{"id":1063,"date":"2021-01-06T22:13:39","date_gmt":"2021-01-06T22:13:39","guid":{"rendered":"https:\/\/www.institutodecoloproctologia.com\/?p=1063"},"modified":"2025-07-29T22:30:28","modified_gmt":"2025-07-29T22:30:28","slug":"tratamiento-para-la-fisura-anal","status":"publish","type":"post","link":"https:\/\/www.institutodecoloproctologia.com\/en\/2021\/01\/06\/tratamiento-para-la-fisura-anal\/","title":{"rendered":"Anal fissure can can be treated"},"content":{"rendered":"

Anal fissure treatment<\/strong><\/p>\r\n\r\n\r\n\r\n

Medical treatment has been shown to be more effective for the healing of acute fissures. If the patient has constipation, a high-fiber diet should be initiated, water intake should be increased, that is, optimal hydration should be maintained, a sitz bath program should be started at least 3 times a day in warm water (Dodi 1986, Shafik 1993, Tejirian 2005) hygiene habits should be changed, toilet paper should not be used, the area should be washed with warm water after defecation to remove debris and soap should not be used for anal cleansing. Existen algunos reportes (Metcalf 2004) en los que se aconseja el uso de cremas t\u00f3picas con esteroides y anest\u00e9sicos locales con algunos resultados favorables, pero en general en nuestro servicio preferimos no utilizar cremas a nivel anal, ya que los resultados no tienen una fuerte evidencia cient\u00edfica. La terapia t\u00f3pica con otros agentes farmacol\u00f3gicos est\u00e1 encaminada a disminuir el tono del EAI.\u00a0<\/p>\r\n\r\n\r\n\r\n

Therapeutic recommendations have been well defined in a recent publication by the \u201cPractice Parameters Task Force\u201d of the American Society of Colon and Rectal Surgeons (Orsay 2004). In that publication, treatment recommendations have been classified according to the existing levels of evidence.<\/p>\r\n\r\n\r\n\r\n

Conservative treatment<\/strong><\/p>\r\n\r\n\r\n\r\n

Initial treatment in all patients consists of increasing fluid intake and the amount of fiber, the use of sitz baths in warm water (which has been shown to produce relaxation of the internal anal sphincter (Dodi 1986, Shafik 1993), the use of stool softeners such as docusate sodium (Dulcolax\u00ae) or mild laxatives, the abolition of toilet paper use for post-defecatory cleansing replacing this practice with perianal washing using a hand-held shower or a regular shower, without using soaps of any kind. These measures decrease pain and bleeding in the vast majority of patients (Orsay 2004). With these measures, healing is achieved in 50% of cases (level of evidence class II, grade of recommendation B). Some authors use topical anesthetics which in some patients help improve pain. In the study by Karandikar and collaborators (2003), it was found that 95% of the surgeons surveyed by the Association of Coloproctology of Great Britain and Ireland used pharmacological medical management as the first therapeutic option.\u00a0<\/p>\r\n\r\n\r\n\r\n

Multiple drugs have been studied and are in use for the treatment of anal fissure.<\/p>\r\n\r\n\r\n\r\n

1.- The use of nitric oxide donors in topical form has demonstrated a healing rate greater than 50% in patients with chronic fissure (Orsay 2004, Lund 1997) (Level of evidence I, grade of recommendation A). However, the review conducted by Cochrane only demonstrated that the use of topical nitroglycerin was marginally better than placebo for achieving healing of a chronic fissure (Nelson 2003a, 2003b, 2004). Topical nitroglycerin significantly reduces pain during the treatment period (Bailey 2002). The dose used varies according to the study reviewed, but in general a cream formulation with a concentration of 0.2 to 0.5% is accepted, which should be applied three times a day for a period of 6 to 8 weeks (Utizig 2003). In Colombia there is no anal formulation available. An evident problem with the use of topical nitroglycerin is the high incidence of headache (20\u201330%) (Antropoli 1999), which leads up to 20% of patients to discontinue the medication (Brisinda 1999). Another difficulty is the need to apply the preparation several times a day, which results in a high percentage of patients not completing the treatment. Recurrence of the fissure, after discontinuation of treatment with these topically used nitric oxide donors, is much higher than after lateral sphincterotomy, morbidity is lower (Orsay 2004, Evans 2001). Patients who do not respond to this therapy may undergo another type of treatment with topical medications or should be referred for surgical treatment (Utzig 2003, Orsay 2004).<\/p>\r\n\r\n\r\n\r\n

2.- The use of calcium channel blockers has demonstrated a healing rate of 65 to 95% (Antropoli 1999, Kocher 2002) (Level of evidence class I, grade of recommendation A). The effect they produce and that promotes healing appears to be a reduction in the tone of the internal anal sphincter. It can be used topically in cream form at a concentration of 0.2% (Antropoli 1999). As with the use of nitric oxide donors, they may produce headache in up to 25% of patients, cutaneous vasodilation and hypotension. Nifedipine, a calcium antagonist, has been used topically, either as a 0.2% cream or as a 2% to 5% gel, achieving healing in 48\u201396.7% of patients (Cook 1999, Jonas 2001, Das Gupta 2002, Katniselos 2005). It has also been used orally, reporting healing but at a lower percentage than when used topically. Unfortunately, side effects are more frequent. In Colombia there is no anal cream formulation available, therefore we use the oily content of nifedipine capsules (Adalat\u00ae) in the 10 mg presentation, applying (digitally spreading) two drops to the perianal region 4 times a day for a period of 6\u20138 weeks.\u00a0<\/p>\r\n\r\n\r\n\r\n

3.- The injection of botulinum toxin into the internal anal sphincter produces a temporary pharmacological sphincterotomy, and allows a healing rate of 60 to 80% after a single injection (Brisinda 2002, Gonzalez 1999) (Level of evidence class II, grade of recommendation B). Botulinum toxin temporarily reduces resting anal pressures and this effect persists for approximately 2 to 3 months. The main effect of botulinum toxin on the internal anal sphincter is the blockade of sympathetic neural output (mediated by norepinephrine). It appears to be a postganglionic effect, which includes a reduction in norepinephrine release at the neuromuscular junction (Bhardwaj 2000). The time required for healing to occur is somewhat longer than when a surgical sphincterotomy is performed. Flatus incontinence has been reported in up to 10% of patients (Maria 1998, Brisinda 2002, Jost 1999), being transient in nature, and in about 5% there may be fecal incontinence, with soiling being more frequent (Jost 1999a). There is still no consensus regarding the injection site. Some inject on each side of the fissure into the internal anal sphincter at 3, 9 and 6 o\u2019clock (Gui 1994), others in the 4 quadrants, distributing the total dose. There is no consensus regarding the dose to be used. It varies between 5 to 30 units distributed according to the described injection sites. The incidence of recurrence is high but allows for a new injection to be performed. Up to 20% of patients do not respond to treatment and must undergo surgical intervention (Gonz\u00e1lez 1999, Maria 2000, Jos\u00e9 1999b). Recently Arroyo and collaborators found in a study with 100 consecutive patients, who were injected with a total of 25 units of botulinum toxin, a healing rate of 47% at three years of follow-up. They found that those patients with a disease duration of more than 12 months, presence of a sentinel papilla, and manometry showing persistently elevated resting pressure after injection, had a higher incidence of recurrence and non-healing (Arroyo 2005a, 2005b). The main problem for the use of botulinum toxin is its cost.<\/p>\r\n\r\n\r\n\r\n

4.- Lateral (surgical) sphincterotomy under assisted local anesthesia (Arroyo 2004) or under general anesthesia is the treatment of choice for patients who have been refractory to medical treatment (Nelson 1999, Jensen 1984) (Level of evidence class I, grade of recommendation A). The Cochrane study concluded that lateral sphincterotomy is superior to anal dilation and sphincterectomy (Nelson 2002). The results are similar with the open or closed technique (Level of evidence class I, grade of recommendation A). The incidence of incontinence after this procedure varies according to the series and the criteria used. Studies in which the preoperative condition of the patients has been measured have demonstrated that up to 28% of patients have some degree of incontinence before the intervention (Ammari 2004). Lateral sphincterotomy is the only treatment with an effectiveness rate greater than 98% (Orsay 2004, Katniselos 2005, Metcalf 2004). The recurrence rate is the lowest (1\u20136%). Early postoperative complications occur in less than 1% of cases and include hematoma, bleeding, abscess and anal fistula (Metcalf 2004). Lateral sphincterotomy produces a permanent decrease in maximum resting pressure (Lindsay 2004, Aytac 2003). Eisenhammer introduced the surgical technique in 1951, and it was initially performed in the posterior midline which produced a keyhole defect, for this reason Notaras popularized lateral sphincterotomy in 1969. The advantage of this technique consists in that the division of the internal sphincter can be performed with control of its extent by the surgeon. The extent of the division is a matter of debate, but it correlates with the incidence of postoperative incontinence. Littlejohn and Newstead (1997) found in a study with 257 patients in whom a \u201climited\u201d lateral sphincterotomy was performed whose division only reached the cephalad edge of the fissure instead of extending to the dentate line, an incidence of incontinence to flatus, liquid stool and solid stool of 1.4, 0.4 and 0% respectively. Recurrence was only 1.7%. Personally, this is the extent of division that I use. The overall incidence of incontinence reported worldwide varies between 0 and 36% for flatus, 0\u201321% for liquid stool and 0 to 5% for solid stool (Roholtz 2005, Casillas 2005, Nyam 1999, Sultan 1994, Nelson 2004). It is generally accepted that the extent of sphincterotomy should be limited to the length of the fissure (Lund 1996, Mentes 2005), since the healing rate is practically the same when compared with the group of patients who undergo lateral sphincterotomy up to the dentate line, but the incidence of incontinence in the latter group is substantially higher. A study from the St Mark\u2019s Hospital group in London (Sultan 1994) demonstrated, by means of anal ultrasound, that the extent of the sphincterotomy division was greater than that considered by the surgeon who performed the procedure: in 9 of 10 women and in 1 of 5 men evaluated the extent of division was 100% of the length. Three of the 9 women developed symptoms of incontinence. In women the length of the internal sphincter is shorter than in men. Farouk and collaborators (1997), in a group of patients in whom the fissure did not heal after internal lateral sphincterotomy, found by ultrasonographic study that in 70% of these patients the internal sphincter was intact. The American Society of Colon and Rectal Surgeons (ASCRS) has recommended that in patients with recurrent fissure after a first sphincterotomy and in women who have previously had an episiotomy or who have suffered a third-degree tear during labor, a manometric study of the sphincter complex as well as an anal ultrasound should be performed before attempting a new sphincterotomy, thus reducing the possibility of postoperative incontinence. A group of patients with anal fissure in whom manometric studies have demonstrated a normal or decreased maximum resting pressure (19% of the men studied and 42% of the women studied) would have a higher risk of incontinence after sphincterotomy considering that in general this procedure decreases the maximum resting pressure by 25% (Ramalingam 2003). Mortensen and his group from Oxford consider that currently every patient should initially receive medical treatment, if this fails, they consider that manometric studies should be performed, if the resting pressure is high, then it would be justified to perform a lateral sphincterotomy (Jones 2005).<\/p>\r\n\r\n\r\n\r\n

Manual dilation of the anal sphincter (Recamier 1838, cited by Lund and Scholefield 1996) or the Lord\u2019s maneuver described in the nineteenth century, is proscribed due to the fact that anal ultrasound studies demonstrated rupture and radial tearing of the internal anal sphincter which produces a risk of incontinence of 20\u201325% (Speakman 1991), with figures up to 39.2% for flatus incontinence and 16.2% for fecal incontinence. Manual anal dilation may produce other complications such as bleeding, infection including reports of Fournier\u2019s gangrene, bacteremia in up to 8% of patients and rectal prolapse in the elderly (Lund 1996, Snooks 1984, Goldman 1992).<\/p>\r\n\r\n\r\n\r\n

5.- The anal mucosal advancement flap as an alternative to lateral anal sphincterotomy should be reserved for patients in whom there is no hypertonia of the anal sphincter (level of evidence class II, grade of recommendation D) (Leong 1995, Tou 2004).\u00a0<\/p>\r\n\r\n\r\n\r\n

Lateral sphincterotomy may be offered to the patient as the first treatment option without attempting prior pharmacological therapy, provided that the advantages and disadvantages of medical treatment, the complications associated with each treatment, the incidence of recurrence and the risk of incontinence associated with lateral sphincterotomy are explained to the patient (level of evidence class I, grade of recommendation A) (Orsay 2004). In Nelson\u2019s study, in which 21 different medical treatment regimens were reviewed in 31 randomized double-blind studies, no advantage was found, with regard to fissure healing, superior to that obtained in the placebo control group. The author concludes that pharmacological medical therapy in the management of chronic fissures may offer a chance of healing but its effect is only marginally better than placebo (Nelson 2003a). A recent Italian study describes the extent of sphincterotomy according to the degree of hypertonia of the internal anal sphincter. They classify hypertonia as mild (50\u201360 mm Hg), moderate (60\u201380 mm Hg) and severe (>80 mm Hg), and according to this classification lateral sphincterotomy should have an extent of 20, 40 and 60% respectively. In this study with 388 patients who were managed according to this proposal, only one patient developed incontinence (Rosa 2005). \u00a0\u00a0<\/p>\r\n\r\n\r\n\r\n

6.- Fissure curettage and botulinum toxin injection. The Oxford group (Lindsey 2005) promotes the curettage of the fissure that has been refractory to medical treatment and then the injection of botulinum toxin with promising early results.<\/p>\r\n\r\n\r\n\r\n

7.- Recently, the use of injected gonyantoxin has been described with encouraging results. This toxin is a paralyzing phytotoxin extracted from dinoflagellates (Garrido 2005).<\/p>","protected":false},"excerpt":{"rendered":"

Tratamiento fisura anal El tratamiento m\u00e9dico ha demostrado ser mas efectivo para la curaci\u00f3n de las fisuras agudas. Si el paciente tiene constipaci\u00f3n se debe iniciar una dieta rica en fibra, aumentar la ingesta de agua, es decir mantener una excelente hidrataci\u00f3n, iniciar un programa de ba\u00f1os de asiento m\u00ednimo 3 veces al d\u00eda en […]<\/p>\n","protected":false},"author":1,"featured_media":1064,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_et_pb_use_builder":"off","_et_pb_old_content":"","_et_gb_content_width":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-1063","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/posts\/1063","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/comments?post=1063"}],"version-history":[{"count":4,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/posts\/1063\/revisions"}],"predecessor-version":[{"id":7484,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/posts\/1063\/revisions\/7484"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/media\/1064"}],"wp:attachment":[{"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/media?parent=1063"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/categories?post=1063"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.institutodecoloproctologia.com\/en\/wp-json\/wp\/v2\/tags?post=1063"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}