Review
Progress in the understanding and treatment of chronic anal
fissure
K McCallion, K R Gardiner
Department of
Surgery, Queen's University, Belfast, UK
Correspondence to: Mr K McCallion, Department of Surgery, Institute of Clinical Science Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BJ, UK k.mccallion{at}qub.ac.uk
Submitted 5 June 2000;
Accepted 3 July 2001
BACKGROUND
Chronic anal fissure is
a common and painful condition associated with internal anal sphincter
hypertonia. Reduction of this hypertonia improves the local blood
supply, encouraging fissure healing. Surgical sphincterotomy is very
successful at healing these fissures but requires an operation with
associated morbidity. Temporary reduction in sphincter tone can be
achieved on an outpatient basis by applying a topical nitric oxide
donor (for example, glyceryl trinitrate) or injecting botulinum toxin
into the anal sphincter.
METHODSA Medline database was used
to perform a literature search for articles relating to the
non-surgical treatment of chronic anal fissure.
RESULTSReview of the literature
shows botulinum toxin injection to be more effective at healing chronic
anal fissures than topical glyceryl trinitrate. Topical isosorbide
dinitrate has not been directly compared with either of these two
agents but has a healing rate approaching that of botulinum toxin
injection. The main side effect of botulinum toxin injection is
temporary faecal incontinence in approximately 2% of cases, whereas
topical nitrates cause headaches in 20%-100% of cases. No long term
side effects were identified with any of the medical treatments.
CONCLUSIONChemical sphincterotomy
is an effective treatment for chronic anal fissure and has the
advantages over surgical treatment of avoiding long term complications
(notably incontinence) and not requiring hospitalisation.
Keywords: chronic anal fissure; sphincterotomy; glyceryl trinitrate; botulinum toxin
© 2001 by The Fellowship of Postgraduate Medicine
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