softeners + High fiber diet. It has been used as treatment regimen itself
and along with the other conservative approaches as well as a pretreatment for the surgical
methods. It serves good as either of them. As a regimen by itself it is effective in easing the
discomfort by hot fomentation. It also relieves the spasm of the sphincter for a short period
of time. About one third to one half of the patients show healing. In these patients the
fissure may not recur if the high-fiber diet is continued and a regular bowel habit is observed
by the patient. It is a successful measure only in acute fissures: though the regimen
definitely makes the life easier even for those with chronic fissure.
Nitroglycerine offers a good non-surgical alternative. Success with this mode of therapy
depends upon prolonged use and support with the W-A-S-H regimen. It takes about 4-6
weeks of use for healing, though some patients may require therapy for as long as 8 weeks.
Success rate are of the order of 60%.[10] Non-compliance may lead to failure to heal or
recurrences. Headaches may occur in the users, which may be severe enough in some
patients that it may necessitate discontinuation of the medication. The second problem with
nitroglycerine topical treatment is that some patients experience tachyphylaxis, wherein
increasing concentrations of the paste are required to maintain the desired effect on the
internal anal sphincter. A regimen of weekly escalating dose starting from 0.2%, increasing
each week by 0.1% to 0.6% has been documented as resulting in a more rapid healing.
However, when the treatment is stopped there is a high rate of relapse.
Oral Nifedipine offers a convenient regimen along with a non-surgical alternative. The
healing is good as Nifedipine enhances the local blood supply, by dilatation of vascular
smooth muscles, in addition to production of spasmolysis. The principal side-effect of oral
Nifedipine is flushing of the face and limbs. This is usually a short-lived phenomenon, lasting
for less than an hour of intake of the medication. It usually wanes with continued use. A
small number of patients experience mild headaches. These patients responded to simple
analgesics. It has been advised that Nifedipine should be avoided in patients who have a
history of severe headaches. Nifedipine has little effect on the skeletal muscles and there
was no difference in maximum squeeze pressure, which is a function of the external
sphincter. Therefore, incontinence does not occur with its use for anal fissures. Interestingly,
Nifedipine has been used to treat severe anal pain associated with hypertension to a good
effect. One may contemplate a judicious selective use of Nifedipine therapy for patients who
have anal fissure and have concurrent hypertension.
Botulinum toxin injections are a good alternative to surgery. These can be given as a clinic
procedure. Anaesthesia or bowel preparation is not required. In one study that used saline
injections in internal sphincter as control medication, seventy-four to seventy-six per cent
patients treated with botulinum toxin showed complete healing of the fissure and
symptomatic relief. Those who showed little benefit were later given a second trial with the
toxin. The total cure rates with two injections reached almost 90%.[19] A second study with
botulinum toxin compared two doses of the toxin for therapy of anal fissure. It found that an
injection of 20 Unit of the toxin in the internal anal sphincter is sufficient for one injection
trial.[20] A third study compared patient the effect of the site of injection on the internal
sphincter. It revealed that the patients who had received injections in the posterior midline
or near the posterior midline showed healing less frequently as compared to those who
received the injections near the anterior midline. The authors proposed that greater degree
of fibrosis in the posterior sites of internal sphincter in patients with anal fissure leads to a
restriction of diffusion of the toxin in the internal sphincter muscles, when injected in or near
the posterior midline and this led to failure of the parasympathetic denervation of internal
sphincter.[21] When accidentally made into the external anal sphincter or the surrounding
tissue, has been reported to cause perianal thrombosis.[22]

Fissurectomy, by itself, is an incomplete treatment as the anoderm heals very slowly and
the factor initiating and/or aggravating the problem - the internal sphincter spasm - is not
tackled. When combined with anal dilatation or sphincterotomy, it may make the procedures
more effective.
Sphincterotomy is a very effective procedure. Posterior sphincterotomy is slow to heal and
has a tendency to lead to a posterior midline keyhole defect that may cause a persistent
seepage or difficulty in continence. It is generally considered an outdated procedure; but it
still has its place in selective cases with a posterior midline fissure complicated by a
posterior midline fistula and perhaps when a stenotic canal is being repaired with a
posteriorly based advancement flap.
The sphincteric mechanism is most weak in the anterior portion, therefore, anterior
sphincterotomy should be avoided.
Lateral sphincteromy, especially after the standardization of the closed method, has been
chosen by many surgeons.[18] The reasons for this favour are the simplicity of the
procedure, minimal anaesthesia requirements, and good results. It takes only 3 to 4 weeks
for healing (as compared to 7 to 8 weeks required by posterior sphincterotomy). The success
of the procedure depends upon (1) cutting the complete thickness of the internal sphincter
in the lower part from dentate line to the lower border of the muscles, and (2) avoiding even
a small violation of the integrity of the anoderm and mucosa. If mucosa is punctured, one
should convert the procedure to an open internal sphincterotomy. If the above stated simple
guidelines are religiously adhered to the recurrence and complication rates of
sphincterotomy for primary anal fissures are very low.
The list of complications that can arise due to procedure is formidable; but with careful and
experienced hands the procedure is safe and simple.[23] Ecchymosis of the anal canal and
perianal skin is the most common complication, it can be quite extensive in the closed
technique and Sitz baths are enough for its management; haemorrhage is a rare
complication as the bleeding is tamponaded. In open procedure haemorrhage can be
managed by careful suturing of the edges of the mucosa. Perianal abscess is associated with
only 1% of the closed sphincterotomies; there are always associated with anal fistula and
presumed to occur as a result of inadvertent penetration of mucosa by the knife. Recurrence
and failure to heal occur in less than 5% cases. If conservative therapy does not help repeat
sphincterotomy can be undertaken. Incontinence occurs due to violation of the external
sphincter fibers or due to a keyhole deformity due to posterior fissurectomy or posterior
midline open sphincterotomy.[28]
Anal dilation has been questioned in relation to its effectiveness, recurrence, and
incontinence as a complication. It has been said that the four (2+2) finger stretch method
produces an uncontrolled fracturing of the internal sphincter. It has also been claimed that
even though it may give an initial relief to the patient, approximately 40% of the patients
develop recurrence and a significant proportion on those treated had incontinence of stools
or flatus.[24-26]
In our clinic, we advise 'W-A-S-H' therapy for several days before the procedure is
undertaken, until the patient decides to undergo the procedure. Anal dilation is performed
manually under general anaesthesia and skeletal muscle relaxation or with liberal local
anaesthesia using about 20 to 25 mL mixture in equal proportions of 2% Xylocaine and
Sensorcaine. The W-A-S-H is continued after discharge from the hospital till the patient
becomes asymptomatic. High fiber diet and maintenance of regular bowel habit in order to
avoid constipation and hard stools is continued for life long. Antibiotics are prescribed for a
few days in the post-operative period. With our own experience of treating anal fissures, we

feel that it is the technique of the procedure of anal dilation that determines the success of
the anal dilatation for allowing healing of the anal fissure and avoidance of incontinence as a
complication. When performed under adequate local anaesthesia or general anaesthesia
and skeletal muscle relaxation, gradual dilation up to six (3+3) fingers with gentle circular
manoeuvring of the inserted fingers achieves the desired effect. It does not cause any
damage to the external anal sphincter (skeletal muscle) and, thus incontinence of stools or
flatus are seldom seen. Incontinence after anal dilatation is usually due to stretching of the
external sphincter and puborectalis muscle. Some of the patients complained of temporary
inability to control bowel movements during the period when skeletal muscle relaxant
medication was still acting. All patients resumed bowel and flatus control within 24 hours
after the procedure. None of our patients showed recurrence of anal fissure in a one year
follow-up. In support of our findings, we found the experiences of Weaver et al[27] who
found that manual dilatation of anus had no significant differences in outcomes than the
internal sphincterotomy. Crapp and Alexander Williams had described anal dilatation as the
procedure of choice for anal fissures.[28]
In our view gentle manual dilatation can be offered to all patients of chronic primary anal
fissure or first recurrence after any conservative mode of treatment. The procedure is simple
involves no incision or suturing, and, in our experience, has been very effective in achieving
its objective. The patient can be discharged one day after the procedure Fissurectomy may
be added to treatment for chronic fissure, especially in the cases that require excision of the
sentinel pile.
Thus we feel that conservative treatment with nitroglycerine, botulin toxin, and oral
Nifedipine are all effective methods that may reduce the need for anaesthesia and surgery
in most of the patients. These can be offered to the patients who do not have fitness for
anaesthesia. The options should be presented to the patient with complete information
about the method, cure rates, complications, and reversibility of the complications and the
final choice should be left in their hands. But selection of patients with regard to the adverse
effect susceptibility profile and wishes of patient are crucial. Surgery has been carried for
primary anal fissures since very long time, we have seen complications and understood the
reasons for them in detail. These complications usually occur with inexperienced or reckless
hands. Besides, surgery comes as one step treatment option with certain cure rates in
careful and experienced approach.
ACKNOWLEDGEMENT
This article is dedicated to the memory of Dr. RK Menda.

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