eMedicine Specialties > Pediatrics: Surgery > General Surgery
Anal Fissure: Treatment
Updated: Dec 10, 2008
Treatment
Medical Therapy
Acute fissures rarely require surgical intervention and usually improve with conservative management. This includes dietary modification, stool softeners, and Sitz baths. Increasing the patient's fluid consumption and fiber intake may be sufficient. If a stool softener is used, it should be carefully titrated to avoid the development of diarrhea and dehydration. The stool softener of choice is an osmotic agent that causes water to be retained with the stool (eg, polyethylene glycol [MiraLax]), and the dosage is titrated for the patient's size. It is available as a powder that is mixed with 8 oz of water before administration.
Symptoms from an acute fissure often resolve within 10-14 days of conservative medical management; however, as long as 6-8 weeks may be necessary for the actual tear to heal. After 6-8 weeks, the fissure is considered chronic, and more active measures such as chemical or surgical sphincterotomy may be considered. Although studies validating the use of chemical sphincterotomy in the pediatric population remain limited, the available literature appears promising.1
Glyceryl-trinitrate (GTN) is the most widely used agent for chemical sphincterotomy.2 GTN 0.2% ointment is applied topically to the lower anal canal 2-3 times daily, until the fissure heals. Complications from this treatment modality are discussed below.
Topical diltiazem (available as an extemporaneously prepared 2% gel) may be a potential alternative to GTN with fewer adverse effects; however, sufficient evidence is lacking in the literature upon which to base recommendations for this agent. Topical diltiazem appears to be more effective than oral diltiazem therapy with fewer adverse effects.
Finally, botulinum toxin injections can reduce internal anal sphincter tonicity by inhibiting the release of acetylcholine into the synaptic gap. This therapeutic option is more invasive and significantly more costly than GTN. Also, the dosing and ideal site(s) of administration of botulinum toxin are not yet well established, and experience with this drug is lacking in the pediatric population. Botulinum toxin may be used for multiple, wide-based, and nonhealing fissures.
Surgical Therapy
As mentioned above, surgery is rarely needed for most infants and children with an acute anal fissure. Some fissures may take as long as 8 weeks to resolve with conservative management. Again, be mindful that if the fissure has not healed following medical therapy, the diagnosis may be in question, and an examination under anesthesia is warranted. If the fissure persists despite medical management, the operative procedure in children and infants is an open lateral internal sphincterotomy.
A chronic ulcer may be excised in addition to the sphincterotomy. All excised tissue should be evaluated by a pathologist. Because any associated anal stenosis is relieved successfully with the sphincterotomy, advancement flaps to treat the associated refractory stenosis are not needed. Relative contraindications to operative treatment include profound immunosuppression (ie, absolute neutrophil counts <100/μL) and inflammatory bowel disease.
Intraoperative Details
Treatment of children with anal fissures is slightly different than adults because an outpatient open lateral internal sphincterotomy is the procedure of choice. This relieves the spasm and, ultimately, the vicious cycle that characterizes the constellation of symptoms ascribed to anal fissure. Anal dilatation to treat anal fissure has been abandoned because of the 30-40% rate of recurrence.
In addition, if the history and physical examination reveal a lifelong history of constipation or failure to pass stool in the first 48 hours of life, an ectopically placed anus and Hirschsprung disease must be considered in the differential diagnosis, and a careful rectal evaluation and rectal biopsy should be performed with the same anesthetic.
Open lateral internal sphincterotomy is performed in the lithotomy position under a light anesthetic administered through a laryngeal mask technique. The intersphincteric groove is palpated, and the submucosa is injected with 0.25% bupivacaine with 1:200,000 epinephrine. A 1-cm curvilinear incision is made overlying the intersphincteric groove. The internal sphincter is medial to the external sphincter and lateral to the submucosa of the anus. The sphincter is then identified and elevated, and using electrocautery, a segment is divided as far proximal as the fissure itself. The overlying incision is closed.
Closed lateral sphincterotomy is also advocated in children. The knife blade is positioned in a similar position as with open sphincterotomy, but the difference is that the knife is inserted in the intersphincteric groove, rotated 90°, and advanced toward the anal mucosa. Hemostasis is achieved by direct pressure, and this puncture wound is not closed.
Chronic anal fissures should be treated by excision of the fissure along with its sentinel tag (pile) and internal sphincterotomy at the base of the ulcer. The wound is left open and should heal in 7-14 days without scarring. Compulsive wound care, consisting of washing the area with soap and water after each bowel movement, is essential for a successful outcome.
Postoperative Details
Patients and their families are educated about urinary retention, severe perianal pain, sepsis, bleeding, and transient fecal incontinence.
Follow-up
Dietary modifications, stool softeners, and Sitz baths should be continued for several weeks after operative treatment. A follow-up visit is scheduled for 2-3 weeks after the procedure.
Complications
Headache and diarrhea are the most common complications of administering topical nitrates and stool softeners, respectively. Significant hypotension with topical nitrate administration has not been reported in the literature. However, during the first office visit, children and their families should be questioned about a history of vascular headaches, and blood pressure should be taken before the initial application of topical nitrates. Incontinence has not been associated with these therapeutic regimens.
Short-term complications of operative therapy include urinary retention, hematoma formation, and incontinence. Long-term complications, such as difficulty controlling flatus, daytime soiling of underwear, and nighttime incontinence, are noted with both open and closed internal sphincterotomy. The exact incidence of long-term incontinence is not clear in the pediatric literature. The incidence of this complication is likely to remain unclear because medical management, including chemical sphincterotomy, is increasingly favored over surgery for chronic fissures.
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References
Brown CJ, Dubreuil D, Santoro L, Liu M, O'Connor BI, McLeod RS. Lateral internal sphincterotomy is superior to topical nitroglycerin for healing chronic anal fissure and does not compromise long-term fecal continence: six-year follow-up of a multicenter, randomized, controlled trial. Dis Colon Rectum. Apr 2007;50(4):442-8. [Medline].
Demirbag S, Tander B, Atabek C, et al. Long-term results of topical glyceryl trinitrate ointment in children with anal fissure. Ann Trop Paediatr. Jun 2005;25(2):135-7. [Medline].
Agnarsson U, Warde C, McCarthy G, Evans N. Perianal appearances associated with constipation. Arch Dis Child. Nov 1990;65(11):1231-4. [Medline].
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Garcia-Granero E, Sanahuja A, Garcia-Armengol J, et al. Anal endosonographic evaluation after closed lateral subcutaneous sphincterotomy. Dis Colon Rectum. May 1998;41(5):598-601. [Medline].
Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum. Aug 2001;44(8):1074-8. [Medline].
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. Jan 1989;32(1):43-52. [Medline].
Knight JS, Birks M, Farouk R. Topical diltiazem ointment in the treatment of chronic anal fissure. Br J Surg. Apr 2001;88(4):553-6. [Medline].
Motson RW, Clifton MA. Pathogenesis and treatment of anal fissure. In: Henry MM, Swash M, eds. Coloproctology and the Pelvic Floor. Butterworth-Heinemann; 1985:340-9.
Parellada C. Randomized, prospective trial comparing 0.2 percent isosorbide dinitrate ointment with sphincterotomy in treatment of chronic anal fissure: a two-year follow-up. Dis Colon Rectum. Apr 2004;47(4):437-43. [Medline].
Pena A. Surgical conditions of the anus, rectum, and colon. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. Philadelphia, PA: WB Saunders Co; 2000:1181-83.
Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. XV. Chronic anal fissure: a new theory of pathogenesis. Am J Surg. Aug 1982;144(2):262-8. [Medline].
Sonmez K, Demirogullari B, Ekingen G, et al. Randomized, placebo-controlled treatment of anal fissure by lidocaine,EMLA, and GTN in children. J Pediatr Surg. Sep 2002;37(9):1313-6. [Medline].
Stafford PW. Anal fissure. In: O'Neill JA, Rowe MI, Grosfeld JL, et al, eds. Pediatric Surgery. Elsevier Health Sciences; 1998:1454-55.
Tander B, Guven A, Demirbag S, et al. A prospective, randomized, double-blind, placebo-controlled trial of glyceryl-trinitrate ointment in the treatment of children with anal fissure. J Pediatr Surg. Dec 1999;34(12):1810-2. [Medline].
Further Reading
Keywords
anal fissure, fissure in ano, anal tear, tear of the squamous epithelial mucosa of the anal canal, tear of the anal canal, bright rectal bleeding, posterior midline tear, constipation, anorectal pain, passage of hard stool, blood in the stool, anorectal blood, rectal blood, rectal bleeding, anal skin tag, chronic ulcer, acquired immunodeficiency syndrome, chlamydia, gonorrhea, syphilis, neoplasm, sexual abuse, inflammatory bowel disease
