Skip to main content

Advertisement

SpringerLink
Log in

Management options for chronic anal fissure: a systematic review of randomised controlled trials

  • Review
  • Published:
International Journal of Colorectal Disease Aims and scope Submit manuscript

Abstract

Introduction

Anal fissure is the most common cause of severe anorectal pain in adults, contributing significantly to coloproctology workloads. There are a wide variety of management options available, including topical nitrites, calcium channel blockers, botulinum toxin injection and sphincterotomy. The aim of this study was to review current options for the treatment of chronic anal fissure.

Methods

A comprehensive search identifying randomized controlled trials comparing treatment options for anal fissure published between January 2000 and February 2020 was performed. The primary outcome assessed was healing at 8 weeks post commencing treatment. Secondary outcomes included recurrence, intolerance of treatment and complications.

Results

A total of 2822 studies were identified. After removal of duplicates and non-relevant studies, we identified nine randomized controlled trials which met pre-defined criteria. There was a total of 775 patients. At 8 weeks, healing rates were 95.13% in those treated with sphincterotomy, 66.7% in the botulinum toxin group, 63.8% in the nitrate group, 52.3% for topical diltiazem and 50% for topical minoxidil. Recurrence was highest amongst those treated with botulinum toxin injection (41.7%) and lowest for sphincterotomy (6.9%). Although the absolute number is low, there was a risk of permanent incontinence with sphincterotomy.

Conclusion

This review of the randomized control data demonstrates that healing was significantly higher amongst those treated with sphincterotomy versus more conservative modalities. Topical nitrites had similar outcomes to botulinum toxin injection but were poorly tolerated in comparison to other treatments. The benefit of sphincterotomy was at a cost of increased complications, notably permanent incontinence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Lockhart Mummery J (1934) Diseases of the rectum and colon and their surgical treatment. W Wood and company

  2. Mapel DW, Schum M, Von Worley A (2014) The epidemiology and treatment of anal fissures in a population-based cohort. BMC Gastroenterol 14:129

    Article  PubMed  PubMed Central  Google Scholar 

  3. Sit M, Yilmaz EE, Canan F, Yildirim O, Cetin MM (2014) Health-related quality of life in patients with anal fissure: effect of type D personality. Prz Gastroenterol 9(2):93–98

    PubMed  PubMed Central  Google Scholar 

  4. Ayantunde AA, Debrah SA (2006) Current concepts in anal fissures. World J Surg 30(12):2246–2260

    Article  PubMed  Google Scholar 

  5. Pescatori M, Interisano A (1995) Annual Reports of the Italian Coloproctology Units. Tech Coloproctol:29–30

  6. Beaty JS, Shashidharan M (2016) Anal fissure. Clin Colon Rectal Surg 29(1):30–37

    Article  PubMed  PubMed Central  Google Scholar 

  7. Lund JN, Scholefield JH (1996) Aetiology and treatment of anal fissure. Br J Surg 83(10):1335–1344

    Article  CAS  PubMed  Google Scholar 

  8. Lepsenyi M, Santen S, Syk I, Nielsen J, Nemeth A, Toth E, Thorlacius H (2011) Self-expanding metal stents in malignant colonic obstruction: experiences from Sweden. BMC Res Notes 4:274

    Article  PubMed  PubMed Central  Google Scholar 

  9. McCallion K, Gardiner KR (2001) Progress in the understanding and treatment of chronic anal fissure. Postgrad Med J 77(914):753–758

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Utzig MJ, Kroesen AJ, Buhr HJ (2003) Concepts in pathogenesis and treatment of chronic anal fissure--a review of the literature. Am J Gastroenterol 98(5):968–974

    CAS  PubMed  Google Scholar 

  11. Jenkins JT, Urie A, Molloy RG (2008) Anterior anal fissures are associated with occult sphincter injury and abnormal sphincter function. Color Dis 10(3):280–285

    Article  CAS  Google Scholar 

  12. Farouk R, Duthie GS, MacGregor AB, Bartolo DCC (1994) Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum 37(5):424–429

    Article  CAS  PubMed  Google Scholar 

  13. Abcarian H, Lakshmanan S, Read DR, Roccaforte P (1982) The role of internal sphincter in chronic anal fissures. Dis Colon Rectum 25(6):525–528

    Article  CAS  PubMed  Google Scholar 

  14. Gibbons CP, Read NW (1986) Anal hypertonia in fissures: cause or effect? Br J Surg 73(6):443–445

    Article  CAS  PubMed  Google Scholar 

  15. Schouten WR, Briel JW, Auwerda JJ (1994) Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 37(7):664–669

    Article  CAS  PubMed  Google Scholar 

  16. Klosterhalfen B, Vogel P, Rixen H, Mittermayer C (1989) Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 32(1):43–52

    Article  CAS  PubMed  Google Scholar 

  17. Abramowitz L, Sobhani I, Benifla JL, Vuagnat A, Daraï E, Mignon M, Madelenat P (2002) Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum 45(5):650–655

  18. Sweeney JL, Ritchie JK, Nicholls RJ (1988) Anal fissure in Crohn's disease. Br J Surg 75(1):56–57

    Article  CAS  PubMed  Google Scholar 

  19. Nadal SR, Manzione CR, Galvão VM, Salim VRBM, Speranzini MB (1999) Perianal diseases in HIV-positive patients compared with a seronegative population. Dis Colon Rectum 42(5):649–654

    Article  CAS  PubMed  Google Scholar 

  20. Smith DL, Cataldo PA (1999) Perianal lymphoma in a heterosexual and nonimmunocompromised patient: report of a case and review of the literature. Dis Colon Rectum 42(7):952–954

    Article  PubMed  Google Scholar 

  21. Higgins J and Green S (2011) Cochrane Handbook for Systematic Reviews of Interventions version 5.1.0. [cited 2019 5th October]; Updated March 2011

  22. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62(10):e1–e34

  23. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13

    Article  PubMed  PubMed Central  Google Scholar 

  24. Higgins JP et al (2011) The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 343:d5928

    Article  PubMed  PubMed Central  Google Scholar 

  25. Alvandipour M, Ala S, Khalvati M, Yazdanicharati J, Koulaeinejad N (2018) Topical minoxidil versus topical diltiazem for chemical sphincterotomy of chronic anal fissure: a prospective, randomized, double-blind, clinical trial. World J Surg 42(7):2252–2258

    Article  PubMed  Google Scholar 

  26. Berkel AE et al (2014) Isosorbide dinitrate ointment vs botulinum toxin A (Dysport) as the primary treatment for chronic anal fissure: a randomized multicentre study. Color Dis 16(10):O360–O366

    Article  CAS  Google Scholar 

  27. Arslan K, Erenoğlu B, Doğru O, Turan E, Eryilmaz MA, Atay A, Kökçam S (2013) Lateral internal sphincterotomy versus 0.25 % isosorbide dinitrate ointment for chronic anal fissures: a prospective randomized controlled trial. Surg Today 43(5):500–505

  28. Valizadeh N, Jalaly NY, Hassanzadeh M, Kamani F, Dadvar Z, Azizi S, Salehimarzijarani B (2012) Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial. Langenbeck's Arch Surg 397(7):1093–1098

    Article  Google Scholar 

  29. Nasr M, Ezzat H, Elsebae M (2010) Botulinum toxin injection versus lateral internal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. World J Surg 34(11):2730–2734

    Article  PubMed  Google Scholar 

  30. Arroyo A, Pérez F, Serrano P, Candela F, Lacueva J, Calpena R (2005) Surgical versus chemical (botulinum toxin) sphincterotomy for chronic anal fissure: long-term results of a prospective randomized clinical and manometric study. Am J Surg 189(4):429–434

    Article  CAS  PubMed  Google Scholar 

  31. Arroyo A, Pérez F, Serrano P, Candela F, Calpena R (2004) Open versus closed lateral sphincterotomy performed as an outpatient procedure under local anesthesia for chronic anal fissure: prospective randomized study of clinical and manometric longterm results. J Am Coll Surg 199(3):361–367

    Article  PubMed  Google Scholar 

  32. Libertiny G, Knight JS, Farouk R (2002) 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. Eur J Surg 168(7):418–421

    Article  PubMed  Google Scholar 

  33. Evans J, Luck A, Hewett P (2001) Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, randomized trial. Dis Colon Rectum 44(1):93–97

    Article  CAS  PubMed  Google Scholar 

  34. Goren A, Shapiro J, Roberts J, McCoy J, Desai N, Zarrab Z, Pietrzak A, Lotti T (2015) Clinical utility and validity of minoxidil response testing in androgenetic alopecia. Dermatol Ther 28(1):13–16

    Article  PubMed  Google Scholar 

  35. Varothai S, Bergfeld WF (2014) Androgenetic alopecia: an evidence-based treatment update. Am J Clin Dermatol 15(3):217–230

    Article  PubMed  Google Scholar 

  36. Wang T (2003) The effects of the potassium channel opener minoxidil on renal electrolytes transport in the loop of henle. J Pharmacol Exp Ther 304(2):833–840

    Article  CAS  PubMed  Google Scholar 

  37. Campese VM (1981) Minoxidil: a review of its pharmacological properties and therapeutic use. Drugs 22(4):257–278

    Article  CAS  PubMed  Google Scholar 

  38. Muthukumarassamy R et al (2005) Treatment of anal fissures using a combination of minoxidil and lignocaine: a randomized, double-blind trial. Indian J Gastroenterol 24(4):158–160

    PubMed  Google Scholar 

  39. Knight JS, Birks M, Farouk R (2001) Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg 88(4):553–556

    Article  CAS  PubMed  Google Scholar 

  40. Carapeti EA, Kamm MA, Phillips RK (2000) Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum 43(10):1359–1362

    Article  CAS  PubMed  Google Scholar 

  41. Cross KL, Massey EJ, Fowler AL, Monson JR, ACPGBI (2008) The management of anal fissure: ACPGBI position statement. Color Dis 10(Suppl 3):1–7

    Article  Google Scholar 

  42. Murad F (1996) The 1996 Albert Lasker Medical Research Awards. Signal transduction using nitric oxide and cyclic guanosine monophosphate. JAMA 276(14):1189–1192

    Article  CAS  PubMed  Google Scholar 

  43. Loder PB, Kamm MA, Nicholls RJ, Phillips RKS (1994) 'Reversible chemical sphincterotomy' by local application of glyceryl trinitrate. Br J Surg 81(9):1386–1389

  44. Jones OM, Moore JA, Brading AF, Mortensen NJMC (2003) Botulinum toxin injection inhibits myogenic tone and sympathetic nerve function in the porcine internal anal sphincter. Color Dis 5(6):552–557

    Article  CAS  Google Scholar 

  45. Sahebally SM, Meshkat B, Walsh SR, Beddy D (2018) Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta-analysis of randomized controlled trials. Color Dis 20(1):6–15

    Article  CAS  Google Scholar 

  46. Lindsey I, Jones OM, Cunningham C, George BD, Mortensen NJM (2003) Botulinum toxin as second-line therapy for chronic anal fissure failing 0.2 percent glyceryl trinitrate. Dis Colon Rectum 46(3):361–366

    Article  PubMed  Google Scholar 

  47. Nelson RL et al (2011) Operative procedures for fissure in ano. Cochrane Database Syst Rev 11:CD002199

    Google Scholar 

  48. Poh A, Tan KY, Seow-Choen F (2010) Innovations in chronic anal fissure treatment: a systematic review. World J Gastrointest Surg 2(7):231–241

    Article  PubMed  PubMed Central  Google Scholar 

  49. Menteş BB, İrkörücü O, Akn M, Leventoğlu S, Tatlcoğlu E (2003) Comparison of botulinum toxin injection and lateral internal sphincterotomy for the treatment of chronic anal fissure. Dis Colon Rectum 46(2):232–237

    Article  PubMed  Google Scholar 

  50. Rotholtz NA, Bun M, Mauri MV, Bosio R, Peczan CE, Mezzadri NA (2005) Long-term assessment of fecal incontinence after lateral internal sphincterotomy. Tech Coloproctol 9(2):115–118

    Article  CAS  PubMed  Google Scholar 

  51. Nelson RL, Manuel D, Gumienny C, Spencer B, Patel K, Schmitt K, Castillo D, Bravo A, Yeboah-Sampong A (2017) A systematic review and meta-analysis of the treatment of anal fissure. Tech Coloproctol 21(8):605–625

    Article  CAS  PubMed  Google Scholar 

  52. Menteş BB, Ege B, Leventoglu S, Oguz M, Karadag A (2005) Extent of lateral internal sphincterotomy: Up to the dentate line or up to the fissure apex? Dis Colon Rectum 48(2):365–370

    Article  PubMed  Google Scholar 

  53. Hasse C, Brune M, Bachmann S, Lorenz W, Rothmund M, Sitter H (2004) Lateral, partial sphincter myotomy as therapy of chronic anal fissue. Long-term outcome of an epidemiological cohort study. Chirurg 75(2):160–167

    Article  CAS  PubMed  Google Scholar 

  54. Khubchandani IT, Reed JF (1989) Sequelae of internal sphincterotomy for chronic fissure in ano. Br J Surg 76(5):431–434

    Article  CAS  PubMed  Google Scholar 

  55. Casillas S, Hull TL, Zutshi M, Trzcinski R, Bast JF, Xu M (2005) Incontinence after a lateral internal sphincterotomy: are we underestimating it? Dis Colon Rectum 48(6):1193–1199

    Article  PubMed  Google Scholar 

  56. Kement M, Karabulut M, Gezen FC, Demirbas S, Vural S, Oncel M (2011) Mild and severe anal incontinence after lateral internal sphincterotomy: risk factors, postoperative anatomical findings and quality of life. Eur Surg Res 47(1):26–31

    Article  CAS  PubMed  Google Scholar 

  57. Elsebae MMA (2007) A study of fecal incontinence in patients with chronic anal fissure: prospective, randomized, controlled trial of the extent of internal anal sphincter division during lateral sphincterotomy. World J Surg 31(10):2052–2057

    Article  PubMed  Google Scholar 

  58. Pfeifer J, Berger A, Uranüs S (1994) Surgical therapy of chronic anal fissure--do additional proctologic operations impair continence? Chirurg 65(7):630–633

    CAS  PubMed  Google Scholar 

  59. Sahebally SM, Walsh SR, Mahmood W, Aherne TM, Joyce MR (2018) Anal advancement flap versus lateral internal sphincterotomy for chronic anal fissure- a systematic review and meta-analysis. Int J Surg 49:16–21

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Colorectal Surgery, St James’ Hospital, Dublin, 8, Ireland

    P. A. Boland, M. E. Kelly, N. E. Donlon, J. C. Bolger, J. O. Larkin, B. J. Mehigan & P. H. McCormick

Authors
  1. P. A. Boland
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. M. E. Kelly
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. N. E. Donlon
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. C. Bolger
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. J. O. Larkin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. B. J. Mehigan
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. P. H. McCormick
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to P. A. Boland.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix

Appendix

Appendix 1 Assessment of risk bias
Full size table

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Boland, P.A., Kelly, M.E., Donlon, N.E. et al. Management options for chronic anal fissure: a systematic review of randomised controlled trials. Int J Colorectal Dis 35, 1807–1815 (2020). https://doi.org/10.1007/s00384-020-03699-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00384-020-03699-4

Keywords

Search

Navigation