|The traumatic risks of receptive anal insertions|
|anamarya||Date: Saturday, 2014-03-29, 11:36:51 | Message # 1|
|The traumatic risks of receptive anal insertions |
The traumatic risks of receptive anal insertions include anal fissure, rectal tear, hemorrhoidal problems (such as prolapsed hemorrhoidal cushions aka piles), and for larger insertions, fecal incontinence from wide stretching and immediate rectal perforation from long objects. A single instance of trauma can result in the development of multiple issues, and cumulative damage is a concern. Any tear may persist as a chronic anal fissure or anal/rectal ulcer and can lead to a variety of secondary issues, including bacterial infections, proctitis (rectal inflammation), abscess, fistula, anal skin tag (sentinel pile, regressed hemorrhoid, or scar tissue, e.g. from a healed fissure), and anal stenosis (narrowing due to stricture scar formation). Fecal incontinence may also arise indirectly as a complication of another issue such as piles, a fistula, or rectal prolapse.
The pectinate aka dentate line lies a few centimeters beyond the anal opening. Past this line, the rectum is lined by a simple columnar epithelium that tears easily and is insensitive to pain. Consequently, any rectal problems that develop may remain undetected until they lead to noticeable symptoms, such as a fistula resulting in fecal incontinence or a localized bacterial infection becoming systemic.
Anal Fissure & Sentinel Pile
"Traumatic complications of rectal intercourse include prolapsed hemorrhoids, anal fistulas and fissures, perirectal abscesses, rectal ulcers, and anal tears."
Primary Care Medicine: Office Evaluation and Management of the Adult Patient (2009) - Page 528
"An anal fissure is a crack or tear in the vertical axis of the squamous lining of the anal canal between the anal verge and the dentate line. The classic symptom is pain during and following defecation, lasting minutes to hours. Bright red bleeding is common, most often seen on the toilet tissue and occasionally streaked onto the stool itself. Fissures occur most often in the posterior midline in both men and women, although anterior midline fissures are more commonly seen in women. Acute fissures are superficial but may deepen to expose the underlying internal sphincter. Chronic fissures are associated with secondary changes, which may include a sentinel tag, hypertrophied anal papilla, induration of the edge of the fissure, and/or relative anal stenosis secondary to spasm or fibrosis of the internal sphincter."
Clinics in Colon and Rectal Surgery. 2007; 20(2): 133-137.
"Anal fissures that do not heal promptly may develop characteristic features including a nipple-like bump (proximal papilla) at the internal start of the fissure, with another hard bump (sentinel pile) at the external end. Fissures may recur, persist, and eventually develop into anal or rectal ulcers. These may result in tissue death (necrosis) and sloughing of the anal tissue. A deep fissure involving the internal anal sphincter may result in scarring and anal narrowing (stenosis) of the anus if the condition persists."
"Anal fissures are common among male homosexuals, presumably as a consequence of traumatic anal intercourse. However, numerous anal and perianal ulcers occur in these individuals that may pose a problem in differential diagnosis. Certainly, a primary syphilitic chancre may be confused with anal fissure."
Colon and Rectal Surgery (2004) - Page 274
"Frequent anal eroticism is associated with anorectal pain, ulcers or fissures, rectal prolapse or leakage, and [symptomatic]hemorrhoids."
Primary Care in Obstetrics and Gynecology: A Handbook for Clinicians (2007) - Page 408
"The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins — hemorrhoids — can develop from an increase in pressure in the lower rectum. Factors that might cause increased pressure include: ... Anal intercourse"
"One theory proposes that it is the shearing (pulling) force of stool [or anal insertions], particularly hard stool, passing through the anal canal that drags the hemorrhoidal cushions downward. Another theory suggests that with age or an aggravating condition, the supporting tissue that is responsible for anchoring the hemorrhoids to the underlying muscle of the anal canal deteriorates. With time, the hemorrhoidal tissue loses its mooring and slides down into the anal canal."
"One of the most important etiologic theories is the “sliding anal cushion theory.” Thompson concluded that a sliding downward of the anal lining is responsible for the development of hemorrhoids... Repeated stretching of the anal supporting tissues (submucosal Treitz's muscle and elastic connective tissue framework) which normally functions to anchor and suspend the anal canal lining causes fragmentation of the supporting tissues and subsequent prolapse of the vascular cushions."
The ASCRS Manual of Colon and Rectal Surgery (2009) - Page 227
"External hemorrhoids may present with redundant tissue around the anus, bleeding, or difficulty in maintaining hygiene after bowel movements. In addition, they may become inflamed. Symptoms are typically less severe than those of internal hemorrhoids, with the exception of acute thrombosis of an external hemorrhoid... The necrotic skin may become gangrenous and rarely cause surrounding cellulitis. After the external hemorrhoid thrombus drains spontaneously or is surgically evacuated, the expanded external hemorrhoid will reduce in size; however, patients are often left with resultant skin tags. These tags may reduce in size over time, but typically do not completely regress."
The ASCRS Textbook of Colon and Rectal Surgery (2011) - Page 178
"The anal canal consists of three fibrovascular cushions that are fed directly by arteriovenous communications. These cushions are supported within the anal canal by a connective tissue framework, and they are important in providing a watertight seal to the anus. The degenerative effects of ageing may weaken or fragment the supporting tissues, and this along with the repeated passage of hard stool and straining produces a shearing [pulling due to friction] force on the cushions, leading to their descent and prolapse. The prolapsed cushions have impaired venous return, which results in engorgement that may be further exacerbated by straining, inadequate fibre intake, prolonged time on the lavatory, and conditions such as pregnancy that raise intra-abdominal pressure."
British Medical Journal. 2008 February 16; 336(7640): 380–383.
"Increased pressure and shearing force in the anal canal may lead to severe changes in topography with detachment of the hemorrhoids from the internal sphincter and fibromuscular network resulting in bleeding, itching, pain and disordered anorectal function, even [fecal]incontinence."
European Journal of Medical Research. 2004 Jan 26; 9(1): 18-36.
Proctitis & Sepsis
"Proctitis is an acute or chronic inflammation of the rectal mucosa. The prognosis is good unless massive bleeding occurs... This condition occurs with high frequency among homosexual men and women who engage in anal intercourse."
Disease Management for Nurse Practitioners (2001) - Page 438
"Proctitis that isn't treated or that doesn't respond to treatment may lead to complications, including:
* Ulcers. Chronic inflammation in the rectum can lead to open sores (ulcers) on the inside lining of the rectum.
* Fistulas. Sometimes ulcers extend completely through the intestinal wall, creating a fistula, an abnormal connection that can occur between different parts of your intestine, between your intestine and skin, or between your intestine and other organs, such as the bladder and vagina. For women, a recto-vaginal fistula can connect the rectum to the vagina, causing bowel contents to drain from the vagina."
"Although much of the proctitis in this population [of homosexual men in a major study] is infectious in origin, culture-negative proctitis occurs with some frequency and has been linked to exposure to the coloring agents and scents found in some of the lubricants used for anal intercourse."
Primary Care Medicine: Office Evaluation and Management of the Adult Patient (2009) - Page 528
"Anorectal infection and sepsis are common challenging problems. Although often used synonymously, sepsis and infection are different. Sepsis are the systemic responses to local infection, including hyperthermia, tachycardia, tachypnea, hypotension and altered mental status. Fortunately, most patients with infectious anorectal diseases present with a localized abscess or fistula, without systemic toxicity... Primary anorectal sepsis refers to bacterial invasion of the soft tissues in the peri-anal area, which is most commonly associated with Crohn's disease (CD) and immunocompromise."
Gervaz PA, Wexner SD. Complicated anorectal sepsis. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: https://www.ncbi.nlm.nih.gov/books/NBK6882/
"Anal intercourse may cause mucosal damage that introduces sepsis beneath that layer with subsequent fistula formation."
Immunology for Surgeons (2002) - Page 80
"This retrospective study details the findings and outcome in 34 homosexual men, out of a total of 177 patients, who underwent surgery for non-condylomatous perianal disease over a 2-year period. Of 34 homosexuals 20 presented with anorectal sepsis compared with 11 of 79 heterosexual male patients... These findings suggest that the prevalence of anorectal sepsis in homosexual men is high..."
The British Journal of Surgery. 1989 Oct; 76(10): 1064-6.
"Certain enteric ailments are particularly common among homosexual men. They are primarily infectious diseases and include not only such common venereal diseases as gonorrhea and syphilis but also infections not usually regarded as being sexually transmitted. Among the latter are shigellosis, salmonellosis, giardiasis, and amebiasis."
Pharmacotherapy. 1982 Jan-Feb; 2(1): 32-42.
Abscess & Fistula
"Proctologic complications of anal intercourse include allergic reactions to anal lubricants, prolapsed hemorrhoids, and fistulas, and fissures. Rectosigmoid tears may result from fist, forearm, and foreign body penetration of the bowel."
Annals of Internal Medicine. 1980 Jun; 92(6): 805-8.
"An anorectal abscess is a collection of pus in the anal or rectal region. It may be caused by infection of an anal fissure, sexually transmitted infections or blocked anal glands... The outcome is good if the abscess is treated promptly. However approximately two thirds of patients with rectal abscesses treated by incision and drainage or by spontaneous drainage will develop a chronic anal fistula."
"A perirectal abscess is a collection of pus in the deep tissues surrounding the anus. By contrast, a perianal abscess is a shallower collection of pus under the skin surrounding the anus; however, both are sometimes described as an anal abscess. Both types of abscesses need immediate medical attention; however, a perirectal abscess usually is the more severe infection. A delay in treatment may cause serious worsening of the condition and unnecessary complications."
"Treatment of anorectal abscesses involves early surgical drainage of the purulent collection. Primary antibiotic therapy alone is ineffective in resolving the underlying infection and simply postpones surgical intervention. Any delay in surgical drainage of anorectal abscesses prolongs infection, augments tissue damage, and may impair sphincter continence function, as well as promote stricture and/or fistula formation."
"The inflammatory process that leads to abscess may begin with an abrasion or tear in the lining of the anal canal, rectum, or perianal skin and subsequent infection by Escherichia coli, staphylococci, or streptococci. Trauma may result from injections for treatment of internal hemorrhoids, enema-tip abrasions, puncture wounds from ingested eggshells or fish bones, or insertion of foreign objects."
Professional Guide to Diseases (2008) - Page 291
"Manual dilatation of the anus first described by Récamier in 1838 is a simple procedure and previously a popular treatment option. Its re-introduction by Goligher and Watts led to its popularisation. However, incontinence was a concern and endo-anal ultrasonography provided an insight as to the degree of damage associated with this procedure; fragmentation is often seen. In an attempt to minimise incontinence, some have advocated gentle digital dilatation of the anus under total neuromuscular blockade, with incontinence seen in 9 (3.8%) of 273 patients following this procedure in one study. Despite these reports, incontinence is a concern and current opinion is that manual dilatation of the anus for the treatment of anal fissures is not recommended."
Annals of The Royal College of Surgeons of England. 2007 Jul; 89(5): 472-478.
"Anal dilatation (sphincter stretch) is another way to treat anal fissure. An older method of anal dilatation was commonly used until LIS was introduced in 1969. In this older method the surgeon inserted his fingers into the anus to spread the anal opening “manually.” This was relatively uncontrolled, and often resulted in some degree of incontinence. In the 1970's LIS became the preferred operation for anal fissure because it produced lower rates of incontinence than “manual dilatation.” In the 1990's Dr. Norman Sohn developed a procedure that stretches the sphincter muscle in a measured and controlled way that is less likely to produce incontinence. This procedure also avoids other postoperative complications, such as sphincterotomy site bleeding, infection and fistula."
"The main long-term complication of all sphincter-damaging procedures is some degree of fecal incontinence. Anal stretching, known as Lords procedure, has long been advocated as a therapy; it is still practiced. The anus is digitally dilated over its full length using up to six fingers. This procedure leads to an uncontrolled fragmentation of the internal sphincter; consequently, it should no longer be a therapeutic option."
Integrated Medical and Surgical Gastroenterology (2005) - Page 390
"Sphincter stretch for anal fissure or manual dilatation as a treatment for hemorrhoids (e.g., Lord's procedure) may be associated with fecal incontinence, probably on the basis of injury to the external as well as the internal sphincter. Obviously, internal sphincter stretch, even when properly performed, must inevitably produce stretching of the external sphincter also."
Colon and Rectal Surgery (2004) - Page 349
"Anal stenosis may follow almost any condition that causes scarring of the anoderm. The causes of anal stenosis include surgery of the anal canal, trauma, ..."
World Journal of Gastroenterology. 2009 April 28; 15(16): 1921-1928.
"[Anal stenosis is an] abnormal narrowing of the anal opening and/or anal canal... The most common form of anal stenosis arises from trauma, such as hemorrhoid operations [or]recurrent and persistent trauma in connection with anal sex... Strictures may develop in relation to a chronic anal fissure... Most patients are asymptomatic."
Textbook of Anal Diseases (1998) - Page 140
"Anal stenosis represents a technical challenge in terms of surgical management. It is a rare but serious complication of anorectal surgery, most commonly seen after surgical hemorrhoidectomy. However, stenosis can also occur in the absence of an anorectal surgical history... Anal stenosis may be anatomic (stricture) or functional (muscular)."
American Journal of Surgery. 2000 Apr; 179(4): 325-9.
"The rectum above the pectinate line is generally insensitive to pain. Thus the perforation of the rectal wall may occur without the individual being aware of it at the time of the injury. Any such perforation can result in peritonitis due to release of faecal contents in the peritoneal cavity."
The New Zealand Medical Journal. 2007 Aug 24; 120(1260): U2685. (PMID 17726499)
Vibrator-induced fatal rectal perforation
"The most common site of colonic perforation is the rectosigmoid colon. Several factors making this bowel segment vulnerable to being injured include a sharp angulation at either the rectosigmoid junction or the sigmoid-descending colon junction, and the great mobility of the sigmoid colon."
World Journal of Gastroenterology. 2010 January 28; 16(4): 425-430.
"The rectosigmoid junction is between the sigmoid colon and rectum and 15 to 17 cm from the anal verge. The rectum is approximately 12 cm long and 4 to 16 cm from the anal verge."
Lubricants damaging the rectal lining
"Personal lubricants are commonly used during anal intercourse; some are not safe to use with fragile rectal tissue. Fuchs, et al. evaluating the effects of marketed vaginal lubricants applied rectally found that hyper-osmolar gels caused rectal epithelial damage by inducing epithelia denudation and luminal secretion."
AIDS Research and Therapy. 2011; 8: 12.
"Phillips et al. demonstrated that rectal application of N-9 resulted in sloughing of surface epithelia. Hyperosmolar fluids have been shown to induce similar changes in the distal colon. Because many water-based personal lubricants are hyperosmolar, such formulations, applied rectally, may induce similar damage."
The Journal of Infectious Diseases. 2007 Mar 1; 195(5): 703-10. (PMID 17262713)
"The simple columnar epithelium lining the rectal mucosa is significantly more fragile than the stratified squamous epithelium found in the ectocervix and vagina."
Current Infectious Disease Reports. 2010 January; 12(1): 19-27.
"The rectal lining is a single cell layer of columnar epithelium covering the luminal surface and lining the crypt-like folds; by contrast, the mucosal lining of the vaginal and ectocervix consists of approximately 35 - 40 layers of stratified squamous epithelium."
Sexually Transmitted Diseases. 2009 June; 36(6): 350-356.
"The rectum is insensitive to stimuli capable of causing pain and other sensations when applied to a somatic cutaneous surface. It is, however, sensitive to distension... No specific sensory receptors are seen on careful histological examination of the rectum in humans. However, myelinated and non-myelinated nerve fibres are seen adjacent to the rectal mucosa, but no intraepithelial fibres arise from these."
Bailliere's Clinical Gastroenterology. 1992 Mar; 6(1): 179-91.
"Simple columnar epithelia consist of elongated cells, including mucus-secreting cells (in the lining of the stomach and cervical tract) and absorptive cells (in the lining of the small intestine)... Stratified squamous (nonkeratinized) epithelia line surfaces such as the mouth and vagina; these linings resist abrasion and generally do not participate in the absorption or secretion of materials into or out of the cavity."
Lodish H, Berk A, Zipursky SL, et al. Molecular Cell Biology. 4th edition. New York: W. H. Freeman; 2000. Figure 6-4, Principal types of epithelium. Available from: http://www.ncbi.nlm.nih.gov/books/NBK21682/figure/A1389/
"The anal canal is defined as the caudal part of the large intestine extending from the anorectal ring to the anal verge and is ~3 to 5 cm in length. Outside of the anal verge lies the anal margin, also referred to as the perianal skin, which commonly encompasses a radius of 5 cm. The anal verge can be identified visually as the part of the anal canal remaining closed when the buttocks are gently retracted. The upper anal canal is lined by columnar tissue that transitions into squamous epithelium at the dentate line. The dentate line, identified by the termination of the anal columns, lies 1 to 2 cm above the anal verge."
Clinics in Colon and Rectal Surgery. 2011 March; 24(1): 54–63.
"The anal canal is an anteroposterior slit 3-4cm in length situated between the rectum above and the perianal skin below. Different workers use different anatomical landmarks to define its precise upper and lower limits; for example, pathologists tend to use the upper and lower borders of the internal anal sphincter, the definition which will be used in this account; while clinicians usually quote the level of the levator ani muscle (the site of the so-called anorectal angle) for the upper limit and the anal orifice for the lower; and anatomists frequently use the levels of the anal valves (see below) and the anal orifice, respectively."
Morson and Dawson's Gastrointestinal Pathology (2003) - Page 643
"The lower anal canal and the anal opening are composed of two muscular constrictions that regulate fecal passage. The internal sphincter is part of the inner surface of the canal; it is composed of concentric layers of circular muscle tissue and is not under voluntary control. The external sphincter is a layer of voluntary (striated) muscle encircling the outside wall of the anal canal and anal opening... The lower part of the canal is very sensitive to heat, cold, cutting, and abrasion."
"The longitudinal smooth muscles of the bowel also continue through the anal canal, interdigitating between the internal anal sphincter, and then insert radially in the skin around the anal opening. These muscles are responsible for the radial folds or puckering of the skin around the anus and are sometimes thus described as the corrugator muscles of the anus (musculus corrugator ani)."
Anorectal and Colon Diseases: Textbook and Color Atlas of Proctology (2002) - Page 13
"Some fibers from this muscle become the corrugator cutis ani and insert on the perianal skin, creating rugal folds and a puckered appearance."
Surgery: Basic Science and Clinical Evidence (2008) - Page 1014
"The Corrugator Cutis Ani.—Around the anus is a thin stratum of involuntary muscular fiber, which radiates from the orifice. Medially the fibers fade off into the submucous tissue, while laterally they blend with the true skin. By its contraction it raises the skin into ridges around the margin of the anus."
Henry Gray's Anatomy of the Human Body (1918)
IV. Myology > 6F. The Muscles and Fasciae of the Perineum
"Hemorrhoids are normal features of the human anatomy. They are pads that bulge into the lumen. Hemorrhoids have three parts: 1) the lining, which can be mucosa or anoderm; 2) the stroma with blood vessels, smooth muscle, and supporting connective tissue; and 3) the anchoring connective tissue system, which secures the hemorrhoids to the internal sphincter and the conjoined longitudinal coat. The anchoring and supporting connective tissue system deteriorates with aging. The hemorrhoids not only bulge, but descend into the lumen. This becomes observable in the third decade of life, with individual differences. The veins become distended as they lose their support. The descended loose lining becomes more sensitive to pressure from straining and to trauma from the stool. There can be a stasis in the veins, with clot formations and swelling, or erosions of the lining, with bleeding. The hemorrhoids become symptomatic."
Diseases of the Colon and Rectum. 1984 Jul; 27(7): 442-50.
You may be able to locate a cited book at a nearby library using an online library catalog. Alternatively, a page preview may be available on Google Books (GB).
Note: GB and Amazon may report a different year of publication for the same book edition; when they disagree, I go with Amazon's. However, both the year of publication and even the page numbers may be unreliable due to differences in different regions and multiple versions such as ebook, hardcover, and paperback. Most book citations were initially found on and transcribed from GB previews.
|anamarya||Date: Saturday, 2014-04-12, 15:34:15 | Message # 3|
|Modern Perspectives in the Treatment of Chronic Anal Fissures |
Anal fissures are commonly encountered in routine colorectal practice. Developments in the pharmacological understanding of the internal anal sphincter have resulted in more conservative approaches towards treatment. Simple measures are often effective for early fissures. Glyceryl trinitrate is well established as a first-line pharmacological therapy. The roles of diltiazem and botulinum, particularly as rescue therapy, are not well understood. Surgery has a defined role and should not be discounted completely.
Data were obtained from Medline publications citing ‘anal fissure’. Manual cross-referencing of salient articles was conducted. We have sought to highlight various controversies in the management of anal fissures.
Acute fissures may heal spontaneously, although simple conservative measures are sufficient. Idiopathic chronic anal fissures need careful evaluation to decide what therapy is suitable. Pharmacological agents such as glyceryl trinitrate (GTN), diltiazem and botulinum toxin have been subjected to most scrutiny. Though practices in the UK vary, GTN or diltiazem would be suitable as first-line therapy with botulinum toxin used as rescue treatment. Sphincterotomy is indicated for unhealed fissures; fissurectomy has been revisited and advancement flaps have a role in patients in whom sphincter division is not suitable.
Keywords: Anal fissures, Glyceryl trinitrate, Diltiazem, Botulinum toxin, Sphincterotomy
An anal fissure is a split in the skin of the distal anal canal. Young adults of both sexes are affected equally. Patients present with anal pain commonly during defaecation and/or rectal bleeding. Whilst acute fissures heal spontaneously or with simple therapeutic measures, a proportion progress to form a chronic linear ulcer. Chronicity of a fissure relates to duration of greater than 6 weeks with fibres of the internal anal sphincter visible at the base of the fissure. Associated pathology may include a sentinel ‘pile’ distally and a fibro-epithelial polyp at the apex. Most anal fissures are idiopathic with no identifiable underlying disease process. There is no simple and unified theory to explain their genesis though constipation and lack of dietry fibre are implicated. Most fissures occur in the posterior midline; this may be anatomically related as there is a lack of tissue support posteriorly within the anal canal. Fissures associated with pregnancy are commonly located anteriorly and are often associated with low anal canal pressures. Other causes of fissures include Crohn's disease, syphilis, human immuno-deficiency virus (HIV) or tuberculosis. These are secondary fissures and are most appropriately treated by addressing the underlying disease process.
Treatment of anal fissuresConservative measuresThe initial approach in the treatment of anal fissures is non-operative. An acute anal fissure may heal spontaneously or in response to medical therapy with warm baths, stool softeners, bulk laxatives, analgesics, topical anaesthetics and re-assurance.1 Dietary bran supplements and warm sitz baths are superior to topically applied, local anaesthetic or hydrocortisone cream2 and fibre ingestion results in fewer recurrences.3 Regular anal dilatation to treat anal fissures is not recommended.4 Other therapies such as cautery, suppositories and sitz baths have been disappointing with low healing rates and high long-term recurrences.5
Operative strategiesMost chronic anal fissures are associated with a raised internal anal sphincter (IAS) pressure and reduced vascular perfusion at the base. Current treatment has aimed at reducing resting anal pressure by diminishing sphincter tone and improving blood supply at the site of the fissure, thus promoting the healing rate.
Manual dilatation of the anus first described by Récamier in 1838 is a simple procedure and previously a popular treatment option. Its re-introduction by Goligher and Watts led to its popularisation.6 However, incontinence was a concern and endo-anal ultrasonography provided an insight as to the degree of damage associated with this procedure; fragmentation is often seen.7-8 In an attempt to minimise incontinence, some have advocated gentle digital dilatation of the anus under total neuromuscular blockade, with incontinence seen in 9 (3.8%) of 273 patients following this procedure in one study.9 Despite these reports, incontinence is a concern and current opinion is that manual dilatation of the anus for the treatment of anal fissures is not recommended.
INTERNAL ANAL SPHINCTEROTOMY
Early advocates of sphincterotomy recommended a generous division of the IAS muscle and, in some cases, total division extending to the circular muscle of the rectum. By 1959, the ‘standard internal sphincterotomy’ comprised division of only half of the IAS to the dentate line in its lateral or posterolateral part.10 Posterior sphincterotomy results in a ‘keyhole deformity’ that can cause mucous leakage in approximately a third of patients and should no longer be performed.11
Notaras12 is credited for promoting the technique of lateral subcutaneous internal sphincterotomy. In this technique, the lower part of the internal sphincter is divided by introducing the knife blade at the anal verge between the anal canal mucosa and the IAS, then directing the cutting edge laterally towards the IAS. Hoffman and Goligher modified this technique by passing the blade between the internal and external sphincters and cutting medially. Both the subcutaneous and open techniques seem equally efficacious with regards to extent of division and effect on anal pressures.13
There are certain principles that should be noted:
The sphincterotomy should be away from the fissure site so that intact mucosal bridges fill the gap between divided muscle fibres to allow rapid healing.
The entire thickness of the lower internal sphincter must be divided, as any remaining intact fibres go into intense spasm to compensate for the divided fibres.
The mucosa over the sphincterotomy site should not be breached as this would predispose to infection.
The upper one-third of the sphincter must remain intact for continence.
The length of the sphincterotomy should be ‘tailored’ to the length of the anal fissure.
Sphincterotomy induces a sustained reduction of maximum resting anal pressure.14 The largest review of the sequelae of internal sphincterotomy for chronic fissure in ano showed rates of flatus incontinence in 715 patients, occurring ‘sometimes’ to ‘infrequently’ in 255 (35.7%), faecal urgency in 35 (4.9%) and soiling in 152 (21.2%).15 Incontinence may be minimised by a ‘tailored sphincterotomy’ where the sphincter is divided to the length of the fissure; this does not appear to compromise the healing rate.16
FISSURECTOMY/FISSURECTOMY AND SPHINCTEROTOMY
Fissurectoniy has a role in midline fissures complicated by underlying fistula. Though further work by Bode et al., Gingold and Di Castro et al.demonstrated fissurectoniy as a viable treatment option, its use has remained sporadic. The recent use with pharmacological agents such as topical isosorbide dinitrate to treat fissures has led to its reintroduction.17
ANAL ADVANCEMENT FLAPThis is indicated for patients with primary or recurrent fissures and for women with a complicated obstetric history with low resting anal canal pressure. In order to aid selection of suitable cases, prior manometry and endosonography is employed. This operation avoids further disruption to the internal sphincter and avoids factors that might otherwise jeopardise continence. Skin flaps can either be triangular (Y-V), a square-shaped sliding graft or a C-anoplasty.18
Endo-anal ultrasound imaging of the anal sphinctersAnal dilatation can be regarded as an uncontrolled tearing procedure that damages the sphincter muscles with considerable detriment to anal function (Fig. 1). Lateral sphincterotomy results in a discrete defect of the IAS; in women, the extent of the division can be greater due the relatively shorter anal canal length (Fig. 2). Endo-anal ultrasonography has also identified inadvertent division of the EAS or inadequate division as reasons for failure of a fissure to heal.19
Endo-anal ultrasound demonstrating the appearance of the internal anal sphincter (IAS) after manual dilatation for chronic anal fissure. The white arrows indicate the defects in the IAS.
Endo-anal ultrasound demonstrating the appearance of the internal anal sphincter (IAS) after lateral sphincterotomy for chronic anal fissure. The white arrow indicates the defect in the IAS.
Chemical sphincterotomyThis term refers to pharmacological manipulation of anal sphincter tone as an alternative modality to surgery for the treatment of anal fissures. The optimal treatment for anal fissures is to induce a temporary reduction of anal canal pressure to promote healing of the fissure without permanently disrupting normal sphincter function. A reduction in anal sphincter tone is achievable by enhancing IAS relaxation through direct action on internal anal sphincter smooth muscle cells. These mechanisms serve to reduce intracellular Ca2+, which reduces the tonic state of the muscle. These can occur through nitric oxide donation, direct intracellular Ca2+ depletion, muscarinic receptor stimulation, α-adrenergic inhibition or β-adrenergic stimulation.20
Nitric oxide donorsGLYCERYL TRINITRATEGlyceryl trinitrate (GTN) and isosorbide dinitrate act as nitric oxide donors and probably aid healing through an increase in local blood flow secondary to a reduction in intra-anal pressure and perhaps also by vasodilatation of the vessels supplying the anal musculature. Early studies with GTN focused on optimal dose schedules, healing rates and side effects. These were validated by numerous trials. Whilst GTN was advocated as first-line treatment for chronic anal fissures with encouraging results, concerns about its effectiveness in clinical practice outside clinical trials emerged.21–23 There was also evidence that the duration of topical GTN was limited24 and that GTN was possibly ineffective altogether.25 Furthermore, data from randomised, controlled trials have shown that GTN is not superior to lateral sphincterotomy.26,27It would seem that those fissures present for greater than 6 months and those with an associated sentinel pile are more likely to fail treatment.28 Alternative modes such as nitroglycerin patches have shown promise but have not been established as common practice.29
Isosorbide dinitrate (ISDN) is an alternative nitric oxide donor that has been used successfully in the treatment of anal fissures. The problems encountered are similar to those with GTN but long-term effectiveness has been questioned.30,31
Calcium antagonistsNifedipine is a dihydropyridine calcium-channel blocker (less correctly referred to as a ‘calcium-antagonist’), which inhibits calcium ion entry through voltage-sensitive areas of vascular smooth muscle and myocardium. Topical and oral formulations of nifedipine have been evaluated but not used in routine clinical practice.32,33
Diltiazem, a non-dihydropyridine calcium-channel blocker, also effects vascular smooth muscle relaxation and dilatation. Topical 2% diltiazem reduces maximum resting pressure (MRP) by approximately 28% and this effect lasts 3–5 h after application.34 Early studies by Carapeti et al.35and Knight et al.36 reported healing rates of chronic anal fissures of 67% and 73%, respectively. Side effects are minimal with diltiazem and include peri-anal dermatitis. Oral diltiazem has been assessed as part of a randomised trial and shown to heal anal fissures; however, significant side effects were noted.37 The topical formulation of diltiazem has been subjected to rigorous scrutiny and is a valid alternative to GTN with similar reductions in MRP, improved healing rates and lower rates of recurrence.38–41 There are also data to suggest that topical diltiazem heals GTN-resistant fissures.42
Muscarinic agonists and sympathetic neuromodulatorsCarapeti et al.,35 using 1% bethanecol gel in 10 volunteers, showed a dose-dependent reduction in the maximum resting anal canal pressure. Its use in a small trial showed that after 8 weeks, in 9 of 15 (60%), the fissure had healed with no side effects. After an initial encouraging study with oral indoramin as an α1-adrenoceptor antagonist which reduced maximum resting anal canal pressure,43 Pitt et al.44 proceeded to conduct a double-blind, randomised, placebo-controlled trial of oral indoramin to treat 23 patients with chronic anal fissure. Nine subjects withdrew within the first 2 weeks of treatment due to side effects which included fatigue, dizziness, headache, dry mouth, nasal congestion and retrograde ejaculation. At 6 weeks, the fissure healed in only one (7%) compared with two (22%) in the placebo group.44 The trial was terminated.
Botulinum toxinThe precise anatomical position in which to inject botulinum toxin has been a matter of some debate as comparable healing rates are seen when injected into the internal or external sphincter (Tables 1 and and2).2). Jones et al.45 have shown that botulinum toxin reduces the internal sphincter tone through its effect on the sympathetic nervous system. Despite concerns with the injection, patients seemed to accept its use in the out-patient setting, though in the UK most users would advocate injection under general anaesthesia. To address this, investigators have treated chronic anal fissures with botulinum delivered in an out-patient setting through a high-pressure device.46This mode of delivery needs further exploration.
Effect of injection of botulinum toxin type A injected into the external ana sphincter in patients with anal fissures
Effect of injection of botulinum toxin type A injected into the internal anal sphincter in patients with anal fissures
As with diltiazem, botulinum toxin is effective in treating fissures that have failed to heal with topical agents. Botulinum toxin can also be combined with surgical modalities. Lindsey et al.47showed that, following injection of 25 U of Botox into the internal sphincter combined with fissurectomy in 30 patients (19 of whom had failed both GTN and botulinum toxin injection), 28 (93%) had healed after a median of 16.4 weeks' follow-up. Dysport is an alternative tolerable commercial formulation of botulinum toxin to Botox; however, the change in dose needs attention as, in one study by Brisinda et al.,48 patients with fissures were randomised to receive 50 U of Botox formulation or 150 U of Dysport.
ConclusionsThe first-line treatment of chronic anal fissures with topical agents has led to management algorithms that can be employed effectively.49 Lindsey et al.50 gave an excellent overview of the current treatment of chronic anal fissures and introduced the idea of poly-pharmacy with and without surgery. This synergy between topical, injectable and operative modalites requires continued appraisal. A practical algorithm that we think is evidence based and encompasses changing practice for the treatment of anal fissures is shown in Figure 3.
Treatment algorithm for chronic anal fissures. If patients heal, a follow-up out-patient appointment should be considered.