Chronic Anal Fissure

, Franz Raulf2 and Horst Mlitz3

(1)
Department of Proctology, Clinic for Dermatology at RWTH Aachen University, Aachen, Germany
(2)
Medical Center of Coloproctology, Münster, Germany
(3)
Medical Center of Coloproctology, Saarbrücken, Germany
 

2.1 Morphology

Chronic anal fissure presents as longitudinal, deep ulcer, sometimes coated with smear. Secondary changes can occur in their development, such as hypertrophied anal papillae close to the proximal edge of the fissure at the level of the pectinate line, also pathologically altered crypts (anal cryptitis) or sentinel tags (secondary skin tags) with or without incomplete or complete fistula. At this stage, the wound edges are scarred and bulging, occasionally callused or undermined. Sometimes, the transversely running, now and then fibrous tissue of the internal anal sphincter appears at the fissure floor. It is not the duration of the existence of the anal fissure that is pathognomonic for the chronic anal fissure, but the appearance of the alterations mentioned earlier. The difficulty of a morphologically related definition of the chronic anal fissure is dealt with in Chap. 4.

2.2 Location

The analysis of 15 trials comprising a total of 6881 patients in Table 2.1 shows that anal fissures are located at the posterior midline with a frequency rate between 45.1 and 86.9% and at the anterior midline with a rate between 8.0 and 39.3%. In the other sectors, they appear with a frequency rate between 0.5 and 12.3%. Goligher (1975) found ventrally located anal fissures significantly more in women than in men (10:1).
Table 2.1
The location of anal fissures in 15 trials with 6881 patients (in %)
Author (year)
Patients
Location of anal fissure
Posterior midline
Anterior midline
Other locations
(n)
(%)
(%)
(%)
Willemsen (1963)
144
45.1
20.8
  
Mazier (1972)
1000
74.8
16.5
  
Soß (1973)
269
84.0
11.5
2.2
Böttcher (1977)
508
77.7
13.5
  
Kühn (1979)
138
82.0
8.0
0.7
Stürmlinger (1986)
153
81.0
9.2
9.8
Khubchandani and Reed (1989)
1077
62.0
25.2
0.9
Eißer (1990)
131
74.0
14.1
11.9
Kleinilbeck (1990)
735
79.0
10.0
12.3
Jost et al. (1991)
130
86.9
6.2
1.5
Oh et al. (1995)
1047
75.3
12.9
  
Hananel and Gordon (1997)
876
73.5
16.4
5.8
Schanne (1998)
56
51.8
39.3
  
Hasse et al. (2004)
209
79.4
16.3
0.5
Lysy et al. (2006)
408
68.4
21.3
  
Total
6881
      
A426194_1_En_2_Fig1_HTML.jpg
Fig. 2.1
Dorsal median chronic anal fissure with sentinel tag
A426194_1_En_2_Fig2_HTML.jpg
Fig. 2.2
Ventral and dorsal median chronic anal fissure with sentinel tag
A426194_1_En_2_Fig3_HTML.jpg
Fig. 2.3
Dorsal median chronic anal fissure with hypertrophied papilla (dilating speculum)
A426194_1_En_2_Fig4_HTML.jpg
Fig. 2.4
Dorsal median chronic anal fissure with pronounced secondary changes
A426194_1_En_2_Fig5_HTML.jpg
Fig. 2.5
Dorsal median anal fissure with abscess; purulent discharge visible at spontaneous perforation of abscess
A426194_1_En_2_Fig6_HTML.jpg
Fig. 2.6
Dorsal median anal fissure with fistula; surgical hook used for exploration

2.3 Age Distribution

The analysis of seven publications which refer to a total of 2346 anal fissure patients yields the age distribution in Table 2.2.
Table 2.2
Anal fissure patients by age groups in seven trials with 2346 patients (in %)
Author (year)
Anal fissure patients
Years of age
0–10
11–20
21–30
31–40
41–50
51–60
61–70
71–80
(n)
(%)
(%)
(%)
(%)
(%)
(%)
(%)
(%)
Willemsen (1963)
144
0.8
3.3
23.1
28.1
33.1
8.2
3.3
–
Mazier (1972)
1000
0.5
2.9
12.9
25.9
29.4
18.7
8.6
1.2
Böttcher (1977)
508
–
1.5
14.5
37.0
27.4
20.3
–
–
Kühn (1979)
138
–
–
10.1
30.4
21.7
18.8
16.7
2.2
Wolff (1986)
272
–
0.7
14.4
22.9
25.8
20.7
10.3
4.7
Stürmlinger (1986)
153
–
–
15.7
26.8
22.2
19.0
11.8
4.6
Eißer (1990)
131
–
1.5
12.9
22.8
31.9
24.3
6.1
–
Total
2346
                
The peak incidence occurs in patients between 30 and 50 years of age.
Twenty-four clinical trials with a total of 4978 anal fissure patients show a peak incidence between 38 and 51.2 years of age (Table 2.3). Anal fissures in children are relatively rare.
Table 2.3
Median age of 4978 anal fissure patients in 24 trials
Author (year)
Anal fissure patients
Median age
(n)
(years)
Hardy (1967)
59
48
Fischer et al. (1978)
66
41.9
Abcarian (1980)
300
35.7
Bode et al. (1984)
121
46.8
Hsu and MacKeigan (1984)
1753
42.4
Jensen et al. (1984)
58
39
Wolff (1986)
271
46.3
Khubchandani and Reed (1989)
1355
42.8
Jost (1989)
130
46.3
Prohm (1993)
396
43.9
Leong and Seow-Choen (1995)
34
39
Maria et al. (1998)
15
38
Brisinda et al. (1999)
25/25
45.1/39.2
Altomare et al. (2000)
59/60
43.7/42.7
Brisinda et al. (2002)
75/75
43/45
Lindsey et al. (2003)
40
38.1
Mentes et al. (2003)
61
40
Brisinda et al. (2004)
50/50
41.6/42.6
Giral et al. (2004)
10/11
41/39
Massoud et al. (2005)
25
35.5
Arroyo et al. (2005)
40/40
38/41
Jones et al. (2006)
15
46
Brisinda et al. (2007)
50/50
46.2/42.0
Brown et al. (2007)
24/27
51.2/47.9
Total
4978
  

2.4 Gender Distribution

The analysis of 28 trials with 11,577 patients (Table 2.4) shows that women and men are almost equally affected, females at rates from 38 up to 72.1% and males from 27.9 up to 62%.
Table 2.4
Anal fissure patient distribution by gender in 33 trials with 11,577 patients (in %)
Author (year)
Anal fissure
patients (n)
Female (%)
Male (%)
Mazier (1972)
1000
49.1
50.9
Böttcher (1977)
508
46.8
53.2
Marby et al. (1979)
253
38.0
62.0
Kühn (1979)
138
43.5
56.5
Abcarian (1980)
300
47.0
53.0
Hsu and MacKeigan (1984)
859
51.0
49.0
Stürmlinger (1986)
153
52.2
47.8
Wolff (1986)
271
47.2
52.8
Vafai and Mann (1987)
696
60.2
39.8
Lewis et al. (1988)
350
63.1
36.9
Khubchandani and Reed (1989)
1077
57.4
42.6
Jost (1989)
1423
41.4
58.6
Kouba (1990)
833
54.5
45.5
Jost et al. (1991)
130
43.5
56.5
Prohm (1993)
396
49.0
51.0
Pernikoff et al. (1994)
500
57.0
43.0
Jost (1997)
100
43.0
57.0
Littlejohn and Newstead (1997)
352
44.3
55.7
Hananel and Gordon (1997)
876
50.1
49.9
Richard et al. (2000)
38
42.1
57.9
Richard et al. (2000)
44
65.9
34.1
Altomare et al. (2000)
59
43.0
57.0
Altomare et al. (2000)
60
46.0
54.0
Bacher et al. (2000)
126
52.4
47.6
Brisinda et al. (2002)
75
44.0
56.0
Brisinda et al. (2002)
75
49.3
50.7
Bailey et al. (2002)
304
45.4
54.6
Mentes et al. (2003)
61
72.1
27.9
Mentes et al. (2003)
50
64.0
36.0
Liratzopoulos et al. (2006)
246
51.2
48.8
Brisinda et al. (2007)
50
48.0
52.0
Brisinda et al. (2007)
50
58.0
42.0
Pascual et al. (2007)
124
53.2
46.8
Total
11,577
    

2.5 Duration of Anal Fissure Disease

Anal fissure patients seem to be very tolerant because they suffer from their pain for an exceptionally long time before they seek treatment. There are several studies that analyze the duration of suffering from the first symptoms until the start of therapy. In eight trials involving 491 patients who had been treated with glyceryl trinitrate (GTN), the period of suffering lasted between 2 and 240 months (Table 2.5). For 405 patients in seven botulinum toxin trials (BTX), the period of suffering lasted between 3 and 94 months (Table 2.6). A total of 842 patients (in nine trials), who had undergone sphincterotomy, showed symptoms for a period of 1–96 months (Table 2.7). On average, the duration of anamnesis lasted more than 10 months.
Table 2.5
Duration of symptoms before GTN therapy for anal fissure in 16 trials with 491 patients
Author (year)

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Jan 29, 2018 | Posted by in UROLOGY | Comments Off on Chronic Anal Fissure

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