Abstract
PURPOSE: The aim of this study was to investigate the relationship between anal pressure and anodermal blood flow. METHODS: We performed Doppler laser flowmetry of the anoderm combined with anorectal manometry in 178 subjects (87 males and 91 females; median age, 55 (range, 17–87) years). This group consisted of 31 healthy volunteers, 23 patients with fecal incontinence, 17 patients with hemorrhoids, and 9 patients with anal fissure. The remaining 98 patients had other colorectal disorders. In 16 controls we examined anodermal blood flow in the four quadrants of the anal canal. RESULTS: Perfusion of the anoderm at the posterior midline was significantly lower than in the other three segments of the anal canal (posterior midline: 0.74±0.26 V; left lateral side: 1.68 ±0.81 V; right lateral side: 1.57±0.52 V; anterior midline: 1.48±0.69 V,P<0.001). In the overall group, we found a significant correlation between maximum anal resting pressure and anodermal blood flow at the posterior midline (r=−0.616,P<0.001). In the nine patients with chronic anal fissure, the mean maximum anal resting pressure was 125±26 mmHg, which was significantly higher than in patients with hemorrhoids (82±15 mmHg), controls (66±19 mmHg), and patients with fecal incontinence (42±14 mmHg,P<0.001), whereas the blood flow at the base of the fissure was significantly lower (0.43±0.10 V vs.0.57±0.19 V vs.0.75±0.26 vs.1.03±0.34 V). In ten patients we also studied the influence of anesthesia on both anal pressure and anodermal blood flow. During the administration of anesthesia, anal pressure dropped from 63±21 mmHg to 32±15 mmHg (P<0.001), whereas anodermal blood flow at the posterior midline increased from 0.79±0.22 V to 1.31±0.35 V (P<0.001). CONCLUSION: Anodermal blood flow at the posterior midline is less than in the other segments of the anal canal. The perfusion of the anoderm at the posterior commissure is strongly related to anal pressure. The higher the pressure, the lower the flow. Our findings support the hypothesis that anal fissures are ischemic ulcers.
Similar content being viewed by others
References
Gibbons CP, Read NW. Anal hypertonia in fissures; cause or effect? Br J Surg 1986;73:443–5.
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 1989;32:43–52.
Ball C. The rectum, its diseases and developmental defects. London: Hodder and Stoughton, 1908.
Motson RW, Clifton MA. Pathogenesis and treatment of anal fissure. In: Henry MM, Swash M, eds. Coloproctology and the pelvic floor. London: Butterworth, 1985:340–9.
Rankin FW, Bargen JA, Buie LA. The colon, rectum and anus. Philadelphia: WB Saunders, 1932:584–93.
Goligher JC. Surgery of the anus, rectum and colon. 4th ed. London: Baillière Tindall, 1980:136–50.
Gordon PH. Fissure-in-ano. In: Gordon PH, Nivatvongs S, eds. Principles and practice of surgery for the colon, rectum and anus. St. Louis: Quality Medical Publishing, 1992:199–219.
Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation: chronic anal fissure: a new theory of pathogenesis. Am J Surg 1982;144:262–8.
Blaisdell PC. Pathogenesis of anal fissure and implications as to treatment. Surg Gynecol Obstet 1937;65:672–7.
Miles WE. Observations upon internal piles. Surg Gynecol Obstet 1919;29:497–506.
Cerdan FJ, Riuz de Léon A, Azpiroz F. Anal sphincteric pressure in fissure in ano before and after lateral internal sphincterotomy. Dis Colon Rectum 1982;25:198–201.
Nothmann BJ, Shuster MM. Internal anal sphincter derangement with anal fissures. Gastroeneterology 1974;67:216–20.
Hancock BD. The internal sphincter and anal fissure. Br J Surg 1977;64:92–5.
Arabi Y, Alexander-Williams J, Keighley MR. Anal pressure in hemorrhoids and anal fissure. Am J Surg 1977;134:608–10.
Fisher M, Thermann M, Hamelmann H. Manometrische Untersuchungen des Analkanals vor und nach der Behandlung durch Dehnung oder Spincterotomie. Chirurg 1978;49:111–3.
Chowcat NL, Aranjo JG, Boulos PB. Internal sphincterotomy for chronic anal fissure: long term effects on anal pressure. Br J Surg 1986;73:915–6.
Author information
Authors and Affiliations
Additional information
Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.
About this article
Cite this article
Schouten, W.R., Briel, J.W. & Auwerda, J.J.A. Relationship between anal pressure and anodermal blood flow. Dis Colon Rectum 37, 664–669 (1994). https://doi.org/10.1007/BF02054409
Issue Date:
DOI: https://doi.org/10.1007/BF02054409