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Fissures / Pruritis Ani

Jan Rakinic, MD
Associate Professor of Surgery
Southern Illinois University School of Medicine

As this is intended to be primarily a clinical update, emphasis will be on newer treatment information. Older supporting references that can be found in standard texts have been omitted here; however, a complete list of references may be requested by email: kservi@siumed.edu

Fissure in ano.

An anal fissure is a crack or tear in the vertical axis of the squamous lining of the anal canal between the anal verge and the dentate line. The classic symptom is pain during and following defecation, lasting minutes to hours. Bright red bleeding is common. Fissures occur most often in the posterior midline. Acute fissures are superficial, but may deepen to expose the underlying internal sphincter. Chronic fissures are associated with secondary changes, which may include a sentinel tag, hypertrophied anal papilla, induration of the edge of the fissure, and/or relative anal stenosis secondary to spasm or fibrosis of the internal sphincter.

Efforts should be made to identify the precipitating cause of the individual patient’s fissure (such as constipation or diarrhea) and manage it appropriately, otherwise the likelihood of recurrence is high. In a minority of patients, a fissure may be associated with a systemic disease (e.g. Crohn’s disease) or may be attributable to another diagnosis (e.g. anal carcinoma, sexually transmitted disease).

Pathogenesis

Fissures are usually caused by local trauma to the anal canal, typically as overstretching of the anoderm by a hard, nondeformable stool. However, other forms of forceful stretching, as well as repeated episodes of loose diarrheic stool, may also precipitate a fissure. A number of anatomic and dynamic studies support the hypothesis that relative ischemia of the posterior midline anal canal contributes to poor healing. Internal sphincter hypertonicity has also been implicated as a pathologic finding, but whether this is cause or effect remains unclear. Treatment that is successful in producing fissure healing also demonstrates increase in anodermal blood flow.

Investigation has also revealed abnormalities at the cellular level. An observed increase in neural proliferation in chronic fissures has been postulated as contributory to the pain of both fissure and pruritis1.  In another study, patients with fissures and hemorrhoids were shown to have circulating anti-endothelial cell antibodies, leading the authors to hypothesize that the interaction of immune components with anal canal endothelium could contribute to ischemia and hypertonicity2.

Treatment

I.  The basics.

Increased fluid and fiber ingestion, use of sitz baths for pain relief, and use of stool softeners such as docusate sodium or docusate calcium are very safe, have virtually no side effects, often decrease pain and bleeding, and should be instituted as a first step for patients with fissure. Healing will occur in up to 50% when so treated. Use of topical anesthetics do not decrease healing rate and are safe, with a low incidence of sensitivity to the agent or vehicle. Maintaining appropriate fluid and fiber intake can minimize recurrence. Local application  of heat has been shown to relax the hypertonic anal sphincter. However, care must be taken to avoid potentially serious burns to the perianal and gluteal areas3.

II.  Nonsurgical therapy.

A Cochrane review of fissure treatment4 concluded that topical and injected therapies are marginally better than placebo in healing fissures, and recommended lateral internal sphincterotomy as the gold standard for anal fissure. Nevertheless, these agents remain in widespread use worldwide. There are several possible reasons for this. One may be reluctance on the part of many patients and surgeons to proceed to sphincterotomy in the face of increasing evidence that impaired continence after sphincterotomy is more common than previously thought5-8. Also, nonsurgical therapy has other advantages, including low risk, repeatability, and the possibility of using a combination of agents to produce improved results9-11.

A. Topical nitroglycerin ointment

Topical nitroglycerin ointment 0.2% is the medical therapy most commonly used for fissures. Patients report pain relief very soon after starting therapy, which is an advantage.  The most common side effect is a dose-related headache, which causes less than one patient in five to stop therapy. Healing rates have been reported as high as 67%, and symptom-free rates are as high as 75%12.

Patients that fail to heal with nitroglycerin, or who cannot tolerate nitroglycerin’s side effects, can be subsequently treated with other agents, such as topical diltiazem9,topical L-arginine13, or injected botulinum toxin10. A significant percentage (50-92%) of patients treated with a second agent after nitroglycerine failure healed without surgery. However, these are small studies.

B. Topical calcium channel blockers

Topical calcium channel blockers (2% diltiazem, 0.3% nifedipine) have been reported to heal 65-95% of fissures14-17. The most common side effects are headache, flushing, and symptomatic hypotension. Topical L-arginine, an intrinsic precursor of nitric oxide, has been shown to lower anal resting pressure in healthy volunteers18 and also to heal 50% of chronic fissures without the side effect of headache13.

C. Oral agents.

Orally administered calcium channel blockers have been less promising  in fissure therapy, with a lower healing rate and higher rate of side effects17. Similarly, orally administered L-arginine failed to affect anal canal resting pressure or anodermal blood flow19.

D. Botulinum toxin

Injection of botulinum toxin into the internal sphincter produces a temporary “chemical sphicterotomy”, allowing healing of 60-80% of fissures after a single injection. Anal canal resting pressures are decreased for two to three months. At higher doses, squeeze pressure may also be temporarily decreased. Healing takes longer than after surgical sphincterotomy, but return to full activity occurs sooner, and risk of new incontinence is zero. Recurrences are common but may be retreated with a good healing rate20-21. There is no consensus on dose, or site(s) or number of injections. Higher doses produce better healing rates and seem as safe as lower doses20. Topical nitrates seem to potentiate the effect of botulinum toxin in patients with refractory fissure22. Up to 20% of patients fail botulinum toxin therapy; this is lower if higher doses are used23. However, few of these studies are randomized controlled trials, and most reports contain small numbers.

E. Other agents.

1. Alpha-1 adrenoreceptor blockade has been evaluated for effect on anal sphincter pressure. A single oral dose of indoramin, an alpha-1 adrenoreceptor antagonist, was given to 7 patients with fissure and 6 healthy controls. This produced a drop in anal canal resting pressure of 36% in fissure patients and 40% in controls, which persisted for three hours24. However, indoramin failed to heal fissures in a subsequently performed small double-blind randomized trial25.  

2. Bethanechol, a cholinomimetic, has been shown to lower anal resting pressure in volunteers. In a small nonrandomized study, bethanechol reduced fissure pain and healed 9/15 fissures, equivalent to topical diltiazem. No long-term follow-up data is available26.  

3. Sildenafil (Viagra), a phosphodiesterase inhibitor, lowered anal resting pressure by 18% after a single intra-anal instillation of 0.75 ml of 10% sildenafil in patients with previously untreated fissures. One of 19 patients failed to respond27. No therapeutic data are yet available.  

4. In a small study, 6 of 8 fissures refractory to other treatment healed after 15 hyperbaric oxygen treatments given over three weeks. There was one relapse at 3 month follow-up28. While intriguing, hyperbaric oxygen therapy has the obvious drawbacks of cost and access, and is unlikely to become a widely used modality for fissure.

III. Surgical therapy.

A. Lateral internal sphincterotomy

Lateral internal sphincterotomy (LIS) is considered the treatment of choice for surgical management of anal fissure, with healing rates of 75-95% reported in most series. LIS produces faster healing, less pain and less postoperative incontinence than fissurectomy and posterior midline sphicterotomy29.The most concerning complication of LIS is fecal incontinence. This may be more common than previously thought: 5 to 10% for major incontinence5-7 and up to 30% for incontinence to flatus8. Some authors found differences relative to patient age, gender, and parity – others did not. Incontinence after LIS does not appear to recover after long-tern follow-up7. Not surprisingly, patients with postoperative continence disturbances showed less quality-of-life improvement than those without continence alteration30.

Patients with fissure appear to be a heterogeneous population. Varying anal canal pressure profiles have been described, ranging from the classic hypertonic to normo- and hypotonic31. A complete preoperative history is essential, including specific information on details of continence, such as soiling of undergarments, incontinence to flatus, and accidental bowel movements32. Several groups have reported their experience with more limited sphincterotomy – termed “calibrated”, “tailored”, “conservative”, or “controlled”. The extent of sphincterotomy is variously gauged as percent of sphincter divided33, as distance below or above the dentate line34-35, or as uni- or bilateral34. Predictably, division of more sphincter correlates with higher incidence of impaired continence; division of less sphincter produces a higher fissure recurrence rate. Numbers in these studies are small and follow-up is limited; time may produce a fuller picture.

Recurrence after sphincterotomy is a particularly vexing problem for patient and surgeon. LIS can be repeated on the side opposite the first LIS; outcome data is limited. An advancement flap procedure may be considered in this difficult situation.

B. Anal advancement flap procedures

Anal advancement flap surgery has been considered an acceptable alternative to LIS, but there is a lack of prospective randomized studies36. This technique may be particularly attractive in patients without sphincter hypertonia; however, further study with long-term follow-up is needed.

C. Anal dilatation

Anal dilatation, manual or pneumatic, has a higher recurrence rate than LIS as well as a higher rate of incontinence29. The use of anal dilatation with medical therapy does not improve healing. Anal dilatation techniques produce uncontrolled sphincter injury and should no longer be used.

IV. Special situations.

Patients with Crohn’s disease often have fissures that are multiple, eccentric in location, and asymptomatic. Therapy directed at the underlying cause, e.g. Crohn’s disease, is usually successful. Any associated suppuration should be managed appropriately.

Patients with HIV/AIDS may have garden variety anal fissures which may be treated as usual. Anal ulcers are a different problem. These are usually deep, with a broad base, often above a dentate line. Specific STDs requiring treatment must be excluded. Often, appropriate antiretroviral therapy combined with attention to diet and bulking agents will preclude the need for further intervention.

Pruritis ani

Pruritis ani is embarrassing for patients and frustrating for physicians. Symptoms are often present for a considerable period time before patients gain the courage to seek medical advice, during which time a number of local therapies have been tried, with varying degrees and durations of relief. Pruritis is often subdivided into primary or idiopathic, with no identifiable cause, and secondary, with an identifiable and usually treatable cause. The latter is obviously easier to manage.

Pathogenesis

Itch was once thought to represent minor pain. Itch and pain have since been shown to have separate receptors and neural pathways, although both are important in nociception.

ITCH can be classified into four categories:

A). Pruritoceptive itch, originating in the skin due to inflammation, dryness, or other skin damage, and transmitted by C nerve fibers. Secondary pruritis ani clearly falls into this category; most primary pruritis probably does as well.

B). Neuropathic itch, which arises due to disease along the afferent pathway, such as seen in herpes zoster neuropathy.

C). Neurogenic itch, which originates centrally without evidence of neural pathology, such as the itch of cholestasis.

D). Psychogenic itch, as in delusional parasitophobia.

Recognizing that pruritis ani originates in the skin, the search for the cause follows. Obvious sources abound: the perianal area is exposed to moisture from sweat, stool and mucus; fecal factors can irritate skin, such as bile salts and stool pH; inadequate hygiene can play a part, as well as overzealous hygiene with introduction of irritating soaps, lotions, and scents; certain food products can exacerbate pruritis; and a sizable role is played by self-medication with every compound imaginable. Diagnosis, patient education, and treatment often proceed simultaneously.

Evaluation

History must be appropriately detailed, and include frequency and quality of stools, any stool or mucus leakage or perianal moisture sensation, or incomplete evacuation. Travel history and current medications (including topical agents) must be detailed. Adults rarely harbor pinworms, but infected children must be inquired about.

Physical examination should include at a minimum abdominal exam, perineal inspection, digital rectal exam, and anoscopy. Skin changes of pruritis ani range from mild to marked erythema and lichenification, but are always bilaterally symmetrical. Lesions that are suspicious, focal, persistent or unilateral must be biopsied. Pathology such as fistulas or prolapsing hemorrhoids are addressed appropriately.

Treatment

I.General management

Therapy is directed at achieving clean, dry, intact skin. Patients are educated regarding local hygiene and the use of psyllium bulking agents as needed. Judicious use of an inert skin barrier such as a zinc oxide ointment can help to avoid continued skin irritation during the early treatment stage. Use of a 1% or 2% hydrocortisone-containing preparation can help in the short term. However, most patients have overused these agents long before seeking colorectal expert advice, and as a result may already have perianal skin more fragile than normal. Careful perianal cleansing seems to be as effective as topical corticosteroids at relieving symptoms of pruritis ani37.

II. Dietary advice

Avoid overuse of caffeine, chocolate, citrus/tomato products, beer – these all exaggerate pruritis ani, possibly by decreasing internal sphincter tone. Many patients have remarkably little insight into the relationship of diet and bowel habits – consultation with a dietician, if available, may help.

III. Specific abnormalities.

A. Sphincter function.

Sphincter abnormality must be entertained. Mechanical sphincter disruptions or pudendal neuropathy are managed as usual for those entities. However, there appears to be a subset of pruritis patients with an abnormal rectoanal inhibitory reflex, but otherwise normal manometric parameters38,39.

B. Anorectal disease.

One study of 109 patients with pruritis found that 52% had identifiable contributory anorectal disease requiring management, and 35% had a significant abnormality on proctoscopy or colonoscopy. Twenty-three percent had a neoplastic lesion; the duration of pruritic symptoms was longer in the group found to harbor neoplasia40.

C. Perianal mycosis.

The possibility of diabetes and concomitant mycosis as cause for pruritis ani is often suggested. There is no evidence that diabetics with pruritis ani have mycosis as the primary cause – these patients are as likely as non-diabetics to respond to the management outlined above. C. albicans appears to be a normal inhabitant of the perianal region, and most patients with pruritis ani and Candida had symptom resolution after treatment for concomitant benign perianal disease41,42. In a minority of patients, symptoms persisted, and this correlated with the presence of dermatophyte species rather than C. albicans42.

D. Primary dermatoses.

The possibility of a primary dermatologic abnormality must not be overlooked. In a British series of 40 consecutive patients referred for pruritis ani, 34 had a recognizable dermatosis, most commonly psoriasis43.

IV. Intractable pruritis ani.

The natural history of pruritis ani seems to be repeated response and relapse. Once educated regarding the benign nature of the problem, most patients can cope with this. The subset of patients with intractable pruritis are a different story.

  A. Topical capsaicin.

Itch is transmitted by dedicated C neurons. Substance P is a neuropeptide that acts as a mediator of pain and itching impulses from the periphery to the CNS. Capsaicin, a derivative of Capsicum chili peppers, appears to exert a depressive effect on the availability and action of Substance P, probably by desensitizing the C neurons44.

A randomized, placebo controlled, crossover study using topical capsaicin and topical menthol showed that 31 of 44 patients with intractable pruritis ani experienced relief with capsaicin. Relief was maintained during the follow-up period (mean 10.9 months) with a single daily application of capsaicin in 29 patients45.

B. Methylene blue injection.

Periodically, intradermal injection of methylene blue is suggested for intractable pruritis ani. Reports in the literature describe injection of 10-15 ml of a 1% methylene blue solution (sometimes mixed with a local anesthetic) intracutaneously and subcutaneously. Older reports related complications of abscess and skin necrosis; more recent publications have not seen these occurrences. Relief is reported as high as 83% at 12 months, with some patients requiring repeat injection46,47.

C. Intralesional corticosteroids.

Anecdotal reports discuss intralesional injection of corticosteroids for intractable pruritis with a focal aspect. As always with a focal lesion, both infectious and neoplastic causes must be ruled out before steroid injections are undertaken.    

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