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Hemorrhoids&FissureinAno
Hemorrhoids
TheprevalenceofsymptomatichemorrhoidsintheUnitedStatesisreportedtobe4.4%withapeakprevalenceoccurring
between45and65yearsofage,equallyinmenandwomen.Approximatelyonethirdoftheseindividualsseekmedical
attention.Treatmentdependsonthedegreeofprolapseandseverityofsymptoms.However,whenundertakinganytreatment
forhemorrhoidaldiseaseitisessentialtoconsiderhemorrhoidsapartofnormalanorectalanatomyimportantinthecontinence
mechanism,thesignificancebeingthatsurgicalremovalmayresultinvaryingdegreesofincontinence(particularlyin
individualswithmarginalpreoperativecontrol).
Anatomy
Hemorrhoidsareanormalfeatureofthehumananorectalanatomy.Thesearefibrovascularcushionslocatedinthe
subepithelialspaceoftheanalcanal,containingarteriovenouscommunications1.Theyaresupportedwithintheanalcanalby
smoothmuscle(Treitzsmuscle)thatoriginatesfromtheconjoinedlongitudinalmuscleandpassesthroughtheinternalanal
sphinctertoinsertintothesubepithelialvascularspace1.Asanindividualstrains,coughsorsneezes,thesefibrovascular
cushionsengorgeandmaintainclosureoftheanalcanaltopreventleakageofstool.Thesecushionsaccountforapproximately
1520%oftheanalrestingpressure2.Theliningofthesecushionsintheanalcanalalsosuppliesvisceralsensoryinformation
thatenablesindividualstodiscriminatebetweenliquid,solidandgas,furtheraidingincontinence.Inaddition,duringtheactof
defecationthefibrovascularcushionsengorgewithblood,cushiontheanalcanalliningandallowtheanalcanaltodilate
withouttearing.
Therearethreemainfibrovascularcushionslocatedintheleftlateral,rightanteriorandrightposteriorpositionsoftheanus,with
interveningsecondarycomplexesinsomeindividuals.Theconfigurationisconstantandbearsnorelationshiptotheterminal
branchingofthesuperiorrectalartery,contrarytowhatwaspreviouslythought.Internalhemorrhoidsarisefromthesuperior
hemorrhoidalplexusproximaltothedentatelineandarecoveredbyinsensatecolumnarandtransitionalepithelium.Bloodin
thesuperiorhemorrhoidalplexusisdrainedthroughthesuperiorrectalveinsintotheinferiormesentericveinandsubsequently
intotheportalsystem.Externalhemorrhoidsarisefromtheinferiorhemorrhoidalplexusdistaltothedentatelineandare
coveredbysquamousepitheliumcontainingnerveendings.Bloodfromtheinferiorhemorrhoidalplexusisdrainedinpart
throughthemiddlerectalveinsintotheinternaliliacveins,butmainlythroughtheinferiorrectalveins,intothepudendalveins
(tributariesoftheinternaliliacveins).
Etiology,pathophysiologyandsymptomology
Hemorrhoidsdonotconstituteadiseaseunlesstheybecomesymptomatic.Hemorrhoidaldiseaserequiresthepresenceof
pathologicchangesthatleadtobleeding,prolapse,pruritus,soiling,thrombosis,oracombinationthereof.Withrepeated
straining,eithersecondarytoconstipation,diarrheaandtenesmusorprolongedattemptsatdefecation,especiallywhile
readingonthecommode,thefibrovascularcushionsslideintheanalcanal,engorgeandtheoverlyingmucosabecomesthin
andfriablewithtraumatotheunderlyingvesselsleadingtopainlessbrightred(duetothearterialoxygentensioncausedbythe
arteriovenouscommunications3)bleedingonthetissuepaper,onthestoolordrippingintothetoiletbowl.Furtherstraining
disruptsthesuspensoryTreitzsmuscleeventuallyleadingtoprolapseandengorgementoftheinternalhemorrhoidalcushions
associatedwithperianalfullnesssanddiscomfort.Prolapsemayalsooccurduringwalking,heavyliftingandpregnancyasa
resultofincreasedintraabdominalpressure.Althoughthismayinitiallyreducespontaneously,overtimethisprolapsewill
resultinpersistentmucoiddischargeassociatedwithpruritusandperianalexcoriation,bloodstainingofundergarments,as
wellasfecalsoiling(particularlyintheelderly).Iftheprolapsebecomesirreduciblebecauseofswellingandspasmofthe
sphincter,theinternalhemorrhoidscanbecomestrangulated,necroticandpainfulandmayleadtosystemicillness.Becauseof
theconnectionwiththeportalsystem,gangrenoushemorrhoidswithsuperimposedinfectioncanleadtopyelephlebitisinrare
cases.Anemiaduetohemorrhoidaldiseaseisuncommon(0.5patients/1000000population)4andiseasilycorrectedwith
hemorrhoidectomy.
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Becausecommunicationexistsbetweentheinternalandexternalhemorrhoidalplexusesatthedentateline,theexternal
hemorrhoidalveinsalsobecomeengorgedwithstrainingandovertimechronicstrainingcanleadtothedevelopmentof
combinedinternalandexternalhemorrhoids.Forthemostpartexternalhemorrhoidsareasymptomaticunlesstheybecome
thrombosed,inwhichcasetheypresentasanacutelypainfulperianallump,ortheskintagsaresolargethathygieneis
impossible
Evaluationandclassification
Notallcomplaintsaretrulyhemorrhoids.Hemorrhoidalsymptomsmaybeamanifestationofseveraldifferentmedical
conditions,andthereforeacarefulevaluationofthepatientshouldbeconductedtodeterminetheunderlyingcausesofthe
patientscomplaints.Ahistoryshouldincludenotonlycharacterizationofbleeding,protrusion,painandbowelhabits,butalso
anassessmentofthepatientscoagulationhistory,andthepossibilityofliverdisease,inflammatoryboweldiseaseor
immunosuppression.Acompleteexaminationincludinginspectionwitheversionoftheanalcanalbyopposingtractionwiththe
thumbs,digitalrectalexamination,anoscopy(withoutandwithstraining)andrigid/flexiblesigmoidoscopyshouldbeperformed
beforetreatment.Onemustentertaintheappropriatespectrumofdifferentialdiagnosesincludingcolorectaltumors,
abcess/fistuladisease,analfissures,inflammatoryboweldisease(particularlyCrohnsdisease),rectalprolapse,hypertrophied
analpapillae,perianalcondylomas,otherSTDsandhidraadenitissupppurativa.Inaddition,anyindividualwithrectalbleeding
shouldundergoappropriateworkuptoexcludethepossibilityofproximalcolorectalneoplasia.Inayoungindividualwithrectal
bleedingandhemorrhoidaldiseaseonexaminationwithnoothersystemicsystemsandnofamilyhistory,anoscopyand
sigmoidoscopyareallthatiswarranted.However,rectalbleedinginanindividualolderthan50,orolderthan40witheithera
familyhistoryofcolorectalcancerorachangeinbowelhabits,demandsacompletecolonoscopy,virtualcolonoscopyorbarium
enemawithflexiblesigmoidoscopy.Apositivefecaloccultbloodtest,orirondeficiencyanemiaalsonecessitateacomplete
colonevaluation5.Hemorrhoidaldiseaseassociatedwithsymptomsofsoilingorincontinencemayrequireanorectal
physiologytestingandendoanalultrasoundifthepatientisbeingconsideredforsurgery.
Internalhemorrhoidsareclassifiedintofourgradesbasedonprolapseandclinicalsymptoms6.GradeIinternalhemorrhoids
bulgeintothelumenoftheanalcanalandmayproducepainlessbleeding.GradeIIinternalhemorrhoidsprolapsewith
strainingbutreducespontaneously.GradeIIIinternalhemorrhoidsprolapsespontaneouslyorwithstrainingandrequire
manualreplacement.Finally,GradeIVinternalhemorrhoidsarepermanentlyprolapsedandirreducible.Accurate
classificationisimportantforbothselectingtheappropriatetreatmentandassessingthereportedefficacyofvarioustreatments.
Ingenerallesssymptomatichemorrhoids,suchasthosethatcauseonlyminorbleedingcanbetreatedwithsimplemeasures
suchasdietarymodificationsandchangeindefecatoryhabits,orofficeprocedures.Moresymptomatichemorrhoidssuchas
gradeIIIandIVhemorrhoidsaremorelikelytorequireoperativeintervention,asnononoperativemanagementisineffective7.
Treatment
I.Conservativemanagement(dietaryandlifestylemodification)
Dietarymanagementconsistingofadequatefluidandfiberintaketorelieveconstipationandeliminatestrainingatdefectaionis
theprimarynoninvasivetreatmentforallsymptomatichemorrhoids5.Fibersupplementssuchaspsylliumworkinconcertwith
watertoaddmoisturetothestoolandsubsequentlydecreasesconstipation.Diarrheamayalsobecontrolledwithpsylliumto
addbulktotheliquidstooltherebyincreasingtheconsistencyanddecreasingthefrequencyofbowelmovements.Arecent
metaanalysisconfirmedthatfibreiseffectiveIntreatingsymptomatichemorrhoidsassociatedwithlesserprolapseand
bleeding(GradesIandII)8,however,conservativemanagementaloneisineffectiveforhemorrhoidswithsignificantprolapse
(GradesIIIandIV)7whicharemorelikelytorequiresurgicalintervention.Stoolsoftenersmaybeaddedifnecessary.Sitzbaths
areusefulforrelievinganalpainandmaintaininganalhygiene9,10.Exerciseshouldberecommended.Simplyinstructing
patientstoavoidreadingonthecommodewillfrequentlyresolvesymptoms.
Overthecountertopicalagentsandsuppositoriescontaininglocalanesthetics,corticosteroids,astringent,antisepticsand
protectantsareavailableandmayalleviatesymptomsofpruritusanddiscomfort.However,longtermuseoftheseagents
shouldbediscouraged,particularlycorticosteroidpreparationswhichcanpermanentlydamageorcauseulcerationofthe
perianalskin.Norandomizedcontrolledtrialsareavailabletosupporttheirwidespreaduse.Inoneprospectiveseries,
nitroglycerinointmentrelievedpainduetothrombosedhemorrhoids,presumablybydecreasinganaltone11.
Oralvenotonics,suchasflavanoids,havebeenusedasdietarysupplementsinthetreatmentofsymptomatichemorrhoidsin
EuropeandtheFarEast.Themechanismofactionofthesedrugsremainsunclear,buttheymayimprovevenoustone,reduce
hyperpermeability,andhaveantiinflammatoryeffects.However,arecentmetaanalysisconcludedthatlimitationsin
methodologicalqualityandpotentialpublicationbiasraisedoubtsaboutthebenefitsoftheseagentsintreatinghemorrhoids12.
FlavanoidshavenotbeenapprovedforuseinAmericabytheFoodandDrugAdministartion.

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II.Nonoperativemanagement(officeprocedures)+Minoroperativeprocedures
Excisionalhemorrhoidectomy(EH)providesexcellentlongtermcureofsymptoms,butattheexpenseofpain,complications
andtimeoffwork.Fordecadesalternativeshavebeensoughttoachieveminimallyinvasivetreatmentoptions.Because
anodermisviscerallyinnervated,itisnotsensitivetotouch,painandtemperature,makingiteasilyamenabletooffice
procedures.Thegoalofofficeprocedures,justlikeEH,istoablatethevesselsinvolvedandfixtheslidinghemorrhoidaltissue
backontothemusclewalloftheanalcanalinordertoimprovesymptomsofbleedingandprolapse.Officeproceduresare
recommendedformostpatientswithrefractoryGradesI,IIorIIIhemorrhoids.Optionsincludesclerotherapy,infrared
coagulation,bipolarcoagulation,directcurrentelectrotherapy,monopolarcoagulation,cryotherapyandDopplerguidedartery
ligation.Only510%ofpatientsrequiresurgery.

a.RubberBandLigation
Themostcommonofficeprocedureusedforthetreatmentofsymptomaticinternalhemorrhoidsisrubberbandligation.Through
asideviewinganoscope,anatraumaticclamp(modifiedAllisforcep)isusedtoretractthetissueattheapexofthe
hemorrhoidalcomplex(2cmproximaltothedentateline)intoaligator(BarronorMcGivney),andasingleordoubleelastic
bandisfiredfromthedrum.Theintroductionofsuctionbandshaveallowedthisproceduretobeperformedbyasingle
operator13.Thisisarelativelypainlessprocedure,aslongastheringsareproperlypositionedabovethedentateline.The
bandedtissueinfarctsandsloughsoverthenext710days,formingasmallulcer,resultinginreductionoftheprolapsed
hemorrhoidaltissueaswellasfixationoftheresidualhemorrhoidintheupperanalcanal.Inourpracticeweprefersingle
ligationsatintervalsof46weekstoreducediscomfortandvasovagalsymptomsandallowtheulcertoheal.However,
prospectivestudieshaveshownnoincreaseinpostligationpainorcomplicationswithmultiplebanding14,15,somany
surgeonsapplyupto3bandsateachvisit.Inattempttoreducethediscomfortofmultiplebanding,injectionoflocalanesthetic
intothebandedhemorrhoidshasbeentried,butwithoutsuccess16.Morerecently,localanesthesiaoftheupperanalcanalhas
beendescribedtoproducefullrelaxationandmaximalmucosalredundancyoftheanalcanal,thusprovidinganexcellent
exposureandallowingaccurate,multiplerubberbandligationwithoutcausingsignificantpainduringoraftertheprocedure17.
However,theseareonlypreliminaryresults.
Rubberbandligation(RBL)iscommonlyusedforGradesI,II,andIIIhemorrhoidsinternalhemorrhoids.Someauthors
recommenditforGradeIVhemorrhoidsafterreductionoftheincarceratedprolapse18,butnolongtermdataisavailable.RBL
wasfoundtobethemosteffectiveoftheofficeproceduresinametaanalysisof18prospective,randomizedtrials.RBLwas
associatedwithalowerrecurrenceratebutmoreoverallpainthansclerotherapyorinfraredcoagulation19.Arecentmeta
analysis20comparingRBLtoEHconfirmedlongtermcurewasbetterwithEH,particularlyforGradeIIIhemorrhoids,although
pain,complicationsandtimeoffworkweresignificantlygreaterthanwithRBL.TheauthorsrecommendedthatRBLbe
adoptedasthetreatmentofchoiceforGradeIIhemorrhoidswithsimilarresultsbutwithoutthesideeffectsofEH,whileEH
couldbereservedforGradeIIIhemorrhoidsorrecurrenthemorrhoidsafterRBL.
Bandingtechniquesappeartoachievecompletereliefofsymptomsin6585%ofpatients.Therecurrenceratemaybeashigh
as68%atfourorfiveyearsoffollowup,butsymptomsusuallyrespondtorepeatligationonly510%ofsuchpatientsrequire
EH21.Complicationsincludepain,bleeding,thrombosisandperinealsepsis.Adullpersistentacheiscommonforthefirst24
48hoursfollowingbanding.Ifsignificantpainisexperiencedimmediatelyfollowingthebanding,thentherubberbandcanbe
removedwithabeaverblade,althoughthisisdifficultendeavor.Ifthepatientdevelopspainlateron,itisgenerallytreatedwith
sitzbaths,analgesicsandavoidanceofconstipation.Bleedinggenerallyoccursimmediatelyafterbandingor710dayslater
whenthebandfallsoff.Thoughrare,thismayrequireoperativeinterventionwithsutureligationtocontrolpersistent
hemorrhage.Bandingiscontraindicatedinpatientswhoareanticoagulated.Occasionally,bandingcanresultinthrombosisof
internalandexternalhemorrhoidsresultinginsignificantpain.Rarelybandingcanleadtolifethreatningperianalsepsis.
Therefore,patientscomplainingofsignificantpain,feveranddysuriashouldbeadministeredbroadspectrumantibioticsand
shouldundergopromptexaminationunderanesthesia.Becauseofthepotentialriskofperianalsepsis,someauthors
recommendavoidinghemorrhoidalbandinginimmunocompromisedindividuals.

b.Sclerotherapy
SclerotherapyisreservedforGradeIandIIhemorrhoids.Itinvolvesasubmucosalinjectionofasclerosant(12mlof5%
phenolinalmondoil,5%quinineurea,or5%sodiummorrhuate)attheapexofthehemorrhoidalcomplexthroughananoscope
usinga25or30gaugeneedle.Thiscausesthrombosisofthevessels,sclerosisoftheconnectivetissue,withshrinkageand
fixationoftheoverlyingmucosatherebydecreasingbleedingandprolapse.Sclerotherapycanbeusedinpatientson
anticoagulation.Sclerotherapycanresultinadullachelasting2448hoursbutcomplicationsareinfrequentandusually
relatedtoincorrectplacementofthesclerosant.Rarely,apatientmaydevelopmucosalulcerationandnecrosis,localinfection
andabcessformation,prostatitis,erectiledysfunctionorportalpyaemia.Thoughitischeap,easytoperformandslightlyless
painfulthanhemorrhoidalbanding19itislesswidelyusedthanbandingbecauseofahigherfailurerate.However,ithasbeen
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usedincombinationwithRBLwithgoodresults22,23.Repetitivesclerotherapyshouldbeusedwithcautionbecauseofthe
potentialofscarringandstrictureformation.
Takanoetal.24describedtheuseofanewsclerosingagentOC18(containingaluminumpotassiumsulfate)forthetreatment
ofGradeIIIandIVinternalhemorrhoidsandfoundittobeaseffectiveasEHat28days.Howeverrecurrencewasstill
significantlyhighercomparedtoEH.Furthermorethistechniquerequiredeitherlocalorspinalanesthesiainordertoinjectthe
solutioninfourareasofeachhemorrhoidalcomplex.Recently,acasestudy25evaluatedtheuseoffoamsclrotherapyby
flexibleendoscopyforGradeIIIVhemorrhoids.Bleedingandprolapsedwereresolvedwithatmost2sessions,whilepain
resolvedafter1session,withnocomplications.However,nocomparativestudiesandlongtermdataareavailable.
a.Infraredphotocoagulation
Theinfraredphotocoagulator(IRC)producesinfraredlightwhichpenetratesthetissueandconvertstoheat,promoting
coagulationofvesselsandfixationofhemorrhoidaltissue.Theamountoftissuedestructiondependsontheintensityand
durationoftheapplication.Itisrecommendedthattheinfraredprobebeappliedfor1.5secondstotheapexofeachinternal
hemorrhoid,andberepeatedthreetimesoneachhemorrhoid.Infraredcoagulationdoesnotcausetissuenecrosisbecauseof
thesmallamountofheatdelivered,andisthereforeonlyusefulinthetreatmentofGradeIandpossiblysmallGradeII
hemorrhoids,withoutsignificantprolapse.Infraredcoagulationseldomcausespainorothercomplications.Inametaanalysisof
randomizedcontrolledtrials,infraredcoagulationwasfoundtobesignificantlylesspainfulthanRBL,butrequiredmore
sessionstorelievesymptoms,hadahigherrecurrencerateandismoreexpensivethanRBL19.
b.Electrocoagulation
LikeIRC,electrocoagulationtechniquesallrelyoncoagulationandfixationofhemorrhoidaltissueattheleveloftheanorectal
ring.ElectrocoagulationhasprovenusefulinthetreatmentofGradesIIIhemorrhoids,whilesomeauthorsfinditusefulfor
GradeIIIhemorrhoidsaswell26.
Bipolar(Bicap)coagulationiselectrocauteryinwhichheatdoesnotpenetrateasdeeplyaswithmonopolarcoagulation.
Cauteryisappliedinonesecondpulsesattheapexofthehemorrhoid,untiltheunderlyingtissuecoagulates.Itseffectis
similartothatofIRC,butunlikeIRC,thedepthofinjurydoesnotincreasewithmultipleapplicationsatthesamesite,whichis
sometimesnecessarywithhighergradehemorrrhoids27.Itdoesnoteliminateprolapsingtissue,andupto20%ofpatients
requireexcisionalhemorrhoidectomy.
Directcurrentelectrotherapy(Ultroid)issimilarlyappliedthroughaprobeplacedviaananoscopeontothemucosaatthe
apexofthehemorrhoid.Thecurrentissettothemaximaltolerablelevelandcontinuedfor10minuteswithmultipletreatments
requiredtothesamesiteinupto30%ofpatientswithhigherdegreehemorrhoids.Bipolarcoagulationcomparedtodirect
currentcoagulationhastheadvantagethattreatmentapplicationlastsonlyseveralsecondscomparedwitheighttotenminutes
perapplicationfordirectcurrent.Becauseofthelimitedeffectinhigherdegreehemorrhoidsandlengthytreatmenttimes,direct
currentcoagulationhasneverbecomepopular.Butbothbipolaranddirectcurrentcoagulationareassociatedwithaminor
complicationrateof10%(pain,bleeding,fissure,orsphincterspasm)andrecurrenceratesbetween25and35%26,28.
Monopolarcoagulation,usingeithertheballtiporthespatulatip,isthecoagulationmethodofchoiceforsomeauthors29,as
analternativetorubberbandligation.Bipolarcoagulationwascomparedtomonopolarcoagulationinarandomizedtrialof81
patients.Monopolarcoagulationwasassociatedwithmorepain,buthighersuccessratesandalowerincidenceof
complications30.Thekeytosuccessistocoagulatethetopsofthehemorrhoidsuntiltheyarecharred,sothemucosawill
ulcerateandfixtotheanorectalring.
c.Cryotherapy
Cryotherapyusescoldcoagulation(nitrousoxideorliquidnitrogen)todestroythehemorrhoidalcushions.However,this
procedureresultsinprofusedischargeassociatedwithafoulsmell,irritationandpainduetonecrosis,andthehealingtimeis
verylong.Inaddition,ifitisnotproperlyperformed,destructionoftheanalsphinctercancauseanalstenosisandincontinence.
Forthesereasons,cryotherapyisnolongerrecommendedforthetreatmentofinternalhemorrhoids.
d.Dopplerguidedhemorrhoidalarteryligation(DGHAL)
DGHALwasintroducedin1995byMorinaga,aJapanesesurgeon.Thistechniqueusesaspeciallydesignedproctoscope
(Moricorn)housingaDopplertransducerthatcanidentifyhemorrhoidalarteriesandpermitstheirligationwithsixtotenfigureof
eightsuturesabovethedentatelineintheinsensateregion.Theinsertionofaringofsutures,whichbunchesupthemucosa,
resultsinpullinguptheprolapsewhileinterruptingitsbloodsupply.HALwasdesignedasaminimallyinvasivealternativeto
EHforprolapsinghemorrhoidsthatdonotrespondtoorarenotamenabletoofficeprocedures.However,DGHALhaslittle
valueforGradeIVhemorrhoidswherethemainproblemismucosalprolapse(notbleeding)evenwithappropriatetechnique
theprolapsedmucosaremainsinplacealongwithsymptoms.DGHALisperformedasanoutpatientprocedureunderlocal
(withsedation),spinalorgeneralanesthesia.Thesuccessratehasbeenreportedtobegreaterthan90%forgradeIII
hemorrhoids3135,withaminimalrateofcomplications(milddiscomfort,tenesmus,limitedrectalbleeding,thrombosis).There
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isnoanalwoundtoheal.Thereisnoriskofincontinenceorstricture.Thefailurerateisabout10%(nearly70%forgradeIV
hemorrhoids).Inasmallrandomizedstudy,DGHALshowedmuchlessanalpain,shorterhospitalstayandearlierreturntowork
comparedtohemorrhoidectomy,andlongtermrecurrenceratesat1yearfollowupweresimilarinboth36.DGHALappearsto
beaneffective,simple,minimallyinvasivealternativetohemorrhoidectomyforprolapsing(butreducible)hemorrhoidsthatfail
torespondtoofficeprocedures.However,morecomparativestudiesandlongerfollowupdataareneeded.
e.Analstretch/dilation
PopularizedbyLordin1968,andstillemployedinEurope,theanalstretchprocedureisbasedonthebeliefthathemorrhoids
areduetoanarrowingoftheanalcanalcausedbyafibrousdeposit(pectenband)thatresultsinabnormalstrainingand
subsequentvenouscongestionleadingtohemorrhoids.Thisprocedureisperformedunderintravenoussedationorgeneral
anesthesia,andtheanalcanalisstretcheduntilfourfingerscanbeinserted.Patientsthenuseananaldilatorintermittentlyover
thenextsixmonths.However,endosonographyhasshownsphincterinjuryassociatedwithanaldilation37andseveralclinical
serieshavereportedhighratesofassociatedincontinence,especiallylongterm38.Inaddition,whencomparedtosurgical
hemorrhoidectomy,analdilationhasahigherfailurerate,withsomepatientsrequiringhemorrhoidectomy39.Mostauthorities
todayadvocateabandoningthisapproach.

III.Surgicaltreatment
SurgicalhemorrhoidectomyisthemosteffectivetreatmentforhemorrhoidsoverallandforGradeIIIinparticular19,withrare
recurrences.However,nonoperativetechniquesarepreferredwhenfeasibleinthefirstinstancebecausesurgeryisassociated
withmorepain,postoperativedisabilityandcomplications.Indicationsforsurgicalhemorrhoidectomyincludefailureofoffice
procedures,patientinabilitytotolerateofficeprocedures,largeexternalhemorrhoidsorcombinedinternal/externalhemorrhoids
withsignificantprolapseandconcomitantconditions(suchasfissureorfistula)thatrequiresurgery.About510%ofpatients,
usuallythosewithgardeIIIorIVhemorrhoids,needsurgicalhemorrhoidectomy.Overtime,severaldifferenttechniqueshave
beendescribed.
a.Excisionalhemorrhoidectomy
Excisionalhemorrhoidectomycanbeperformedwitheitheropenorclosedtechniques.IntheMilliganMorgan(open)
hemorrhoidectomy,usedmostlyinGreatBritain,theinternalandexternalcomponentsofeachhemorrhoidareexcisedandthe
skinisleftopeninathreeleafcloverpatternthathealssecondarilyforfourtoeightweeks.IntheFerguson(closed)
hemorrhoidectomy,thehemorrhoidcomponentisexcisedandthewoundsareclosedprimarily.Fourrandomizedtrialshave
comparedopenversusclosedhemorrhoidectomy4043.Bothtechniquesaresafeandeffective.Themajorityoftrialsshowed
nodifferenceinpostoperativepain,analgesicuse,hospitalstayandcomplications,whereascompletewoundhealingshowed
mixedresultswithasuggestionthatclosedhemorrhoidectomypromotesfasterwoundhealing.AsopposedtotheUnited
Kingdom,moremembersoftheAmericanSocietyofColonandRectalSurgeonsreportusingaclosedratherthanopen
technique44.
Postoperativepainremainsthemajorobstacletopatientsseekingsurgicalmanagementoftheirhemorrhoids.Narcoticsare
generallyneededtocontrolpain,andmostpatientsdonotreturntoworkfor24weeksaftersurgery4548.Randomizedtrials
haveshownnodifferenceinpainscoresbetweentheuseofdiathermyorscissorsforEH4951.Earlyreportssuggestedthat
laserhemorrhoidectomywasassociatedwithlesspostoperativepainhowever,arandomizedtrialoftheNd:YAGlaserversus
coldscalpeldidnotshowanydifferenceinpostoperativepainoranalgesicuse5254.Furthermore,laserhemorrhoidectomy
wasassociatedwithhighercostsandimpairedwoundhealing.Newerinstrumentshavecomeintovogueforperforming
hemorrhoidectomysuchastheHarmonicScalpelorLigaSureTM.Fourrandomizedcontrolledtrialsevaluatedthe
ultrasonicallyactivated,HarmonicScalpelandshowedconflictingresultswithrespecttopostoperativepain5558.Twosmall
randomizedtrialssuggestedapossibleminoradvantagewithbipolardiathermy(LigaSureTM),butpainscoresdidnotdiffer
significantly5960.Theadditionalcostsoftheseinstrumentsandthelackofsuperiorresultsprecludetheirrecommendationfor
routineuse.
Manydifferentattemptsatreducingpainhaveincludedlimitingtheincision,suturingonlythevascularpediclewithoutan
incision,usingaconcomitantlateralinternalsphincterotomy,administeringmetranidazole,injectinglocalanesthetics,using
analsphincterrelaxantsincludingnitroglycerin,usinganxiolyticsandusingparasympathomimetics(toavoidurinary
retention)6170.However,eachofthesestrategieshashadlimitedormixedresultsandthereforecannotberecommendedfor
routineuse.However,postoperativeanalgesicsaswellaslaxativesarenecessarytoreducepainduringthefirstpostoperative
motion.
Thecomplicationsofhemorrhoidectomyincludeurinaryretention(236%),bleeding(0.03%6%),infection(0.55.5%),anal
stenosis(06%)usuallyasaresultofinadequatemucosalbridgesandincontinence(212%)21.Sphincterdefectsassociated
withincontinencehavebeendocumentedbyendoanalultrasoundandanalmanometryinupto12%ofpatientsafter
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hemorrhoidectomy7174,probablyduetoexcessiveretractionanddilationoftheanalcanal.
OtherhemorrhoidectomytechniquesdescribedintheliteratureincludetheWhiteheadhemorrhoidectomyandtheParks
hemorrhoidectomy.TheWhiteheadhemorrhoidectomy,involvescircumferentialexcisionofthehemorrhoidalcomplexes
beginningatthedentatelineandproceedingproximallyinasimilarmannertoaDelormeprocedureforrectalprolapse.This
procedurehasbeenbyinlargeabandonedintheUnitedStatesduetothehighcomplicationrates,includingstricture,lossof
analsensationanddevelopmentofmucosalectropion.Parksdescribedasubmucosalhemorrhoidectomythatreconstructed
theanalcanalandthereforewasexpectedtopreservebettersensorycontinenceandreducepostoperativepain.This
techniqueisnotfrequentlyused,becauseitdoesnotofferasolutiontotheexternalhemorrhoidalcomponent.
Emergencyexcisionalhemorrhoidectomyforstrangulated,gangrenoushemorrhoidscanbeperformedsafely75.Asdiscussed
earlier,arandomizedtrialcomparingexcisionalhemorrhoidectomytoRBLwithincisionforacutestrangulatedhemorrhoids,
showedthatbothtechniquescanbeperformedsafely,althoughearlyrecoveryisslightlyimprovedafterRBLandincision18.
Thereisnoscientificdatacomparingtreatmentoptionsforexternalhemorrhoidalthrombosis.Clinicalexperiencehasledtothe
recommendationthatindividualswhopresentwithsymptomsforlessthan4872hoursarebesttreatedbylocalexcision,
whereasthosepatientswhosesymptomshavebeenpresentformorethan72hourscanbetreatedconservatively(avoidance
ofconstipation,analgesia,sitzbaths).Incisionandclotevacuationshouldbeavoided5.Perianalskintagscanbeexcisedif
symptomatic.
Lateralinternalsphincterotomyduringconventionalhemorrhoidectomywasassumedtoreducethepostoperativepain,even
whentherewasnoevidenceofanalfissure.Currently,thereisnoevidencethatpatientswithoutconcomitantanalfissurewill
benefitfromthisprocedure.Infact,studieshavesuggestedthatthisproceduredoesnotreducepainandmayhavedeleterious
effectsoncontinence76.
b.Stapledhemorrhoidectomy
Stapledhemorrhoidectomy,alsoknownascircularstapledhemorrhoidectomy[CSH],procedureforprolapsedhemorrhoids
[PPH]andstapledanopexy,hasbeendevelopedasaminimallyinvasive,lesspainfulalternativetoexcisional
hemorrhoidectomy.Thisprocedure,likeRBL,essentiallyremovesredundantanalmusosaatthetopofthehemorrhoids.
However,itresectsmuchlargerredundantrectalmucosathanRBLandshouldbeperformedinGradeIIandIIIwhichdonot
respondtoRBLandGradeIVhemorrhoidsthatarereducibleunderanesthesia.ItisLongowhopopularizedthetechnique
usingaspeciallydesignedcircularstapler(EthiconEndoSurgery)whichperformsacircumferentialresectionofmucosaand
submucosaabovethehemorrhoidsandthenstaplesclosedthedefect.Thegoalistoresuspendtheprolapsinghemorrhoidal
tissuebackintotheanalcanal,aswellastointerruptthearterialinflowthattraversestheexcisedsegment.So,infactthis
procedureisastapledhemorrhoidopexyratherthanhemorrhoidectomysincethehemorrhoidsarenotremoved,butrather
returnedtotheiranatomicposition.
Thepreservationoftheanalcushionsmayinfactcontributetothelowrateofincontinenceafterthisoperation.Noexternal
woundsarecreatedandthestaplingdevicecutswellabovethedentateline,thereforepostoperativepainisminimaland
usuallyabsent.Incontrasttoconventionalhemorrhoidectomy,however,skintagsandenlargedexternalhemorrhoidsarenot
removedusingthestapledtechnique.Thoughcomplicationsarerare,severalseriouscomplicationshavebeenreportedafter
stapledhemorrhoidopexy,includingrectalperforation,retroperitonealsepsis,anovaginalfistulaandpelvicsepsis,whichare
likelyduetoexcisionoffullthicknessrectalwallratherthanmuscosaandsubmucosaonly.Smoothmusclefibershavebeen
detectedinavariablepercentageofstapledhemorrhoidopexyspecimens,althoughsuchfibershavealsobeendetected
followingconventionalhemorrhoidectomy.Ofpotentiallymorefunctionalconsequence,fragmentationoftheinternalsphincter
wasnotedin14%ofpatientswhounderwentstapledhemorrhoidectomyusingastandard37mmanaldilator.Themain
complicationoftheprocedureisbleedingfromthestapleline,whichcanbeeasilyoversewn.Withthesecondgeneration33
mmhemorrhoidalcircularstaplerandaclosedheightof.75mm,bleedinghasbeenmarkedlydecreased.21
AsingletrialcomparedstapledhemorrhoidopexytoRBLandfoundmorepainwithstapling,butimprovedreliefofsymptoms
77.AmetaanalysisperformedbyNisaretal78in2004demonstratedthatpatientsundergoingstapledhemorrhoidopexyhave
improvedperioperativeoutcomes,particularlywithrespecttopainandreturntonormalactivitiescomparedtotheconventional
techniques.AmorerecentCochranesystematicreview79ofstapledhemorrhoidopexyconcludedthattheprocedurewasas
safeasconventionalhemorrhoidectomywithveryfewcomplicationsreported.However,stapledhemorrhoidopexyisassociated
withahigherlongtermriskofhemorrhoidrecurrenceandthesymptomofprolapse.Itisalsolikelytobeassociatedwitha
higherlikelihoodoflongtermsymptomrecurrenceandtheneedforadditionaloperationscomparedtoconventionalexcisional
hemrroidsurgeries.Theauthorsconcludedthatifhemorrhoidrecurrenceandprolapsearethemostimportantclinical
outcomes,thenconventionalexcisionalsurgeryremainsthegoldstandardinthesurgicaltreatmentofinternalhemorrhoids.

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IV.Specialsituations

a.HemorrhoidsinPregnancy.Hemorrhoidalsymptomscommonlyoccurandintensifyduringpregnancy(particularlyduring
thelasttrimester)anddelivery.Constipationshouldbeavoidedduringpregnancy.Mildlaxativesshouldbegivenduringthelast
threemonthsofpregnancyandpostpartumperiodparticularlyforpatientswithconstipationproblems.Hemorrhoidsthat
intensifyduringdeliverytendtoresolve.Hemorrhoidectomyisindicatedduringpregnancyonlyifacuteprolapseand
thrombosisoccur.Itshouldbeperformedunderlocalanesthesiaintheleftlateralposition.Anoperationisindicatedinthe
immediatepostpartumperiodifprolapseandthrombosisoccurduringdelivery,orsymptomatichemorrhoidsthatwerepresent
priortopregnancyandaggravatedduringpregnancypersistafterdelivery.
b.Hemorrhoids,VaricesandPortalHypertension.Portoystemiccommunicationsexistintheanorectalcanalthesuperior
hemorrhoidalveins,whichdraintheupperanalcanalandrectumintotheportalcirculation,aredecompressedviathemiddle
andinferiorhemorrhoidalveinsofthesystemiccirculationinpatientswithportalhypertension.Anorectalvaricesdevelop
commonlyinportalhypertension,butunlikeesophagealvaricestheyrarelybleed.Intherarecaseofsymptomatic,bleeding
anorectalvarices,sutureligationin34columnsrunningfromtheashighintherectumaspossibletojustoutsidetheanuswill
usuallystopthebleeding.Othertreatmentsincludestapledhemorrhoidopexy,portaldecompressionviaatranshepatic
potosystemicshunt(TIPS)ligationoftheinferiormesentericvein,andpotosystemicshunts.
Themajorityofpainlessrectalbleeding,evenincirrhotics,isduetointernalhemorrhoids.Massivebleedingfromprolapsed
hemorrhoidsinsuchpatients,thoughrare,canbelifethreatning.Thiscommonlyoccursduringtreatmentforencephalopathy
whichresultsinseverediarrhea.Sutureligationisnecessarytostopthebleeding.Hemorrhoidectomyisreservedfortherare
situationinwhichsutureligationfailstocontrolthebleeding.Itisalsoimportanttocorrectanycoagulopathyandcontrolthe
diarrhea.

c.Hemorrhoidsininflammatoryboweldisease.MostanalproblemsinIBDresultfromdiarrhea.Hemorrhoidscanbetreated
operatively,ornonoperativelyinpatientswithulcerativecolitis.However,patientswithanorectalCrohnsdiseaseorCrohns
proctitishaveasubstantialriskoflocalcomplicationsthatcanbesevereenoughtorequireproctectomy.Ifnecessary
hemorrhoidectomycanbeperformedintheCrohnspatientwithquiescentilealorcolonicdisease.

d.Hemorrhoidsintheimmunocompromised.Correctionofanycoagulopathyandadministrationofantibioticsisthemainstay
therapyforhemorrhoidaldiseaseinthesepatients.Operativetreatmentcanresultinpoorwoundhealingandabcessformation,
andisthereforeusedasalastresorttorelievepainandsepsisinthispopulation.

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199712:296297.
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SystematicReviews2006,Issue4.Art.No.:CD005393.

FissureinAno
Ananalfissureisalinearulcerinthesquamousliningoftheanalcanalextendingfromthedentatelinetotheanalverge.
Patientstypicallycomplainofseveresharppainduringandafterdefecation,lastingminutestohours.Brightredbloodis
commonlyseenbutscant,mostlyonthetoilettissueorstreakingthestoolsurface.Fissuresaremostcommonlyfoundinthe
posteriormidlinebutcanbeseenintheanteriormidlineinupto13%ofwomenand8%ofmen,orinbothlocationsinupto3%
ofpatients1.Anacutefissureappearsasasimpletearintheanodermthatusuallyhealsspontaneouslywithin68weeks.A
chronicfissurepersistsmuchlongerandtendsnottohealwithoutintervention.Chronicfissuresaremarkedbysecondary
changessuchasasentinelpile,ahypertrophiedanalpapilla,fibrousindurationofthefissureedges,andfinallyfibrosisofthe
baseoftheulcer(internalanalsphincter)whichcanresultinaspastic,contractedinternalsphincter.Aprecipitatingcause
shouldbesought,typicallyconstipationordiarrhea,andcorrectedotherwisethefissurewilllikelyfailtohealorrecur.
Secondarycausesmaybeduetotraumapostanalsurgeryorchildbirthinwomen.Atypicalfissuressuchasthoseoccurringin
thelateralpositions,multiple,painlessornonhealingfissuresshouldpromptanevaluationforotherdiseasessuchasIBD,
HIV/AIDS,syphilis,tuberculosis,leukemia,sarcoidoranalSCCwhichmustbeexcluded.
EtiologyandPathogenesis
Itisgenerallyacceptedthattheinitiatingfactorinthedevelopmentofafissureistraumatotheanalcanal,usuallyduetothe
passageofalarge,hardstool.However,ahistoryofconstipationisnotalwaysobtained,andinfact,somepatientsdescribe
repeatedepisodesofdiarrheapriortotheonsetofsymptoms.Theellipticalarrangementoftheexternalsphincterinthe
posteriormidlinemayofferlesssupporttotheposterioraspectoftheanalcanalduringdefecation,contributingtotheformation
ofamidlinefissureduringthepassageofalarge,hardstool.Perpetuatingfactorsincludepersistentlyhardorliquidstool,which
continuouslyaggravatetheanalcanal.Increasedrestingpressureswithintheinternalanalsphincter(IAS)inpatientswith
fissures210,hasbeendescribedasanotherperpetuatingfactor.Ithasbeendemonstratedthatpatientswithanalfissureshave
anabnormalovershootcontractionoftheirIASfollowingexpectedreflexrelaxationduetorectaldistension2.Whether
increasedrestingpressureswithintheIASarethecauseortheeffectofdevelopmentofananalfissureremainsunclear.In
addition,anumberofstudieshaveshownthattheposteriorcommisureisperfusedmorepoorlythantherestoftheanal
canal11,afactorwhichispostulatedtoplayaroleinthepathogenesisoffissureinano.ItisbelievedthattheincreasedIAS
toneinpatientswithafissureresultsindecreasedbloodflowandpathogeneticallyrelevantischemiaintheposteriormidline
whichpreventsthefissurefromhealing.SphincterotomyhasbeenshowntodecreasepressureoftheIASandimprove
anodermalbloodflowattheposteriormidline,resultinginfissurehealing12.
AnunderstandingofthephysiologyoftheIASshedssomelightonthepathophysiologyofanalfissuresasrelatedto
increasedIAStoneandresponsetononsurgicaltreatment.ThebasaltoneoftheIASisdependentonintracellularcalcium.
ThereforecontractionofthesmoothmusclecellswithintheIASismediatedbyinfluxofcalciumthroughcalciumchannels,butit
isalsoaffectedbyneurohormonalstimulationof1adrenoreceptorsatthesmoothmusclecells.Activationof2
adrenoreceptorsinthemyentericinhibitoryneuronsmostlikelypresynapticallyinhibitsnonadrenergic,noncholinergic(NANC)
relaxation.Relaxationofthesecellsismediatedthroughdirectlydecreasingintracellularcalciumconcentrationaswellas
increasingcGMPandcAMP.Potassiuminfluxhyperpolarizesthecellmembraneanddecreasescalciumentry.Activationof2
adrenoreceptorsincreasescAMP,returningintracellularcalciumtothesarcoplasmicreticulum.Inaddition,thereareinhibitory
neurotransmittersthatmediateNANCrelaxation,includingnitricoxide(NO)andvasoactiveintestinalpeptide(VIP).NOisthe
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majorneurotransmittermediatingNANCrelaxationoftheIASbyincreasingcGMP.VIP,like2adrenoreceptorsincreases
cAMP13,14.Larginine,aprecursorofnitricoxide,hasbeenfoundtorelaxIASsmoothmuscleperhapsbyincreasingsubstrate
fornitricoxidesynthase(NOS),theenzymeinvolvedinNOsynthesis15.ApreliminarystudyhasshownreducedNOSintheIAS
ofpatientswithanalfissurescomparedtocontrols16.ThereducedproductionofNOprovidesapossibleexplanationforthe
highIASpressuresseeninmostfissurepatientsandalsowhypressuresreturntopretreatmentvaluesinpatientswhose
fissureshavehealedwithnonsurgicalmethods17.
Treatment
I.Conservativemanagement
Theaimoftreatmentofanacutefissureistobreakthecycleofahardstool(orloosestool),painandreflexspasm.Thiscanbe
accomplishedbytheingestionofadequatefluidandfibertocreatealargebutsoftbulkystool,warmsitzbathsorlocal
applicationofheattorelievesphincterspasmandifnecessarystoolsoftenerssuchasdocusate.Upto50%ofpatients
diagnosedwithacutefissureswillhealwiththesemeasures1.However,fibershouldbecontinuedforlifetopreventrecurrence,
asupto25%offissureswillrecuriftherapyisstopped18.Thegoalforadultsistoconsume2530goffiberdailyeitherthrough
mealsorsupplements.Topicalanestheticsareequivalenttoplaceboandmaycauseperianaldermatistis19.Antiinflammatory
(hydrocortisone)suppositorieshavenoadvantageoverfiberandsitzbaths19andinsertioncanbepainful.
II.Nonsurgicaltherapy
ThegoalinthetreatmentofnonhealinganalfissuresistorelievetheabnormallyhighIASpressures.Thegoldstandardfor
treatmenthasbeenalateralinternalsphincterotomy(LIS)toproduceapermanentreductioninIASpressures.However,dueto
increasingconcernsoflongtermimpairedcontinenceasaconsequenceofsuchanintervention,physicianshaveturnedto
chemicalsphincterotomy.Chemicalagentshavebeenusedtocreateareversiblereductioninsphincterpressureuntilthe
fissurehashealed.ACochranereviewofnonsurgicaltherapyforanalfissure20,hasconcludedthatmedicaltherapyfornon
healingfissuresmaybeappliedwithachanceofcurethatismarginallybutsignificantlybetterthanplacebo,butfarless
effectivethansurgeryandrecurrencesarehigher.Nonetheless,theriskofusingsuchtherapiesisnotgreat,withoutapparent
longtermadverseeffectandthetherapycanberepeated.Thesetherapiesmightthereforebeusedinindividualswantingto
avoidsurgicaltherapy,withsurgerybeingreservedfortreatmentfailures.Thatsaid,thesemedicationsareonlyeffectivewhile
inuse,explainingthehigherriskofrecurrencecomparedtooperativemanagement.
a.TopicalNitrates
NitratesaremetabolizedbysmoothmusclecellstoreleaseNO.NOistheprinciplenonadrenergic,noncholinergic
neurotransmitterintheIAS,anditsreleaseresultsinIASrelaxation.Studieshaveshownthattopicalnitroglycerineffectively
reducesmeanrestingIASpressure2123transientlyfor90minutes,andsignificantlyincreasesanodermalbloodflow24.
Topicalnitroglycerinointment0.2%administered23timesdailyfor48weeksiscurrentlythefirstlinetreatmentinmany
centersfornonhealingfissures.Thistreatmentsignificantlyreducespainondefecationafter2weeks,eveninpatientswho
dontheal28.Higherdosingdoesnotimproveoutcome2527.Repeatedapplicationsmaybenecessary.Theprincipleside
effectisheadachein27%ofpatients,oftenaffectingcomplianceinthosepatients,andhypotensionin6%.Theoverallhealing
rateintheCochranemetaanalysisis48.6%comparedto37%withplacebo,butlaterecurrenceoffissureiscommon,inthe
rangeof50%ofthoseinitiallycured.Thereisnoadvantagetoeitherbotoxorcalciumchannelblockerswhencomparedto
nitroglycerin20.SecondlineBotoxandcalciumchannelblockerscanbeusedinpatientswhofailtohealwithnitroglycerinor
whocannottolerateitssideeffectswithhealingratesnear5077%insmallstudies29,30,36.
b.CalciumChannelBlockers
Calciumchannelblockerspreventinfluxofcalciumintosmoothmusclecells,decreasingintracellularcalciumandpreventing
musclecontraction.CalciumchannelblockersthereforepromotefissurehealingbyreducingrestingIASpressure3135.Oral
agentsappeartohavepoorerhealingratesandhigherratesofsideeffectsthantheirtopicalcounterparts31.Untilrecently,most
studiesshowedthattopicalcalciumchannelblockers(diltiazem2%,nifedipine0.3%)achievefissurehealingtoasimilar
degreereportedwithtopicalnitrates20,butwithoutsideeffects.However,thereportedadverseeffectsduringtopicaldiltiazem
treatmentmaybemorecommonthanpreviouslythought36.Inarecent2yearfollowupofpatientstreatedwithtopical
diltiazem,21%reportedsideeffects(perianalitching,mildheadaches,nauseaandflushing),althoughtheyrarelyledto
reducedcompliance.Inaddition,forthefirsttime,thisstudylookedatrecurrencerateoveralongtermperiod.Disappointingly
59%ofpatientsrequiredfurthertreatment,nobetterthanrecurrencerateswithnitroglycerintreatment.
Unliketopicalnitroglycerin,neitherdiltiazemnornifedipinehasundergonecomparativestudieswithplacebo.However,topical
nifedipinehasbeencomparedtolidocaineandhydrocortisonewithsignificantlybetterhealingrates(95%vs35%)39,40.Until
recently,therehavebeennostudiescomparingtopicalcalciumchannelblockerstosurgicalsphincterotomy.Arandomized
studybyKatsinelosetal38in2006showedthattopical0.5%nifedipinet.i.dfor8weekscouldachievecompletehealingin
96.7%ofpatients,notsignificantlydifferentfromthegrouptreatedwithLIS.Althoughthedosagewasmorethandoublethatof
previousstudies,therewasnoincreaseinadverseeffects.However,recurrenceremainedaproblemcomparedtoLIS.This
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grouphashypothesizedthatthehighhealingrateofnifedipinemaybeattributednotonlytothereductionoftheanalcanal
pressurebutalsototheantiinflammatoryactionofnifedipineaswellasitsantioxidant,antiulcereffects.
c.Neurotoxins
Neurotoxinsaremetalloproteinasesthatenterperipheralnervesandinhibitreleaseofneurotransmitters,therebycausing
musclerelaxation.Botulinumtoxin(BT)isanexotoxinproducedbythebacteriumClostridiumbotulinum.Wheninjectedinto
skeletalmuscletotreathypertoniaorcosmeticdisorders,BTbindstothepresynapticnerveterminalattheneuromuscular
junctionpreventingreleaseofacetylcholineandresultingintemporaryparalysisoftheinjectedmuscle.Botulinumtoxinis
unlikelytobepreventingacetylcholinereleaseattheIASneuromuscularjunction,asacetylcholinecausesrelaxationinthis
tissue,andarise,notafallinanaltonewouldbeexpected.IntheIASitisbelievedthatbotulinumtoxinactsonthe
postganglionicsympatheticnervestoreducenoradrenalinerelease41therebyblockingsympatheticoutputandproducing
sphincterrelaxationthatoccursinafewhoursandlastsforapproximately23monthsallowingfissurehealing.Relapseisdue
toreinnervationwhichoccursthroughsproutingofnerveendings.
Reporteddataisdifficulttointerpretbecauseofvariedinjectiontechniqueswithdosesvaryingfrom10to100units,injection
siteslocatedatvariouslocationsaroundtheanalcanalineithertheEASortheIAS,varyingnumberofinjections,aswellas
varyingfollowupprotocols.Theoptimumdoseandmethodofinjectionhavenotbeendetermined,though2025unitsisusually
appliedoneithersideofthefissuredirectlyintotheinternalsphincter.Forpatientswithaposteriorfissure,injectionofBT
anteriorlyresultsinearlierhealingprobablyduetothescarofthefissurelimitingdiffusionofthetoxin48.Forthoseauthorswho
recommendinjectionofBTintotheEAS,themechanismofactionmustbediffusionofthetoxinintotheIAS,asthefundamental
pathogenesisinchronicanalfissureformationisanelevatedIASpressure.
BTtemporarilydecreasesmeananalcanalrestingpressures42,43for23months44,healing6080%offissuresatarate
higherthanplacebo45andlidocaine46.ThedoseofBTinjectedappearstobecriticaltosuccessfulhealingoffissures
44,47,48withhigherdosesproducingbetterhealingrateswithoutanincreaseinadverseeffects.Themostcommonsideeffect
istemporaryincontinencetoflatusinupto10%ofpatients44,45,48andtostoolinapproximately5%ofpatients52.Although
patientsreturntofullactivitysooner,BTremainsinferiortosurgeryincuringfissures49,50,withlongertimetohealing49and
recurrencesofhealedfissureexceeding4050%after1year50,51.However,failuresandrecurrencescanberetreatedwitha
reasonablerateofhealing48,52.StillapproximatelyonequarterofpatientsfailBTtherapyandgoontosurgery49.Incombined
analysesBTwasfoundtobenobetterorworsethantopicalnitrates20,butBTiseffectiveinhealing5070%ofpatientswith
fissuresresistanttotopicalnitrates53,29andmaybemoreeffectiveinrefractoryfissuresifcombinedwithtopicalnitrates54,55.
Gonyautoxin,aphycotoxinproducedbyshellfish,hasalsobeenusedinanalfissuremanagement.Inarecentreport56,23
patientswereinjectedwith100unitsintheIASevery4days.Totalremissionwasachievedinallpatientswithin714days.No
relapseswereobservedduringthe10monthfollowup.Nosideeffectswerenoted.Allpatientsshowedimmediatesphincter
relaxationdetectedbydigitalexamandconfirmedafter4minutesbymanometry,withimmediatepainrelief.However,a
randomizedcontrolledtrialhasyettobeconducted
d.OtherPharmacologicAgents

1.Larginine,aprecursorofNO,appearstopromotefissurehealingin60%ofpatientswhenappliedtopically57byreducing
analtone15.However,thiseffectappearstobeindependentofNO59,whichperhapsexplainstheabsenceofsignificant
headacheswithitsuse.Noeffectonrestinganalpressureswasobservedwithoralpreparations58.
2.Adrenergicantagonists,particularlyalpha1adrenoreceptorblockers,areeffectivesmoothmusclerelaxantsthathavebeen
showntoreducerestinganalpressuresinopossums60aswellasinpatientswithanalfissuresandhealthycontrols61.
Howeveralpha1adrenoreceptorsarecurrentlynotadvocatedinthetreatmentofanalfissuresduetothelackofefficacyshown
inaplacebocontrolledtrialwhereindoramin,analpha1adrenoreceptoradministeredorallysucceededinhealingonly1in23
patientsdespitea30%reductioninMARPafter6weeksoftreatment,withalargenumberofsideeffectsleading50%of
patientstowithdraw62.
3.Cholinergicagonists,suchasbethanechol,areinhibitorytotheIAScausingrelaxationoftheIAS.A24%reductionin
MARPhasbeendocumentedinhealthyvolunteersusing0.1%topicalbethanecol63.Asubsequentnonrandomizedstudy
reportedfissurehealingin60%ofpatientswithoutsideeffects,resultsequivalenttodiltiazem35.Howeverarandomized
controlledtrialandlongtermfollowuparelacking.
4.PhosphodiesteraseInhibitorsinhibitthebreakdownofintracellularcyclicguanylatemonophosphate(cGMP),thereby
producingsmoothmusclerelaxation.Topicalsildenafil(Viagra),aphosphodiesterase5inhibitor)usedinerectiledysfunction,
hasbeenreportedtoreduceanaltonebyanaverageof18%inlessthan3minutesinpatientswithchronicanalfissures64.
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Thesefindingshavebeenconfirmedininvitrostudies65,66.However,therearenopublishedstudiesonitseffectonfissure
healing.
5.Potassiumchannelopenersareknowntorelaxsmoothmuscleandhavebeenpostulatedtoreduceanaltone.Adouble
blindrandomizedtrialcomparedtheefficacyoftopicalminoxidil,apotassiumchannelopener,withtopicallidocaineanda
combinationofthetwo67.Therewasnosignificantdifferenceinhealingratesorpainreliefbetweenall3groupsat6weeks,
howeverpatientshealedfasterwiththecombinationoftreatmentscomparedtothesingletreatments.Comparativestudiesare
requiredandthesafetyofthesetopicalpotassiumchannelopenersmustbeconfirmedasanumberofcasestudiesreportanal
ulcersassociatedwiththeuseoftheoralpotassiumchannelopenernicorandilinanginapatients6870.
6.Angiotensinconvertingenzymeinhibitors(ACEI).Thereninangiotensinsystem(RAS)isfoundinvascularsmoothmuscle
andhasbeenshowntobepresentwithintheIAS71.ReninconvertsangiotensinogentoangiotensinI,whichisthenconverted
toangiotensinIIbyangiotensinconvertingenzyme(ACE)resultingincontractionofsmoothmusclecells.ACEIpreventthe
productionofangiotensinIIresultinginrelaxationofsmoothmuscle.Recently,0.28%topicalcaptopril,anACEI,wasshownto
reduceMARPin50%ofvolunteersbyupto44%at20minutes72,73.Furtherstudiesareneededtodemonstrateitsuseinthe
treatmentofanalfissures.
7.Hyperbaricoxygentherapyprovidesasignificantincreaseintissueoxygenationinhypoperfusedwounds,enhancing
fibroblastreplication,collagensynthesisandneovascularizationandtherebypromotingwoundhealing.Itwashypothesized
thatrecalcitrantchronicanalfissureswouldhealwithhyperbaricoxygentherapy.Inasmallnonrandomizedstudy74,5of8
patientswithfissuresrefractorytotopicalnitrateshealedwith15treatmentsofhyperbaricoxygengivenover3weeks.2patients
failedtohealandonerelapsedafter3months.Thistreatmentiscostlywithrespecttotimeandresources,butmaybeofbenefit
inrecalcitrantfissuresthatarenotamenabletoorhavefailedsurgery.

III.Surgicaltherapy

A.Lateralinternalsphincterotomy(LIS)
LISiscurrentlythesurgicaltreatmentofchoiceformanagementofanalfissuresrefractorytononsurgicaltherapyandmaybe
offeredwithoutatrialofpharmacologictreatmentafterfailureofconservativetherapy75.Theinitiallyadvocatedposterior
midlinesphincterotomythroughthefissurebed82oftenresultedinakeyholedeformitycomplicatedbyincontinencetogas
and/orstoolorfecalsoiling.LISissuperiortofissurectomyandposteriormidlinesphincterotomywithrespecttohealingrates,
painreliefandincontinence85,86.Theprocedureinvolvesdivisionoftheinternalanalsphincterlaterally76,81fromitsdistal
mostenduptothedentateline,orforadistanceequaltothatofthefissure77,anapproachthatcutslessmuscleinattemptto
diminishtheriskofimpairedcontinence.Thesphinctercanbedividedinanopen(througharadialorcircumferentialincision)
orclosed(throughastabwound)fashionwithsimilarresults78,79,80.Woundhealingistwiceasfastwithprimaryclosureof
thewoundascomparedwithhealingbysecondaryintention87.Thefissureitselfdoesnotrequiresurgicaltherapy(
fissurectomy),butverylargesentinelpilesorprolapsing,hypertrophiedanalpapillaemightberemovedforcosmeticor
cleansingpurposes84.Theproceduremaybedonewiththepatientunderlocal,regionalorgeneralanesthesia,andcanbe
combinedwithotheranorectalprocedures85suchashemorrhoidectomy.
LISisusuallysuccessfulwithoverallhealingratesof90100%88.Complicationssuchasecchymosisandhemorrhage,
perianalabcess,fistulainanoandprolapsedhemorrhoidsarerare.However,ratesofcontinenceimpairmentvarywidely
throughouttheliteraturerangingfrom0%to50%88,butincontinencesufficienttocauseanymeasurableimpairmentinquality
oflifeisuncommon,intherangeof3%89,90.Inaddition,arecentstudyreportedthatratesofincontinencefollowingLISare
similartothoseinpatientsundergoingtopicaltherapy91,althoughincontinenceaftertopicaltherapyisusuallytransient.
Recurrenceratesarelow(themajorityintherangeof13%88)andgenerallyattributedtoinadequatesphincterotomythat
canbeconfirmedbyendoanalultrasound92.Insuchcases,asecondlateralinternalsphincterotomycouldbeperformedon
theoppositeside5,83,butoutcomedataislimited.
Notallpatientswithfissureshavetheclassichypertonicinternalsphincter.Somepatientsarenormoorevenhypotonic93.
Therefore,carefulpatientselectionandabsenceofpreoperativecontinenceproblemsonhistoryarenecessarypriorto
performingsurgery.Cautionshouldbeexercisedbeforeperforminginternalsphincterotomyinpatientswithdiarrhea,irritable
bowelsyndrome,diabetes,andintheelderlyorpostpartumwomen,particularlyiftheyhaveundergoneanepisiotomyor
sufferedatearduringlabor,aswellaspatientswhohaveundergoneprevioussphinctersurgery83.Preoperativeanal
manometryandendoanalultrasoundshouldbeperformedinthosepatientsathighriskofprevioussphincterdamage,
particularlyinthosepatientswithrecurrentfissuresafterLISandinwomenwhohaveundergoneanepisiotomyorsuffereda
tearduringlabor94.

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B.Analadvancementflaps
EarlystudiescomparingadvancementflapstoLISshowedcomparablehealingrates95andwereespeciallysuccessfulinthose
patientswithoutsphincterhypertonia96.Howeverfurtherprospective,randomizedstudieswithlongtermfollowupareneeded.
Currentlyadvancementflapsarerecommendedforchronicanalfissuresinpatientswithnormalorhypotonicanalsphincters
suchasthosewhodevelopfissurespostpartumorhavehadprevioussphincterinjury97.
C.Analdilation
Analdilationforthetreatmentofanalfissureiscurrentlyobsolete.Analstretch(manualorpneumatic)carriesahigherriskof
fissurepersistenceorrecurrencethaninternalsphincterotomyandalsoasignificantlyhigherriskofimpairedcontinencethan
sphincterotomy98duetouncontrolledsphincterdisruption.Useofmedicaltherapyinconjunctionwithdilationdoesnotimprove
outcome.Inarecentsmallrandomizedtrial,hecombinationofcryothermaldilatorswithtopicalNTGprovedtobeeffective,safe
andwithstatisticallybetterratesofhealing,recurrence,andreductioninanaltonethandilationorNTGalone,withoutimpaired
continence101.Confirmationoftheseresultsinlargerrandomizedtrialsarenecessary.
IV.Specialsituations

A.CrohnsdiseaseCrohnsfissuresarefrequentlymultipleandoffthemidline,andaresometimesasymptomatic.
Traditionally,anorectalsurgeryhasbeenavoidedinpatientswithCrohnsdiseasebecauseoffearsregardingpostoperative
incontinence,exacerbatedbypreexistingdiarrheathatmayresultinproctectomy.Forthisreason,treatmentshouldbefocused
oncontrollingthediarrhea.TherearenodatatosupporttheuseoftopicalsphincterrelaxantsorBTinthetreatmentoffissures
inCrohnsdisease.Ifthefissurepersistsdespiteconservativemeasures,examinationunderanesthesiaandlimited
sphincterotomyshouldbeperformed.In2smallretrospectivereviews,surgeryhasbeenreportedtoresultinuncomplicated
woundhealingin>80%ofcases99,100.
B.HIV/AIDSItisessentialtodifferentiatebetweentypicalfissuresinHIVpositivepatientswhichmaybetreatedasusualand
HIVassociatedanalulcerswhicharebroadbasedanddeep,occuranywherewithintheanalcanalandareassociatedwitha
lowratherthanhighsphinctertone.STDsmustbeexcludedandtreatedifpresent.Typicallyantiretroviraltreatmentcombined
withconservativemeasuresiseffective.Thereisnodataavailableabouttheriskofpostoperativeincontinenceortheuseof
topicalsphincterrelaxantsorBTastreatmentoptions.

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