Treatment Algorithm for Chronic Anal Fissure – A Review of Literature and it’s Apply in University Clinical Center Mother Teresa – Skopje

Abstract

Chronic anal fissure is one of the most frequent anorectal disorders. Symptoms vary but typically include bright red rectal bleeding, itching and discomfort or pain during and after defecation. Treatment has undergone a transformation in recent years from surgical to medical, all approaches sharing the goal of reducing the spasm.

According to the researched treatment guidelines and the experience at the “University Clinical Center Mother Teresa†(Clinic of Gastroenterohepatology and Clinic of Abdominal Surgery) in Skopje, Macedonia, we propose the following algorithm for treatment of chronic anal fissure in three steps: from topical  nifedipine + lidocaine cream (first-line) to second course of nifedipine + lidocaine cream or digital anal dilatation or botulinum toxin type A injection (second-line) to lateral internal sphincterotomy (third-line).

The proposed treatment algorithm allows patients to start with the least invasive treatment. There is no doubt that patients are willing to try less invasive modalities with the hope of avoiding surgery, with its risk of permanent disability. It should be up to the patients to decide which treatment they prefer. Although chemical sphincterotomy is less successful from lateral internal sphincterotomy, the algorithm allows feasibility, efficacy and cost-effectiveness, as well as risk reduction for surgical morbidity.