Anal Fissure 2

ANAL FISSURE
dr Samuel Sampetoding, Sp.B-KBD

INTRODUCTION
● An anal fissure is a common anorectal

problem, with a longitudinal tear distal to
the dentate line
● They are usually located in the posterior or
anterior mid line
● The main presenting symptom is pain
during defecation with variable amount of
bleeding, causing emotional stress and
effects the quality of life
Lakshmi AV, Vasavi C, Rao MV. A clinical study on the management of chronic anal fissure. International Journal of Health and Clinical Research, 2021; 4(15):246-249
Çakır C, İdiz UO, Aydın İ, Fırat D, Ulu- suyor Aİ, Yazıcı P. Comparison of the effectiveness of two treatment modalities for chronic anal fissure: Botox versus sphincterotomy. Turk J Surg 2020; 36 (3):
264-270.
EPIDEMIOLOGY
● Lakshmi et al showed that the disease is more frequently occurs in young people,
without significant differences between genders
D’Orazio B et al. Fissurectomy and anoplasty in posterior normotensive chronic anal fissure. Acta biomed. 2021; 92. DOI: 10.23750/abm.v92i5.11200
CLASSIFICATION
ACUTE
● 3-6 weeks of symptom onset
● Clean longitudinal tear in the
anoderm with little surrounding
Anal fissure is inflammation
classified into ● Heals spontaneously within 6
two types weeks
CHRONIC
● >6 weeks of symptoms
● Deeper and internal sphincter
fibres is exposed in its base
● Frequently associated with a
hypertrophic anal papilla and
sentinel pile
Ozdamar MY, Hirik E. Anal fissure epidemiology and related diseases in children. South Clin Ist Euras. 2018; 29(4): 295-300
Shakya P, Kala S, Verma PK. Surgical vs medical management of anal fissure: a comparative study. International Journal of Scientific Research. 2018; 7(11)
CLINICAL MANIFESTATIONS
● Majority of patients have pain

during defecation and
bleeding on defecation,
constipation other symptoms
were itching, mucus
discharge, and skin tag
● In some study, posterior anal
fissure is seen in 138 patients
(78%) and anterior anal
fissure is seen 42 patients
(22%)
Basak SN, Jana D. Study on chronic anal fissure for partial lateal internal sphincterectomy. International Journal of Scientific Research. 2020; 9(2).
PATOPHYSIOLOGY
INFECTION
ANATOMIC FACTORS
THEORY
INTERNAL
TRAUMA SPHINCTER
FACTORS SPASM
THEORY
Shaoming C, Qinghuan Y. A new theory on the cause of anal fissure – impaction theory. J Coloproctol. 2020; 40(4): 321-325.
PATOPHYSIOLOGY
● The external anal sphincter is divided into two parts from the tailbone
to the rear of the anal canal, which encircles the anal canal along
ANATOMIC both sides of the anal canal
THEORY ● The external anal sphincter is connected to the two parts in front of
the anal canal, leaving a gap in front and rear of the anal canal
● The back and the front of the anal canal are not as strong as the two
sides and are easy to be damaged. The anal canal forms an anal and
rectal angle downward and backward, and the back of the anal canal
is subject to greater fecal pressure
● The blood supply of the posterior median line of the anal canal is less
and its elasticity is less
PATOPHYSIOLOGY
● The causes of anal fissure include foreign body in rectum, improper

method of anal expansion, anal operation, delivery, congenital anal
stenosis and prococolonitis
TRAUMA ● Hard feces can tear the skin of anus, while frequent defecation
FACTORS causes sensitive constriction of anal canal, and normal consistency
feces can also cause damage
● Chronic inflammation of anal canal, hyperplasia of fibrous tissue,
formation of anal comb induration will hindering sphincter relaxation,
making anal canal easy to be damaged and torn.
● Two theory related to trauma factors :
● Ball’s theory
● Blaisdell’s theory
PATOPHYSIOLOGY
● Acute and chronic anal sinusitis, anal papilla, internal hemorrhoids,

and polyps are the main causes of infection
● Infection of hemorrhoids, inflammation of anal papilla, constipation →
INFECTION dysdefecation, formation of new anal fissure → new anal fissure
FACTORS (fresh wound) → infection → non healing of wound → spasm of anal
sphincter → hypertrophy of anal papilla, hyperplasia of internal
hemorrhoids, constipation due to pain and fear of stool (increased
impaction factor)
● Two theory related to infection factors :
● The theory of crypt gland infection
● Theory of residual epithelial infection
PATOPHYSIOLOGY
● The anal sphincter is in spasm state because of the injury or

inflammation stimulation of the anal canal, resulting in the
INTERNAL enhancement of anal canal force and the easy injury of anal fissure
SPHINCTER ● Eisenhammer in the 1950s found that the muscle bundle at the
SPASM bottom of the anal fissure was the internal sphincter rather than the
THEORY lower part of the external sphincter skin. He proposed that the cause
of anal fissure was spasm or fibrosis of the internal sphincter rather
than the so called chlamydoscopy.
● However, this hypothesis has no experimental basis and may be
misleading because the pain of anal fissure disappeared and the
average anal Maximum Resting Pressure (MARP) did not decrease
after local anesthesia, which suggested that spasm was not
secondary to pain
MANAGEMENT
MEDICAL SURGICAL PHYSICAL THERAPY
2 % Diltiazem ointment LIS, MAD, fissurectomy Pelvic floor physical

twice daily topically with V-Y anoplasty, BTI therapy
MEDICAL
● Diltiazem, a non-dihydropyridine calcium channel blocker, that induces

vascular smooth muscle relaxation and dilation
● Topical 2% diltiazem reduces maximum resting pressure and effect lasts for
3-5 hours
● The ointment is applied into the anus for 6 consecutive weeks
● Side effects are minimal, such as perianal itching and dermatitis
SURGICAL
LATERAL INTERNAL SPHINCTERECTOMY (LIS)
● Of the surgical modalities available, the gold

standard procedure is lateral internal
sphincterotomy
● The LIS procedure was carried out in a jack-
knife position for patients in whom spinal
anesthesia was not contraindicated and in the
lithotomy position for patients in whom spinal
anesthesia was contraindicated (those with
improper posture or cardiac problems)
● Lateral internal sphincterotomy was performed
with a 10 mm incision at the level of the
dentate line and at the 3 o’clock level of the
anal channel
264-270.
SURGICAL
LATERAL INTERNAL SPHINCTERECTOMY (LIS)
● Although LIS is the Gold Standard, not all

patients qualify for its performance
● There is a group of patients with certain
associated conditions (>50 years,
incontinence, risk factors for incontinence
known in the literature as: previous anal
surgery, multiple vaginal deliveries, diabetes,
inflammatory bowel disease, etc.) or with anal
fissure without associated hypertonia, in
which there is a greater risk of residual
incontinence after surgery
Acar et al. Treatment of chronic anal fissure: is open lateral internal sphincterectomy (LIS) a safe and adequate option? Asian Journal of surgery. 2019; 42: 628-633
264-270.
SURGICAL
FISSURECTOMY WITH V-Y ANOPLASTY
● In order to expose the anal canal, use four Kocher pliers

placed at 3,6,9 and 12 hours to avoid employing anal
retractors
● The fibrotic edges were excised with a scalpel until normal
non-fibrotic anodermal tissue showed sufficient bleeding. The
sentinel skin tag and hypertrophied papilla at the level of
dentate line were excised when present
● The tissue at the base of the fissure was curetted until there
were clean muscle fibers of the IAS. Standard advancement
anoplasty was performed using a flap of healthy skin tissue
● The flap was secured without tension to the anal canal and
the skin was closed tension free in a V-Y manner with
interrupted rapid absorbable suture
D’Orazio B et al. Fissurectomy and anoplasty in posterior normotensive chronic anal fissure. Acta biomed. 2021; 92. DOI: 10.23750/abm.v92i5.11200
SURGICAL
MANUAL ANAL DILATION (MAD)
● Described by Recaimer in the treatment of anal fissure, carried out

under spinal anaesthesia and patient is placed in lithotomy position
● The dilatation is done up to four fingers in place and stretched for
four minutes
SURGICAL
BOTULINUM TOXIN INJECTION (BTI)
● The procedure was carried out by a 25 IU botulinum toxin injection

to the internal anal sphincter at 3 o’clock and 9 o’clock levels (50 IU
in total)
● The patients were in a semi-jackknife position
264-270.
PHYSICAL THERAPY
PELVIC FLOOR PHYSICAL THERAPY
(PFPT)
● The aim of PFPT is to increase awareness and proprioception, to restore

abdominopelvic coordination, to improve muscle relaxation and elasticity of
the pelvic floor, and reduce pain
● The treatment protocol was comprised of intrarectal myofascial techniques,
such as stretching the puborectalis muscle and myofascial release on
identified trigger points in the pelvic floor to increase flexibility, release
muscle tension, and improve circulation
● If patients were unable to contract or relax the pelvic floor muscles,
neuromuscular electrical stimulation was applied intra-anally during the
biofeedback session
Reijn-Baggen DA, Elzevier HW, Putter H, Pelger RCM, Han-Geurts IJM. Pelvic floor physical therapy in patients with chronic anal fissure: a randomized controlled trial. Techniques in Coloproctology.
2022. https://doi.org/10.1007/s10151-022-02618-9
RESTING PRESSURE
● The resting pressure that is known as

normal and according to International
standards is 40-70mmHg, figures that
can vary greatly in patients with anal
fissure
● Several authors have studied anorectal
pressures in patients with anal fissure
using manometric techniques and most
studies have shown an increase in the
pressure at rest in individuals with anal
fissure
Castillo EV, Amaral IM, Dominguez A, Rojas A, Lopez S, Chiantera D, Paz MP, Coacuto JD. Manometry in chronic anal fissures: clinical and therapeutic correlation. Adv Res Gastroentero Hepatol.
2021; 16(4) : 555943. DOI: 10.19080/ARGH.2021.16.555943
RESTING PRESSURE
● In relation to continence, despite not being

statistically significant, fecal spotting, flatus and
fluid incontinence had a frequency of 3.2% in
patients with resting pressure less than 90
mmHg with a recurrence rate of 9.7%
● Compared to 0.7% with resting pressure greater
than 90 mmHg with a recurrence of 2.1%.
Demonstrating the importance of pre-surgical
manometry
Castillo EV, Amaral IM, Dominguez A, Rojas A, Lopez S, Chiantera D, Paz MP, Coacuto JD. Manometry in chronic anal fissures: clinical and therapeutic correlation. Adv Res Gastroentero Hepatol.
2021; 16(4) : 555943. DOI: 10.19080/ARGH.2021.16.555943
COMPLICATIONS
● According to Shakya et al, the comparison between internal sphincterotomy

and Diltiazem gel therapy showed a difference in pain relief (P<0.00001) and
fissure healing (P = 0.00001) which is statistically significant
● But there was no significance regarding bleeding (p=0.68) as both are showing
similar results
Shakya P, Kala S, Verma PK. Surgical vs medical management of anal fissure: a comparative study. International Journal of Scientific Research. 2018; 7(11)
COMPLICATIONS
● Symptom duration, hospitalization
period, and duration of remission
of the complaints after treatment
of the LIS group were statistically
and significantly higher
● When total complications were
observed, no statistically
significant difference was found
between the groups
● However, the number of
recurrences was statistically
higher in the BTI-applied patients
264-270.
COMPLICATIONS
● Lakshmi et al stated that by the end of

6 weeks, 22 patients (37%) were
having some degree of incontinence
for stool and flatus, 3 patients had
incontinence for flatus only and 12
patients (21%) had persisting ulcer
and 2 patients developed signs and
symptoms of recurrent anal fissure in
4th post op week
● Manual anal dilatation resulted in
complete healing of fissure in 63% of
patients only
THANK
YOU
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ANAL FISSURE

dr Samuel Sampetoding, Sp.B-KBD

● An anal fissure is a common anorectal

● Majority of patients have pain

● The causes of anal fissure include foreign body in rectum, improper

● Acute and chronic anal sinusitis, anal papilla, internal hemorrhoids,

● The anal sphincter is in spasm state because of the injury or

MEDICAL SURGICAL PHYSICAL THERAPY

2 % Diltiazem ointment LIS, MAD, fissurectomy Pelvic floor physical

● Diltiazem, a non-dihydropyridine calcium channel blocker, that induces

● Of the surgical modalities available, the gold

● Although LIS is the Gold Standard, not all

● In order to expose the anal canal, use four Kocher pliers

● Described by Recaimer in the treatment of anal fissure, carried out

● The procedure was carried out by a 25 IU botulinum toxin injection

● The aim of PFPT is to increase awareness and proprioception, to restore

● The resting pressure that is known as

● In relation to continence, despite not being

● According to Shakya et al, the comparison between internal sphincterotomy

● Lakshmi et al stated that by the end of

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