Therapy for Acute 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

The therapy for acute anal fissure comprises the following methods: (1) basic therapy, (2) self-bougienage, (3) local therapy, (4) manual anal dilatation, and (5) lateral internal sphincterotomy.

10.1 Basic Therapy

The basis of each treatment is stool regulation with the help of dietary fibers (among others, bran, linseed, psyllium seed husks, Mucofalk®) and sufficient intake of liquids to reach a formed stool and thus a physiological dilatation of the anal canal. Jensen (1986) achieved very fast healing in 87% of his cases with sitz baths and the administration of dietary fibers, and was able to prove a significant reduction of the relapse rate.

10.2 Self-Bougienage

The patient himself carries out protracted sphincter dilatation by means of a conically tapering anal dilator, made of plastic or glass (Fig. 10.1). The length of the dilator is designed in such a way that the surgical anal canal in its entire length can be dilated. The tip of the anal dilator is covered with lubricants and is introduced as far as possible with cautious pressure and then left there for a few minutes. In the case of a very narrow anus or strong pain, the dilator is inserted only a little in the beginning. Bougienage should be repeated several times a day for a few minutes in a relaxed posture, for example, while lying down or squatting. In a survey among coloproctologists, 82% of the participants considered the use of anal dilators to be an important element in the treatment for anal fissure (Kraemer et al. 1998).

Fig. 10.1

Anal dilator (Dr. KADE)

Klug and Knoch (1993) prescribed self-bougienage for 20 anal fissure patients and recorded a healing rate of 90% within 21 days. After 4 weeks of dilatation treatment, Gaj et al. (2006) observed a healing rate of 90% (20 patients), McDonald et al. (1983) of 68.6% (35 patients) within 6 weeks, and Lock and Thompson (1977) recorded a healing rate of only 55% (137 patients) after 9 weeks. Gough and Lewis (1983) reported a healing rate of 41.9% (43 patients) within 8 weeks.

10.3 Local Therapy

10.3.1 Sitz Baths

Trials with healthy and proctological patients describe the positive effect of a warm sitz bath of 40, 45 and 50°C (sic!) for a duration of 10 min each (Shafik 1993). It is believed to reduce rectal neck pressure and, as a consequence, lead to a reduced sphincter tone of the internal anal sphincter muscle. Jensen (1986) treated 32 patients for acute anal fissure with a warm sitz bath of 40 °C for 15 min twice daily and additional 2×10 g of dietary fibers per day. After 3 weeks, a healing rate of 87% was recorded. Gupta (2006), however, saw in a randomized controlled trial of 52 anal fissure patients no advantage of such a treatment with regard to the healing rate. A survey among coloproctologists revealed that the sitz bath treatment was supported by only 52% of the practitioners (Kraemer et al. 1998).

10.3.2 Local Anesthetics/Corticosteroids

After the application of 2% lidocaine gel three times a day over a period of 4 weeks, Gough and Lewis (1983) saw healing in 43.6% of 39 anal fissure patients. Jensen (1986) prescribed lidocaine gel for three times a day and found a healing rate of 60% during a 3-week therapy. The application of a 2% hydrocortisone ointment three times a day effected healing in 82.4% of the cases (Jensen 1986). When a combination of 1% lidocaine and 1% hydrocortisone was used, the healing rate after 3 weeks was 50% (Antropoli et al. 1999).