[en] Anal fissure is a common problem which can evolve to chronicity. Chronic anal fissure is thought to be an ischemic ulceration related to sphincter hypertonia. Lateral internal sphineterotomy, the most common treatment for chronic anal fissure, may cause permanent injury to anal sphincter leading to fecal incontinence. To avoid such side effect were developed medications producing a temporary or reversible sphincterotomy reducing the sphincter pressure only until the fissure has healed : nitrates, calcium channel antagonists and botulinum toxin. Authors aimed to summary the state of research on such treatments (efficacy, side effects, recurrence risk) and to clarify the role of these different medical options in the current treatment of chronic anal fissure.
Disciplines :
Gastroenterology & hepatology
Author, co-author :
Van Kemseke, Catherine ; Centre Hospitalier Universitaire de Liège - CHU > Gastro-Entérologie-Hépatologie
Belaiche, Jacques ; Université de Liège - ULiège > Département des sciences cliniques > Hépato-gastroentérologie
Language :
English
Title :
Medical treatment of chronic anal fissure. Where do we stand on reversible chemical sphincterotomy?
Lock, M.R., Thomson, J.P.S., Fissure-in-ano the initial management and prognosis (1977) Br. J. Surg., 65, pp. 355-358
Shub, H., Salvati, E., Rubin, R., Conservative treatment of fissure: An unselected, retrospective and continuous study (1978) Dis. Colon Rectum, 21, pp. 582-583
Hananel, N., Gordon, R.H., Re-examination of clinical manifestations and response to therapy of fissure-in-ano (1997) Dis. Colon Rectum, 40, pp. 229-233
Jensen, S.L., Treatment of first episodes of acute anal fissure: Prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran (1986) Br. Med. J., 292, pp. 1167-1169
Klosterhalfen, B., Vogel, P., Rixen, H., Mittermayer, C., Topography of the inferior rectal artery: A possible cause of chronic, primary anal fissure (1989) Dis. Colon Rectum, 32, pp. 43-52
Farouk, R., Duthie, G.S., Macgregor, A.B., Bartolo, D.C., Sustained internal sphincter hypertonia in patients with chronic anal fissure (1994) Dis. Colon Rectum, 37, pp. 424-429
Schouten, W.R., Briel, J.W., Auwerda, J.J., Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures (1994) Dis. Colon Rectum, 37, pp. 664-669
Schouten, W.R., Briel, J.W., Auwerda, J.J.A., De Graff, E.J.R., Why do anal fissures heal after lateral internal sphincterotomy? (1995) Dis. Colon Rectum, 37, p. 9
De Parades, V., Parisot, C., La fissure anale à l'épreuve de l'evidence based medicine: Définition et concepts pathogéniques (2000) Le Courrier de Colo-Proctologie, 1, pp. 5-7
Nelson, R.L., Meta-analysis of operative techniques for fissure-in-ano (1999) Dis. Colon Rectum, 42, pp. 1424-1428
Nyam, D.C., Pemberton, J.H., Long-terms results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence (1999) Dis. Colon Rectum, 42, pp. 1306-1310
Garcia-Aguilar, J., Belmonte, C., Wong, W.D., Lowry, A.C., Madoff, R.D., Open vs closed sphincterotomy for chronic anal fissure: Long-term results (1996) Dis. Colon Rectum, 39, pp. 440-443
Madoff, R., Fleshman, J., AGA technical review on the diagnosis and care of patients with anal fissure (2003) Gastroenterology, 124, pp. 235-245
Utzig, M.J., Kroesen, A.J., Buhr, H.J., Concept in pathogenesis and treatment of chronic anal fissure. A review of litterature (2003) Am. J. Gastroenterol., 98, pp. 968-974
Loder, P.B., Kamm, M.A., Nicholls, R.J., Phillips, R.K., 'Reversible chemical sphincterotomy' by local application of glyceryl trinitrate (1994) Br. J. Surg., 81, pp. 1386-1389
Lund, J.N., Armitage, N.C., Scholefield, J.H., Use of glyceryl trinitrate ointment in the treatment of anal fissure (1996) Br. J. Surg., 83, pp. 776-777
Schouten, W.R., Briel, J.W., Boerma, M.O., Auwerda, J.J., Wilms, E.B., Graatsma, B.H., Pathophysiological aspects and clinical outcome of intra-anal application of isosorbide dinitrate in patients with chronic anal fissure (1996) Gut, 39, pp. 465-469
Oettle, G.J., Glyceryl trinitrate vs. sphincterotomy for treatment of chronic fissure-in-ano. A randomised controlled trial (1997) Dis. Colon Rectum, 40, pp. 1318-1320
Lund, J., Scholefield, J., A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate oinment in treatment of anal fissure (1997) Lancet, 349, pp. 11-14
Bacher, H., Mischinger, H.-J., Werkgartner, G., Cerwenka, H., El-Shabrawi, A., Pfeifer, J., Schweiger, W., Local nitroglycerin for treatment of anal fissures: An alternative to lateral sphincterotomy? (1997) Dis. Colon Rectum, 40, pp. 840-845
Brisinda, G., Maria, G., Bentivoglio, A.R., Cassetta, E., Gui, D., Albanese, A., A comparison of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure (1999) N. Engl. J. Med., 341, pp. 65-69
Carapeti, E.A., Kamm, M.A., Mc Donald, P.J., Chadwick, S.J., Melville, D., Phillips, R.K., Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate (1999) Gut, 44, pp. 727-730
Kennedy, M.L., Sowetr, S., Nguyen, H., Lubowski, D.Z., Glyceryl trinitrate ointment for the treatment of chronic anal fissure: Results of a placebo-controlled trial and long-term follow-up (1999) Dis. Colon Rectum, 42, pp. 1000-1006
Altomare, D.F., Rinaldi, M., Milito, G., Arcana, F., Spinelli, F., Nardelli, N., Scardigno, D., Loverglio, R., Glyceryl trinitrate for chronic anal fissure: Healing or headache? Results of a multicenter, randomised, placebo-controlled, double-blind trial (2000) Dis. Colon Rectum, 43, pp. 174-179
Richard, C.S., Gregoire, R., Plewes, E.A., Silverman, R., Burul, C., Buie, D., Reznick, R., Mc Leod, R., Internal sphincterotomy is superior to topical nitroglycerin in the treatment of chronic anal fissure: Results of a randomised, controlled trial of the Canadian Colorectal Surgical Trials Group (2000) Dis. Colon Rectum, 43, pp. 1048-1057
Zuberi, B.F., Rajput, M.R., Abro, H., Shaikh, S.A., A randomised trial of glyceryl trinitrate ointment and nitroglycerin patch in healing of anal fissures (2000) Int. J. Colorectal. Dis., 15, pp. 243-245
Evans, J., Luck, A., Hewett, P., Glyceryl trinitrate vs lateral sphincterotomy for chronic anal fissure. Prospective, randomised trial (2001) Dis. Colon Rectum, 44, pp. 93-97
Werre, A.J., Palamba, H.W., Bilgen, E.J., Eggink, W.F., Isosorbide dinitrate in the treatment of anal fissure: A randomised, prospective, double-blind, placebo-controlled trial (2001) Eur. J. Surg., 167, pp. 382-385
Kocher, H.M., Steward, M., Leather, A.J.M., Cullen, P.T., Randomised clinical trial assessing the side-effects of glyceryl trinitrate and diltiazem hydrochloride in the treatment of chronic anal fissure (2002) Br. J. Surg., 89, pp. 413-417
Libertiny, G., Knight, J., Farouk, R., Randomised trial of topical 0.2% glyceryl trinitrate and lateral internal sphincterotomy for the treatment of patients with chronic anal fissure: Long-term follow-up (2002) Eur. J. Surg., 168, pp. 418-420
Bailey, H.R., Beck, D., Billingham, R., Binderow, S., Gottesman, L., Hull, T., Larach, S., Gibbons, R., A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures (2002) Dis. Colon Rectum, 45, pp. 1192-1199
Scholefield, J.H., Bock, J.U., Marla, B., Richter, H.J., Athanasiadis, S., Pröls, M., Herold, A., A dose finding study with 0.1%, 0.2% and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures (2003) Gut, 52, pp. 264-269
Bieleckt, K., Kolodziejczak, M., A prospective randomised trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure (2003) Colorectal Disease, 5, pp. 256-257
Ezri, T., Susmallian, S., Topical nifedipine vs. topical glyceryl trinitrate for treatment of chronic anal fissure (2003) Dis. Colon Rectum, 46, pp. 805-808
Watson, S., Kamm, M., Nicholls, R., Philips, K., Topical glyceryl trinitrate in the treatment of chronic anal fissure (1996) Br. J. Surg., 83, pp. 771-775
Lund, J., Scholefield, J., Follow-up of patients with chronic anal fissure treated with topical glyceryl trinitrate (1998) Lancet, 352, p. 1681
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 (1998) Dis. Colon Rectum, 41, pp. 1406-1410
Jonas, M., Lund, J., Schoelfield, J., Topical 0.2% glyceryl trinitrate ointment for anal fissures: Long-term efficacy in routine clinical pratice (2002) Colorectal Disease, 4, pp. 317-320
Pitt, J., Williams, S., Dawson, P., Reasons for failure of glyceryl trinitrate treatment of chronic fissure-in-ano (2001) Dis. Colon Rectum, 44, pp. 864-867
Christie, A., Guest, J.F., Modelling the economic impact of managing a chronic anal fissure with a proprietary formulation of nitroglycerin (Rectogesic) compared to lateral internal sphincterotomy in the United Kingdom (2002) Int. J. Colorectal. Dis., 17, pp. 259-267
Chrysos, E., Xynos, E., Tzovaras, G., Zoras, O.J., Tsiaoussis, J., Vassilakis, S.J., Effect of nifedipine on rectoanal motility (1996) Dis. Colon Rectum, 39, pp. 212-216
Cook, T.A., Humphreys, M.M., Mc Mortensen, N.J., Oral nifedipine reduces resting anal pressure and heals chronic anal fissure (1999) Br. J. Surg., 86, pp. 1269-1273
Carapeti, E.A., Kamm, M.A., Phillips, R.K., Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects (2000) Dis. Colon Rectum, 43, pp. 1359-1362
Antropoli, C., Perrotti, P., Rubino, M., Mating, A., De Stefano, G., Migliore, G., Antropoli, M., Piazza, P., Nifedipine for local use in conservative treatment of anal fissures: Preliminary results of a multicenter study (1999) Dis. Colon Rectum, 42, pp. 1011-1015
Perrotti, P., Bove, A., Antropoli, C., Molino, D., Antropoli, M., Balzano, A., De Stefano, G., Attena, F., Topical nifedipine with tidocaine ointment vs active control for treatment of chronic anal fissure (2002) Dis. Colon Rectum, 45, pp. 1468-1475
Knight, J.S., Birks, M., Farouk, R., Topical diltiazem ointment in the treatment of chronic anal fissure (2001) Br. J. Surg., 88, pp. 553-556
Jonas, M., Neal, K.R., Abercrombie, J.F., Scholefield, J.H., A randomised trial of oral vs topical diltiazem for chronic anal fissures (2001) Dis. Colon Rectum, 44, pp. 1074-1078
Das Gupta, R., Franklin, I., Pitt, J., Dawson, P.M., Successful treatment of chronic anal fissure with diltiazem gel (2002) Colorectal Disease, 4, pp. 20-22
Jonas, M., Speake, W., Scholefield, J., Diltiazem heals glyceryl trinitrate-resistant chronic anal fissures. A prospective study (2002) Dis. Colon Rectum, 45, pp. 1091-1095
Griffin, N., Acheson, A.G., Jonas, M., Scholefield, J.H., The role of diltiazem in the treatment of chronic anal fissures that have failed glyceryl trinitrate therapy (2002) Colorectal Disease, 4, pp. 430-435
Sampaio, C., Ferreira, J.J., Simoes, F., Dysbot: A single-blind randomised parallel study to determine whether any differences can be detected in the efficacy and tolerability of two formulations of botulinum toxin type A- Dysport and Botox- assuming a ratio of 4:1 (1997) Mov. Disord., 12, pp. 1013-1018
Odergren, T., Hjaltason, H., Kaakkola, S., A double blind, randomised, parallel group study to investigate the dose equivalence of Dysport and Botox in the treatment of cervical dystonia (1998) J. Neurol. Neurosurg. Psychiatry, 64, pp. 6-12
Jost, W.H., Schimrigk, K., Use of botulinum toxin in anal fissure (1993) Dis. Colon Rectum, 36, p. 974
Jost, W.H., One hundred cases of anal fissure treated with botulinum toxin: Early and long-term results (1997) Dis. Colon Rectum, 40, pp. 1029-1032
Jost, W.H., Schrank, B., Chronic anal fissures treated with botulinum toxin injections: A dose-finding study with Dysport (1999) Colorectal Dis., 1, pp. 26-28
Madalinski, M., Jagiello, K., Labon, M., Adrich, Z., Kryszewski, A., Botulinum toxin injection into only one point in the external anal sphincter: A modification of the treatment for chronic anal fissure (1999) Endoscopy, 31, pp. S63
Madalinskj, M., Slawek, J., Duzynski, W., Zbytek, B., Jagiello, K., Adrich, Z., Kryszewski, A., Side effects of botulinum toxin injections for benign anal disorders (2002) Eur. J. Gastroenterol. Hepatol., 14, pp. 853-856
Gui, D., Cassetta, E., Anastasio, G., Bentivoglio, A.M., Maria, G., Albanese, A., Botulinum toxin for chronic anal fissure (1994) Lancet, 344, pp. 1127-1128
Mason, P.P., Watkins, M.J., Hall, H.S., Hall, A.W., The management of chronic fissure-in-ano with botulinum toxin (1996) JR Coll. Surg. Edinb., 41, pp. 235-238
Maria, G., Brisinda, G., Bentivoglio, A.R., 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 (1998) Ann. Surg., 228, pp. 664-669
Maria, G., Cassetta, E., Gui, D., Brisinda, G., Bentivoglio, A.R., Albanese, A., A comparison of botulinum toxin and saline for the treatment of chronic anal fissure (1998) N. Engl. J. Med., 338, pp. 217-220
Minguez, M., Melo, F., Espi, A., Garcia-Granero, E., Mora, F., Lledo, S., Benages, A., Therapeutic effects of different doses of botulinum toxin in chronic anal fissure (1999) Dis. Colon Rectum, 42, pp. 1016-1021
Maria, G., Brisinda, G., Bentivoglio, A.R., Cassetta, E., Gui, D., Albanese, A., Influence of botulinum toxin site of injections on healing rate in patients with chronic anal fissure (2000) Am. J. Surg., 179, pp. 46-50
Brisinda, G., Maria, G., Sganga, G., Bentivoglio, A.R., Albanese, A., Castagneto, M., Effectiveness of higher doses of botulinum toxin to induce healing in patients with chronic anal fissures (2002) Surgery, 131, pp. 179-184
Colak, T., Ipek, T., Kanik, A., Aydin, S., A randomised trial of botulinum toxin vs lidocain pomade for chronic anal fissure (2002) Acta Gastroenterol. Belg., 65, pp. 187-190
Fernandez Lopez, F., Conde Freire, R., Rios Rios, A., Garcia Iglesias, J., Cainzos Fernandez, M., Potel Lesquereux, J., Botulinum toxin for the treatment of anal fissure (1999) Dig. Surg., 16, pp. 515-518
Lysy, J., Israelit-Yatzkan, Y., Sestiery-Ittah, M., Weksler-Zangen, S., Keret, D., Goldin, E., Topical nitrates potentiate the effect of botulinum toxin in the treatment of patients with refractory anal fissure (2001) Gut, 48, pp. 221-224
Mentes, B.B., Irkorucu, O., Akin, M., Leventoglu, S., Tatlicioglu, E., Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure (2003) Dis. Colon Rectum, 46, pp. 232-237
Siproudhis, L., Sebille, V., Pigot, F., Hemery, P., Juguet, F., Bellissant, E., Lack of efficacy of botulinum toxin in chronic anal fissure (2003) Aliment Pharmacol. Ther., 18, pp. 515-524
Lindsey, I., Jones, O., Cunningham, C., George, B., Mortensen, N., Botulinum toxin as second-line therapy for chronic anal fissure failing 0.2 percent glyceryl trinitrate (2003) Dis. Colon Rectum, 46, pp. 361-366
Madalinski, M., Slawek, J., Duzynski, W., Zbytek, B., Jagiello, K., Adrich, Z., Kryszewski, A., Side effects of botulinum toxin injection for begnin anal disorders (2002) Eur. J. Gastroenterol. Hepatol., 1, pp. 853-856
Minguez, M., Herrebos, B., Espi, A., Garcia-Granero, E., Sanchiz, V., Mora, F., Lledo, S., Benages, A., Long-term follow-up (42 months) of chronic anal fissure after healing with botulinum toxin (2002) Gastroenterology, 123, pp. 112-117
American Gastroenterological Association medical position statement: Diagnosis and care of patients with anal fissure (2003) Gastroenterology, 124, pp. 233-234