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Abstract
Anal fissure is a split in the lining of the distal anal canal. Lateral internal sphincterotomy remains the gold standard for treatment of anal fissure. Although technique is simple and effective, a drawback of this surgical procedure is its potential to cause minor but some times permanent alteration in rectal continence. Conservative approaches (such as topical application of ointment or botulinum toxin injections) have been proposed in order to treat this condition without any risk of permanent injury of the internal anal sphincter. These treatments are effective in a large number of patients. Furthermore, with the ready availability of medical therapies to induce healing of anal fissure, the risk of a first-line surgical approach is difficult to justify. The conservative treatments have a lower cost than surgery. Moreover, evaluation of the actual costs of each therapeutic option is important especially in times of economic crisis and downsizing of health spending.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.
No writing assistance was utilized in the production of this manuscript.
Key issues
Chronic anal fissure (AF) is a cut or crack in the anal canal or anal verge. Chronicity is defined by both chronology and morphology.
AF causes and the reasons for their failure to heal remain unclear.
Recognized features common to most chronic AF are a high resting anal pressure owing to internal anal sphincter (IAS) hypertonicity.
Lateral internal sphincterotomy is a surgical technique to cure AF. It has been favored by most of the surgeons, because it offers long-lasting relief in sphincter spasm.
Surgery permanently weakens the IAS and may lead to anal incontinence. Although most episodes of incontinence are minor and transient, in a subset of patients incontinence is permanent.
Nitric oxide donors may promote healing of anal fissure by increasing local blood flow. Many patients have experienced transient headache when using topical glyceryl trinitrate (GTN) preparations and have reported a burning sensation in the anus.
Benefit from GTN is not always permanent, and recently, it has been stated that the treatment with topical GTN is less efficacious than previously reported.
It may, therefore, be possible to lower anal sphincter pressure using calcium channel antagonists and cholinergic agonists without side effects. Nifedipine has also been used in treatment of chronic AF as reported in a number of studies. A combination of lidocaine and nifedipine can be a reliable non-surgical method for treating AF.
Botulinum toxin (BT) is widely commercially available. Three preparations are available for clinical use.
BT appears as a safe treatment for patients with chronic AF. It is easier to perform than surgical treatment and does not require anesthesia. It is also more efficacious than nitrate therapy. No adverse effects or permanent IAS damage have resulted from BT injection.
BT injection has an excellent healing rate, can be repeated if necessary and obviates the patient’s compliance. The potential BT side effects should be kept in mind, however, including patient aversion to injection. One major problem of conservative therapy for AF is compliance.
BT therapeutic approach is more cost-effective than the ointment approach.