Anal Fissure: the Facts

(Are there any?)Tamzin Cuming

Colorectal ConsultantHomerton University Hospital

Classic fissure in ano

90% posterior

< 6 weeks: acute

> 6 weeks + sentinel pile + visible sphincter

= chronic

When is a fissure not a fissure?

• Be suspicious • multiple or lateral– Crohn’s

?fissure

• Post-childbirth woman– ‘low-pressure fissure’– Anterior– Weak pelvic floor– rectocele

?fissure

• In an old person– Cancer: – anal cancer even– (esp if HIV+)

?fissure

• In someone with bad skin• Eczema, psoriasis, dermatitis

OK some facts

• 90% are the fissures you are thinking of– Young man– High pressure anus– Split is posterior • Because the blood supply is worst at the back• The pain is from anal spasm

Management

Acute Lignocaine, Fybogel and sympathy (90% cure)

Chronic

ALL THE TREATMENTS (except one) TREAT THE SPASM

and let the body heal the fissure

Anal spasm treatment I

• Give it nitrous oxide– GTN 0.4% >0.2% • 25% headache (cling film)

• Cure 60%1 Recurrence 50%2

– Diltiazem 2% • 15% pruritis• Cure: 75%3 RRecurrence 0.664

• Why not block the Ca2+ channels?– nifedipene top/oral

1 2006 Cochrane Review Nelson 2 DCR 2004;47:422-431 3Steele SR 2006 Aliment Pharm 4Sajid MS Colorectal Dis 2013

Anal Spasm treatment II

Paralyse it!

• At least Botox wears off

• Clinical conviction

• Less expensive than 5 years ago

Cochrane review• Healing rate variable: 75%• Recurrence rate 50% at 4 yrs• 10% temporary incontinence• No better than GTN 0.2%• More expensive than NO

(£77/pt)• Works for NO-resistant

Nelson 2012; NICE ESUOM14; Lindsey DCR 2004

Anal spasm treatmentCUT IT!

– Lateral anal (internal) sphincterotomy

– FINALLY! A CURE!

• 95%

– 5% up to 47% ‘mild’ incontinence• forever

No longer

• Posterior sphincterotomy: key-hole deformity

• Lord’s anal stretch

If all else fails

• Histology to exclude odd things plus DOSH• Advancement flap anoplasty– 48% cure with 0% incontinence– Also a treatment for low pressure fissures– recur if pelvic floor dysfunction not addressed

Anoplasty options

• V-Y or rotational island advancement flap• Mucosal advancement flap• Cutaneous advancement flap using sentinel pile

(SCAFA)

• Probably fail due to same high • pressure ischaemia– Botox AND anoplasty if high pressures– LAS and anoplasty

Conclusion

• If it’s not at the back in a young man: worry– (but you don’t need to do a PR)

• If it is:• Diltiazem is good• Botox is good• LAS short term good long term bad• and• Anoplasty can be good if desperate