, 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 |
Fig. 2.1
Dorsal median chronic anal fissure with sentinel tag
Fig. 2.2
Ventral and dorsal median chronic anal fissure with sentinel tag
Fig. 2.3
Dorsal median chronic anal fissure with hypertrophied papilla (dilating speculum)
Fig. 2.4
Dorsal median chronic anal fissure with pronounced secondary changes
Fig. 2.5
Dorsal median anal fissure with abscess; purulent discharge visible at spontaneous perforation of abscess
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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