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Water stream in a bidet-toilet as a cause of anterior fissure-in-ano: a preliminary report
Abstract
A bidet-toilet is an integration of a toilet and a bidet, whereby a nozzle is attached to an existing toilet for cleaning the anus and perianal region. This is commonly used in Asian countries. Water stream of the bidet-toilet causing fissure-in-ano has not been reported in literature. We report a series of 10 patients having anterior fissure-in-ano, perhaps caused by water stream of the bidet-toilet.
... e cross-sectional survey by Tsunado et al. correlated bidet use with the odds of experiencing symptoms of hemorrhoids [16]. e case series by Garg described the development of anterior anal fissures in 10 patients after bidet use, reporting the resolution of symptoms with discontinuation of bidet use [17]. Shulman et al. described a case report on the development of a third-degree perianal burn with bidet use [18]. ...
... e case series by Garg ( Figure 4) scored well in reporting the demographics of patients, disease Evidence-Based Complementary and Alternative Medicine Figure 2: Cohort study quality assessment [12]. Evidence-Based Complementary and Alternative Medicine development, and treatment provided [17]. However, a detailed description of the exposure to the bidet and possible confounding factors were not reported. ...
... Garg reported a case series on 1 female and 9 male patients who presented with an anterior fissure and a history of bidet use [17]. Two out of ten patients had acute fissures while 8/10 had chronic fissures. ...
Background:
Benign perianal disease carries significant morbidity and financial burden on the healthcare system. Given that sitz baths are recommended as a treatment modality, we considered whether using a continuous stream of water, in the form of a bidet, offers a convenient and effective alternative. Bidet use is the predominant form of perianal hygiene in Asia, but its role in perianal disease is unknown.
Purpose:
To critically analyze and systematically review the current evidence regarding the effect of habitual bidet use on symptoms of benign perianal disease. Data Sources. A database search was conducted on MEDLINE and Epub Ahead of Print, Embase, ClinicalTrials.gov, the Cochrane Library, and ProQuest Dissertations. All studies on bidet use in pruritus ani, hemorrhoids, or anal fissures were included. Data Extraction. The studies were screened and critically analyzed by two independent reviewers in line with PRISMA guidelines.
Results:
Two prospective trials and 1 cross-sectional study found that habitual use of bidets had no impact on the odds of developing hemorrhoids or hemorrhoidal symptoms. One RCT concluded that using bidets was non-inferior to sitz bath for post-hemorrhoidectomy pain. Two prospective trials and 1 cross-sectional study determined that habitual bidet use may increase the odds of developing pruritus ani. Two case series found that habitual bidet use may cause perianal burns or anterior anal fissures. A meta-analysis was not performed because only a limited number of studies were available, and they were of variable quality.
Conclusion:
The current evidence does not identify using bidets as a treatment modality for perianal disease, and further research is warranted to study this increasingly utilized technology.
... Richter et al. [29] observed a sphincteric disfunction after vaginal delivery in the 35% of cases. Another risk factor recently took into account for the occurrence of CAF of the anterior commissure is the usage of water-jet stream in a bidet-toilet, which according to Garg [30] strongly increase the incidence of this condition. Moreover, we conducted a review of the literature showing an incidence of CAF of the anterior commissure as high as 35.4% [31], this data owes its justification to the high number of multiparous women who gave birth by vaginal delivery along with the routine habit of using water-jet stream in a bidet toilet [30]. ...
... Another risk factor recently took into account for the occurrence of CAF of the anterior commissure is the usage of water-jet stream in a bidet-toilet, which according to Garg [30] strongly increase the incidence of this condition. Moreover, we conducted a review of the literature showing an incidence of CAF of the anterior commissure as high as 35.4% [31], this data owes its justification to the high number of multiparous women who gave birth by vaginal delivery along with the routine habit of using water-jet stream in a bidet toilet [30]. ...
Introduction
Lateral internal sphincterotomy (LIS) is still the approach of choice for the treatment of chronic anal fissure (CAF) regardless to the internal anal sphincter tone but it is burdened by high risk post-operative faecal incontinence (FI). In female patient there are some anatomical and functional differences of the sphinteric system which make them more at risk of FI and vaginal birth could cause sphinteric lesions affecting the anal continence function. The aim of our study is to evaluate the results of saving sphincter procedure as treatment for female patients affected by CAF.
Methods
We studied 110 female patients affected by CAF undergone fissurectomy and anoplasty with V–Y cutaneous flap advancement associating pharmacological sphincterotomy in patients with hypertonic IAS. The follow up was at least for 2 years. The goals were patient’s complete healing, the evaluation of FI, recurrence rate and manometry parameters.
Results
All wounds healed within 40 days after surgery. We recorded 8 cases of recurrences 6 healed with medical therapy and 2 with dilatation. We recorded 2 “de novo” temporary and low grade post-operative cases of FI. Post-operative value of MRP were unmodified in patient with normotonic IAS but significantly lower at 12 months follow up as compared with the pre-operative ones in patients with hypertonic IAS; after 24 months from surgery MRP values were within the normal range.
Conclusion
The fissurectomy and anoplasty with V–Y cutaneous flap alone or in association with a pharmacological sphincterotomy in patients with hypertonic IAS may represent an effective approach for the treatment of CAF in female patients.
... According to several studies, patients with fissures had higher internal anal sphincter resting pressure than healthy controls. 3,4,5,6,7,8,9 . Some of the discomfort and spasm associated with feaces are caused by this hypertonicity of the anal sphincter, which also impairs wound healing by decreasing blood flow to the injured anoderm. ...
PRP or autologous platelet-rich plasma, has been hailed as a successful
method of treating wounds. There is, however, still a shortage of data to back
up its application in patients with both acute and chronic wounds. This study
set out to thoroughly investigate the efficacy, synergy, and potential
mechanism of PRP-mediated treatment for acute fissure-in-ano. Acute fissure
with indications of pain, bleeding, and elevated sphincter tone was identified
at six o'clock. As a control, PRP was applied to the area of the fissure. The
pace of fissure healing, as well as the reduction in discomfort, bleeding, and
sphincter tone, were evaluated on the third and tenth days. PRP significantly
enhanced fissure healing, which was connected to wound healing control,
angiogenesis augmentation, re-epithelialization, and collagen deposition. As
PRP raises local vascular intensity, enhances re-epithelialization, and is
linked to increased growth factor production, it dramatically improves the
healing process of fissures while also reducing discomfort, bleeding, and
worsened sphincter tone.
... A previous study reported 10 cases of anterior fissures due to bidet toilet use for 1-5 min [16]. The author speculated that the stronger water pressure of the bidet use with a longer duration may be the causative factor of the anterior fissure. ...
Electric bidet toilets are widely used in Japan and are sanitary devices, that are integral to daily life. Approximately, half of the population washed the anus before or after defecation. Cleaning the anus after defecation using the bidets contributes to hand hygiene and local comfort, and it may be effective against constipation. However, excessive bidet use potentially causes anal pruritus and anal incontinence (AI). Physicians are advised to instruct patients with anal pruritus to avoid excessive cleaning of the anus and those with AI to discontinue bidet use. For the estimation of the inherent severity of AI, physicians should instruct a bidet user with AI to discontinue bidet use and assess the severity of AI later. Additionally, the nozzle surface and splay water of bidet toilets may be contaminated with fecal indicator bacteria, such as Escherichia coli and Pseudomonas aeruginosa, as well as antimicrobial-resistant bacteria, rendering them a potential vehicle for cross-infection. In the hospital setting, compromised patients must be cautious regarding the shared use of bidet toilets to prevent infection by antimicrobial-resistant bacteria. Specifically, they should be provided with bidet toilets exclusive for them or may need to be instructed to not use a bidet.
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... There are other novel reasons published in the literature for a specific set of cases. Garg [10] linked bidet-toilet to anal fissure. Bidettoilet is an integration of a toilet and a bidet, whereby a nozzle is attached to the backside of an existing toilet for cleaning the anus and perianal region. ...
Anal fissure is one of the most common anorectal diseases resulting from a longitudinal tear in anoderm under the dentate
line. It causes painful defecation and bleeding per anum. Most of the fissures heal by conservative means but a significant
proportion turns chronic, leading to a negative impact upon the overall quality of life of a patient. The treatment options for
chronic fissures are generally based on reducing the anal pressures and include non-surgical and surgical modalities. Lateral
internal sphincterotomy still remains the gold standard for definitive management of anal fissure though anal incontinence
is a serious complication of the procedure. In recent years, various modifications have evolved to minimize chances of
incontinence besides the evolution of a wide range of non-surgical options of management. This review outlines the key
points in the clinical presentation, etiopathogenesis, impact on the quality of life and management of anal fissure in the light
of the recent updates in literature
... this single water stream coming from behind hits the anterior anal canal and has been found to cause anterior fissure-in-ano in these populations. 9 the same has been reported regarding commercially available electronic water bidets that have a high force of water stream. 10 scald burns have also been reported, especially in the elderly, when hot water has been used for perianal washing in the bidet. ...
... Several studies have shown that the resting pressure of the internal anal sphincter is higher in patients with fissures compared with normal controls. [3][4][5][6][7][8][9] This hypertonicity of the anal sphincter is responsible for some of the pain and spasm experienced with defecation, and it also has a deleterious effect on wound healing by reducing blood flow to the traumatized anoderm. ...
Anal fissure (fissure-in-ano) is a very common anorectal condition. The exact etiology of this condition is debated; however, there is a clear association with elevated internal anal sphincter pressures. Though hard bowel movements are implicated in fissure etiology, they are not universally present in patients with anal fissures. Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents. When nonoperative management fails, surgical treatment with lateral internal sphincterotomy has a high success rate. In this chapter, we will review the symptoms, pathophysiology, and management of anal fissures.
... Perianal burn was caused by hot water from a bidet [22], and rectal mucosal prolapse developed from bidet overuse [23]. Anterior fissure-in-ano was also reported as a result of the water stream of a bidet-toilet [24]. ...
A bidet has been proposed as a replacement for the sitz bath. Like a sitz bath, it brings water into contact with the perineum. However, the high force of water from commercially used electronic bidets may harm the anus. We developed a new electronic bidet and evaluated its effects on anal resting pressure compared with a warm sitz bath.
Forty volunteers used the electronic bidet and sitz bath on separate days. The electronic bidet was newly designed with warm (38 °C) water and very low force (10 mN) with a fountain type of flow. Anal resting pressure at the high-pressure zone was measured before (control) and after the electronic bidet and sitz bath. Pressure changes after bidet or sitz bath were expressed as percentages compared with control. Water temperatures and rectal temperatures were also recorded.
The anal resting pressures before the electronic bidet and sitz bath were 90.2 ± 24.6 and 88.1 ± 16.8 mmHg, respectively. At 3 min after the electronic bidet and sitz bath, the anal resting pressures were 71.3 ± 23.4 and 69.6 ± 19.8 mmHg, respectively. The pressure changes compared with the control were 78.2 ± 12.9 and 78.1 ± 12.5 %, respectively, which were not significantly different. The maximal increase and minimal decrease were not significantly different. The rectal temperature was not elevated, and the water temperature decreased significantly with the sitz bath (p < 0.001).
Our new electronic bidet may reduce the anal resting pressure much like a warm sitz bath does.
... There is also a suspicion that the water stream from bidet-toilets may be a cause of anterior fissure-in-ano [18] . 3%-11% of anal fissures are associated with childbirth and typically this type of etiology predisposes to fissure localization in the anterior anal commissure [19] . Links between sexual abuse and AF have been considered [20] . ...
Chronic anal fissure (CAF) is a painful tear or crack which occurs in the anoderm. The optimal algorithm of therapy for CAF is still debated. Lateral internal sphincterotomy (LIS) is a surgical treatment, considered as the 'gold standard' therapy for CAF. It relieves CAF symptoms with a high rate of healing. Chemical sphincterotomy (CS) with nitrates, calcium blockers or botulinum toxin (BTX) is safe, with the rapid relief of pain, mild side-effects and no risk of surgery or anesthesia, but is a statistically less effective therapy for CAF than LIS. This article considers if aggressive treatment should only be offered to patients who fail pharmacological sphincterotomy. Aspects of anal fissure etiology, epidemiology and pathophysiology are considered with their meaning for further management of CAF. A molecular model of chemical interdependence significant for the chemistry of CAF healing is examined. Its application may influence the development of optimal therapy for CAF. BTX is currently considered the most effective type of CS and discussion in this article scrutinizes this method specifically. Although the effectiveness of BTX vs. LIS has been discussed, the essential focus of the article concerns identifying the best therapy application for anal fissure. Elements are presented which may help us to predict CAF healing. They provide rationale for the expansion of the CAF therapy algorithm. Ethical and economic factors are also considered in brief. As long as the patient is willing to accept the potential risk of fecal incontinence, we have grounds for the 'gold standard' (LIS) as the first-line treatment for CAF. The author concludes that, when the diagnosis of the anal fissure is established, CS should be considered for both ethical and economic reasons. He is convinced that a greater understanding and recognition of benign anal disorders by the GP and a proactive involvement at the point of initial diagnosis would facilitate the consideration of CS at an earlier, more practical stage with improved outcomes for the patient.
... Furthermore, the increase in anal sphincter pressure required to prevent water ingress might injure the mucosa and sphincter in the long term. In fact, a case of rectal mucosal prolapse syndrome associated with overuse of bidet has been reported (17), and another study concluded that anal fissure might be caused by bidets operated at high water pressures (18). During the present study, which was conducted using normal healthy volunteers without any history or presence of anal disease, a number complained of an unpleasant, sometimes painful sensation at the high-pressure setting. ...
Although bidets are widely used in Korea, its effects on anorectal pressures have not been studied in detail in terms of the water settings used. Twenty healthy volunteers were placed on a toilet equipped with a bidet, and anorectal pressures were measured with a manometry catheter inserted into the rectum and anal canal before and after using the bidet at different water forces (40, 80, 160, 200 mN), temperatures (24°C vs 38°C), and water jet widths (narrow vs wide). The pressure at anal high pressure zone decreased from 96.1 ± 22.5 to 81.9 ± 23.3 mmHg at water jet pressure of 40 mN and 38°C wide water jet (P < 0.001), from 94.3 ± 22.4 to 80.0 ± 24.1 mmHg at water jet pressure of 80 mN and 38°C narrow water jet (P < 0.001), and from 92.3 ± 22.4 to 79.6 ± 24.7 mmHg at a water jet pressure of 80 mN and 38°C wide water jet (P < 0.001). At other settings, no significant changes were observed. Our results indicate that, in addition to cleansing effect, bidet could be used to reduce anal resting pressure in the same manner as the traditional warm sitz bath under the conditions of low or medium water jet pressure, a warm water temperature, and a wide type water jet.
As we know that fissure in ano is very pain full anorectal disorders, which is mainly caused by constipation. In today life, constipation is a big problem which is mainly created by faulty diet and life style. If we see in ancient era there was no any disease as like fissure in ano. Although Parikartika is defined in our text which can take same as fissue in ano. Many Ayurvedic Sages defined the Parikartikaas a complication of Panchkarma Therapy (Basti therapy or virechan therapy). But now a days Fissure in ano is described as separate disease. If our younger generation is taking interest as such in flawed Diet (fast food, junk food, spicy food, artificial drinks etc.) and Life style (not performing exercise or Yoga, late night sleep, late morning awake, excess use of smartphone for entertainment, not follow the seasonal regimen, spend more time in toilet and stain during toilet etc.) than there is no such time away when constipation will be count as a separate disease in separate chapter rather than symptoms of anorectal disorders. Constipation is also affected the social and mental status of the person. Ayurveda mainly emphasize on Aahar (Diet) and Vihar (Life style) in each and every disease, which is altered in modern scenario and produces so many anorectal disorders, not only the Anorectal disorders, produces systemic disorders also. So, we can cure the Fissure in Ano (mainly caused by primary cause like constipation) by modification in Diet and life style and also improve the quality of life of patients.
A prospective study of 60 patients with anal fissures that aims to compare between two different types oftreatment ( Botulinum toxin A injection BTA and lateral internal sphincterotomy LIS ) regarding pain-relief,healing rates and side effects and to establish a systematic method to be followed in the treatment.
The best nonoperative or operative anal fissure (AF) treatment is not yet established, and several options have been proposed. Aim is to report the surgeons’ practice for the AF treatment. Thirty-four multiple-choice questions were developed. Seven questions were about to participants’ demographics and, 27 questions about their clinical practice. Based on the specialty (general surgeon and colorectal surgeon), obtained data were divided and compared between two groups. Five-hundred surgeons were included (321 general and 179 colorectal surgeons). For both groups, duration of symptoms for at least 6 weeks is the most important factor for AF diagnosis (30.6%). Type of AF (acute vs chronic) is the most important factor which guide the therapeutic plan (44.4%). The first treatment of choice for acute AF is ointment application for both groups (59.6%). For the treatment of chronic AF, this data is confirmed by colorectal surgeons (57%), but not by the general surgeons who prefer the lateral internal sphincterotomy (LIS) (31.8%) (p = 0.0001). Botulin toxin injection is most performed by colorectal surgeons (58.7%) in comparison to general surgeons (20.9%) (p = 0.0001). Anal flap is mostly performed by colorectal surgeons (37.4%) in comparison to general surgeons (28.3%) (p = 0.0001). Fissurectomy alone is statistically significantly most performed by general surgeons in comparison to colorectal surgeons (57.9% and 43.6%, respectively) (p = 0.0020). This analysis provides useful information about the clinical practice for the management of a debated topic such as AF treatment. Shared guidelines and consensus especially focused on operative management are required to standardize the treatment and to improve postoperative results.
Pankaj Garg’s story is an interesting one and is a source of inspiration for all physicians and budding innovators. He started his career as a community doctor about two decades back in the year 2001, then changed gears in between to become an avid researcher and innovator. He progressed to become a leading international figure in his field. Garg has exemplified three important points. First, with proper temperament, it is possible to achieve academic excellence and conduct research even in a primary care setting. Second, every specialist should fulfill the role of a family physician as well. While pursuing any specialty, the role of a “general physician” should never be ignored. Third, innovation is a state of mind, and big institutions and well-equipped laboratories with costly gadgets are not a prerequisite to it. This is clearly exemplified by Pankaj Garg’s story that it is possible to excel in research, academics, and clinical work at the global level without any research budget, big institute tag, or the help of government or non-government organizations. Garg has more than 175 publications in high-impact journals. He has 30 innovations to his name, in and outside his field of expertise, all of which have been published in international journals. The innovations include new operative procedures, successful non-operative management, the discovery of new anatomical spaces, new concepts in disease understanding and management, and finding non-operative treatment for diseases for which surgery is routinely performed. It is impressive that seven of his innovations are popularly known by his name - Garg classification, Garg space, Garg protocol, Garg cardinal principles, Garg scoring system, Garg phenomenon, and Garg incontinence scores. Due to 30 innovations done single-handedly, Garg has been certified as a “doctor with maximum innovations” by several record books. Due to his ability to think “out-of-the-box” and his immense contribution to advancements in the field of proctology, he is recognized as a global icon in his field. Garg is a master teacher. He has taught surgical skills and the art of scientific paper writing to hundreds of surgeons and doctors. In spite of limited resources at his disposal, Garg goes out of his way to help poor people. He performs about 30–40% of operations free of cost. He has successfully treated patients from 41 countries and several patients from royal families of the Gulf who offered him lucrative money to move to the Middle East. However, Garg flatly refused all offers because his priority was to serve his country and countrymen first. Hence, a simple doctor working in a small city was never discouraged by the lack of resources, and the fear of working alone in a small set-up and without any help from the government has carved out a tale that can motivate professionals in any corner of the world. Dr. Garg’s story provides immense inspiration to every practicing physician in the country to innovate whether he/she is practicing in a primary healthcare center or a rural area.
Electric bidet toilets are automatic devices that deliver water jets to clean the anus. Although the use of bidets to clean the anus after defecation contributes to hand hygiene and local comfort, excessive use may cause anal pruritus and incontinence. However, no cases of anorectal aphtoid ulcers caused by bidet use have yet been reported in literature. A 61-year-old woman presented to our hospital with anal bleeding and pain. Anoscopy revealed an aphtoid ulcer in the anterior midline anorectum. She reported using a bidet toilet and washing her anus before and after defecation for one year. The frequency of washing was five times or more per day, the force of the water jet was strong, the thickness of the water was thin, and the duration of washing per use was 1 min or more. She responded well to the advice of stopping bidet use. At the follow-up, 5 weeks after discontinuing bidet use, she became asymptomatic, and the anoscope showed that the aphtoid ulcer had completely healed. The water jet of the bidet toilet seemed to be the causative factor for the anterior aphtoid ulcer in the anorectum.
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ANAL ÇAT ƏLİYEV E.A., SADIQZADƏ T.B., AYDINOVA P.R., ŞİRİNOVA X.N. Azərbaycan Tibb Universitetinin I-cərrahi xəstəliklər kafedrası, Bakı, Azərbaycan Anal Fissure Aliev E.A., Sadıkzade T.B., Aydınova P.R., Shirinova Kh.N. Summary: Anal fissure (fissure-in-ano) is a very common anorectal condition. The exact etiology of this condition is debated; however, there is a clear association with elevated internal anal sphincter pressures. Though hard bowel movements are implicated in fissure etiology, they are not universally present in patients with anal fissures. Half of all patients with fissures heal with nonoperative management such as high fiber diet, sitz baths, and pharmacological agents. When nonoperative management fails, surgical treatment with lateral internal sphincterotomy has a high success rate. In this chapter, we will review the symptoms, pathophysiology, and management of anal fissures. Keywords: anal fissure, sphincterotomy Анальная трещина Алиев Э.А., Садыкзаде Т.Б., Айдынова П.Р., Ширинова Х.Н. Резюме: Анальная трещина является очень распространенным аноректальным состоянием. Обсуждается точная этиология этого состояния. Однако существует четкая связь с повышенным внутренним давлением анального сфинктера. Хотя жесткие испражнения участвуют в этиологии фиссуры, они не всегда присутствуют у пациентов с анальными трещинами. Половина всех пациентов с трещинами заживают при неоперативном лечении, таком как рацион с высоким содержанием клетчатки, ванны с сидящие ванна и фармакологические средства. Когда неоперативное лечение недает еффекта, применяетса хирургическое вмещательства. Лечение с боковой внутренней сфинктеротомии имеет высокий показатель успеха. В этой главе мы рассмотрим симптомы, патофизиологию и лечение анальных трещин. Ключевые слова: анальная трещина, сфинктеротомия.
A linear tear in the anal canal that may stretch from the mucocutaneous junction to the dentate line is known as an anal fissure [1]. It is a painful anorectal condition predisposed to nonhealing and persistence [2]. Anal fissures are usually the result of constipation and diarrhea. Despite being a painful condition, its etiopathogenesis remains obscure [3].
Anal fistula is an abnormal communication between the anorectum and the skin or a blind tract originating from the anorectum and causing recurrent sepsis [1].
Background
Water used as a single sharp stream in toilet commode for post defecation cleansing is a common practice in several countries across the globe including India. Repeated hitting of the anus by water stream could potentially cause injury to the anal canal epithelium and lead to development of fissure-in-ano. As the water stream is emanating from the backside of the toilet commode, the possible injury, if any, would be on the anterior anal canal.
Objectives
The present study aimed at determining whether water stream usage in toilet commodes increased the incidence of anterior fissure-in-ano; this was determined by the incidence of anterior fissure-in-ano the study and control groups.
Methods
All consecutive fissure-in-ano patients referring to a colorectal clinic from February 2012 to 2015 were included in the study. The patients were classified as a study group (who were using water stream for cleansing purposes in toilet commodes) and a control group (patients who were not using water stream). The characteristics and location (position) of the fissure-in-ano was noted.
Results
In this study, 165 patients were prospectively enrolled. Male/female ratio was 96/69, and the mean age was 36.3 ± 11.2 years. The anterior fissure-in-ano in the study group was 55.9% (47/84), while it was 17.3 % (14/81) in the control group (P < 0.0001, odds ratio: 6.08, 95% CI: 2.96 - 12.47].
Conclusions
Water used as a single sharp stream to cleanse after defecation in toilet commodes is hazardous and should be avoided.
Up to 40% patients with chronic fissure-in-ano require operative intervention. As of today, antibiotics, local or oral, have no role in the treatment of chronic fissure-in-ano. In a prospective study, fissure-in-ano was classified as follows: acute <6-week duration, chronic >6-week duration with normal/low anal tone, and acute-on-chronic >6-week duration with high anal tone. The resting anal tone was assessed clinically on an objective scale—DRESS score—the digital rectal examination scoring system. Local and oral antibiotics with avoidance of constipation (LOABAC) treatment was advocated for 6 months. For refractory cases, liquid paraffin and, for high anal tone, diltiazem cream along with sitz bath were prescribed. Non-responders underwent a MRI to look for fissure deepening (presence of sinus/fistula). Healing of fissure-in-ano was assessed by absence of pain, burning, itching, or spasm after defecation and absence of tenderness on per-rectal examination. Out of 109 fissure-in-ano patients recruited over 20 months, 90 (M/F—50/40) were finally included. Mean age was 37.6 ± 12.3 years. Conservatively managed, 86.7% (78/90) patients had significant relief and were cured without requiring any further intervention. Twelve out of ninety (13.3%) patients had no/minimal relief and underwent a MRI which revealed a fissure-sinus/tract in 10/90 (11.1%). MRI was normal in 2/90 (2%). Five out of ten patients with sinus underwent surgery (laying open of the sinus) and became alright subsequently. The rest of the five patients were lost to follow-up. In chronic fissure-in-ano, the regimen of local and oral antibiotics with avoidance of constipation significantly decreases the need for operative intervention.
Es motivo de satisfacción que Cirugía Andaluza dedique esta edición, de carácter monográfico, a la patología colorrectal, destacando de esta forma la selecta actividad de los profesionales de nuestro entorno. En este contexto, la actividad perseverante del Grupo Andaluz de Coloproctología merece ser subrayada, asimismo que compañeros que en ella se agrupan, desempeñen labores activas en los comités científicos y directivos de la Asociación Andaluza de Cirujanos (ASAC), la Asociación Española de Coloproctología (AECP) y en la sección
específica de la Asociación Española de Cirujanos (AEC). En el momento actual todos los hospitales de referencia en Andalucía disponen de secciones y unidades específicas para el diagnóstico y tratamiento de las enfermedades colorrectales, siendo notables las acreditaciones del Consejo Europeo (European Board of Coloproctology) entre nosotros. Aprovechando esta especialización se ha intentando elegir a los distintos
responsables, priorizando a los andaluces, para redactar los diversos capítulos de este monográfico y retendiendo no solo que los temas sean defendidos por especialistas colorrectales sino también por expertos en los temas elegidos, sin que esto suponga la más mínima sospecha de pretender ignorar a otros colegas y centros pioneros en esta especialidad, pero incluir a todos hubiera sido labor imposible.
Con estas premisas, el grueso de la monografía se ha centrado en aspectos oncológicos, donde el cirujano colorrectal debe seguir liderando el tratamiento de los equipos multidisciplinares.
Hemos creído atractivo combinar asuntos puramente técnicos con aspectos que requieren amplio conocimiento fisiopatológico sin olvidarnos de las pruebas de imagen. Añadir nuestra satisfacción al incluir una contribución de fuera de nuestras fronteras, firmada por el único centro de excelencia
para cirugía colorrectal de toda Alemania, lo cual contribuirá a la calidad de este monográfico.
Debo, finalmente, como director invitado, testimoniar mi gratitud a nuestra revista y a los profesionales que la dirigen por la oportunidad brindada. A los distintos autores nuestro reconocimiento por la energía y disponibilidad demostrada.
A female in her 80s was referred to our hospital due to sudden abdominal pain and small bowel escape from the peritoneum when going to the toilet. A year earlier, she had undergone laparoscopic rectopexy for rectal prolapse, but it recurred in the early postoperative period. On admission, the small bowel escape from the peritoneum was continuing, and we found by rectal examination that it originated from the prolapsed rectum. It was difficult to reposition the small bowel because her abdominal and rectal pain was severe. We performed single-port laparoscopic Mile's surgery and sigmoid colostomy. She recovered well, and was discharged from our hospital on the 26th postoperative day.Reports of an escaped small bowel from the peritoneum reveal that half of such cases had a history of rectal or uterine relapse. The current patient had also experienced chronic rectal prolapse. In view of the broken nozzle of a bidet located on the toilet bowel, the cause of the small bowel escape was thought to be due to the nozzle of the bidet striking the thinned rectum. There have been no previous reports of such a case, so this is thought to be a very rare case.
Lateral internal sphincterotomy is an effective treatment for fissure in ano but carries a definite risk of incontinence. In trial to avoid this complication, segmental lateral internal sphincterotomy was used to treat chronic anal fissures.
The lateral internal sphincterotomy was done in two parts and at different planes.
This study was conducted in the General Surgery Department, Zagazig University Hospital, Egypt.
This study was undertaken on 50 patients (43 men and seven women, with mean age of 37.3 years) with chronic fissure in ano from January 2009 to December 2010.
Under general or local anesthesia, lateral internal sphincterotomy was done in two segments under direct vision. Preoperative and postoperative anal manometry study was recorded.
Postoperative course with early and long-term results were recorded. Mean follow-up was 18.5 months (ranging from 6 to 24 months).
In 31 patients, the technique was done under general anesthesia and the remainder under local anesthesia. The fissures and anal wounds were healed within 4 weeks. Pain was significantly reduced in all patients at day 1 postoperative. Early complications included mild hematoma and urine retention in one male patient (2%). No transient or any persistent degree of incontinence occurred in these patients group.
Segmental lateral internal sphincterotomy is a safe, easy, and effective procedure and not associated with risk of incontinence for the treatment of chronic anal fissure.
Microvascular perfusion of the anoderm was assessed by laser Doppler flowmetry in 27 patients with anal fissure. Anal pressure was recorded simultaneously. Both measurements were repeated 6 weeks after lateral internal sphincterotomy and compared with those obtained from 27 controls. Means(s.d.) maximum anal resting pressure was significantly higher in those with a fissure than in controls (121.07(24.48) versus 68.78(16.97) mmHg, P < 0.001). Anodermal blood flow at the fissure site was significantly lower than at the posterior commissure of the controls (0.46(0.20) versus 0.76(0.28) V, P < 0.001). The fissure healed in 24 patients within 6 weeks of sphincterotomy. In these patients a significant pressure decrease was noted (35 per cent) which was accompanied by a consistent rise in blood flow (65 per cent) at the original fissure site. The increased internal sphincter tone in patients with a fissure reduces anodermal blood flow at the posterior midline. Reduction of anal pressure by sphincterotomy improves anodermal blood flow at the posterior midline, resulting in fissure healing. These findings provide evidence for the ischaemic nature of anal fissure.
One hundred patients with various anorectal disorders but intact anal sphincters were evaluated prospectively by three independent observers to determine the specificity, sensibility and accuracy of digital exploration and anal ultrasound compared to anal manometry, in assessing internal and sphincter hypertonicity (IH) and the relaxation of sphincters on straining (SR). Accuracy of the digital examination in evaluating IH was 80 vs 74%, while the SR was detected by the three observers in 82, 71 and 65% of cases. The thickness of internal sphincter increased with age (r = 0.37, P = 0.01), whereas the resting tone decreased with age (r = 0.27, P = 0.06). There was an inverse correlation between the sonographic thickness of the internal sphincter and the manometric resting tone (r = 0.29, P = 0.004). The internal sphincter thickness was 1.97 +/- 0.41 mm in constipated patients, 2.06 +/- 0.39 in the others (P = 0.03). In conclusion, IH and SR may be assessed by digital exploration with a good accuracy and the thickness of internal sphincter at ultrasound may change according to its functional state.
Anal fissure is a common problem that causes significant morbidity in a young and otherwise healthy population. Treatment has remained largely unchanged for over 150 years and the pathogenesis of this condition is not yet fully explained. Acute fissure should be treated conservatively with dietary modification. Chronic fissures do not respond to conservative treatment. The current recommended surgical treatment for chronic fissure is lateral internal sphincterotomy. However, there is a disturbance of continence in a sizeable proportion of those undergoing this procedure. As yet there is no proven non-surgical treatment for chronic fissure. Although local injection of botulinum toxin and the topical application of nitrates show early promise, further controlled trials are needed.
Anal sphincter hypertenia is commonly thought to underlie development of anal fissure, yet anal fissure is particularly common after childbirth, a time when anal canal pressure may be reduced. This paradox was investigated by a prospective study of the effect of parturition on the pelvic floor.
Anal manometry was performed 6 weeks before and after delivery in 209 primigravid women with no pre-existing history of anorectal disease. Postpartum studies only were performed on a further 104 primiparae. Anal fissure was diagnosed by history and direct examination.
Some 29 women (9 per cent) developed postpartum anal fissure. Antepartum anal canal resting and squeeze pressures were similar in women who did and those who did not develop fissure. Resting and squeeze anal canal pressures decreased post partum in both groups. Postpartum constipation was more common in those with fissure (62 per cent) than in those without (29 per cent) (chi 2 = 10.6, 1 d.f., P < 0.01). The mode of delivery or use of epidural analgesia did not affect the incidence of fissure.
Postpartum anal fissure is associated with reduced anal canal pressures, and surgical interference with the anal sphincter mechanism should be avoided.
This study was designed to reassess clinical manifestations of fissure-in-ano, in particular, the frequency of constipation and rate of response to medical management.
Records of 876 patients with fissure-in-ano seen between February 1975 and December 1993 were reviewed. Information gathered included age, gender, site, symptoms, bowel habits, associated anorectal problems, response, failure, and recurrence rates.
There were 439 women (51.1 percent) and 437 men (49.9 percent); mean age was 39.9 (range, 13.5-95) years. The fissure was located in the posterior mid line in 644 patients (73.5 percent), the anterior mid line in 144 patients (16.4 percent), both in 23 patients (2.6 percent), and only tenderness documented in 65 patients (7.4 percent). The fissure was located in the anterior midline in 12.6 percent of women and 7.7 percent of men. Dominant presenting symptoms included pain in 90.8 percent and bleeding in 71.4 percent of patients. Infrequent hard bowel movements (> or = 3 days) occurred in only 13.8 percent of patients. Mean follow-up was 26 (range, 0.5-215) months. A total of 44.7 percent of patients responded to nonoperative therapy, 60 percent of them in the first two months; of these, 18.6 percent developed recurrent symptoms. Of the latter group, 60 percent responded to further medical therapy, and 20 percent underwent a lateral internal sphincterotomy. Of the patients who initially did not respond to medical treatment (50.5 percent), lateral internal sphincterotomy was recommended.
Anterior fissures are much more common in both men and women than previously reported, and constipation and hard bowel movement are not universally present in patients with fissure-in-ano.
A consistent debate exists about the association between anal fissure and hypertonic anal canal. The aim of this study was to determine if the manometric findings in patients with chronic anal fissures varied according to the topography of the fissure.
Seventy-three outpatients (52 men, 71%) with chronic anal fissures and nine healthy volunteers (5 men, 55%) were examined. Patients were classified according to the topography of the anal fissures: posterior midline (group A), anterior midline (group B), and lateral position (group C). We use computerized anorectal manometry to evaluate anal resting pressure, maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance.
In Group A, the mean pressure was higher than that of controls (p<0.05), and the resting pressure 2 cm from anal verge was higher than that of other groups and controls (p<0.05). Normotonic anal canal was found in 49.1% of patients in group A, in 66% of those in group B and in 57.1% of those in group C. Four elderly patients (7%) of group A had a hypotonic anal canal. No differences were found regarding maximal voluntary contraction, recto-anal inhibitory reflex, rectal sensations and rectum compliance between patients and controls.
Patients with chronic anal fissures may have several anal pressure profiles. The anal canal is often normotonic. Fissures with hypertonic or normo-hypotonic anal canal need different therapies.
Although there is enthusiasm for nonoperative management of anal fissures, most trials have been of short duration (6-8 weeks) and long-term outcome is unknown. The purpose of this study was to assess long-term outcome in two cohorts of patients who had participated in a randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure.
Between February 1997 and October 1998, 82 patients with chronic anal fissure were accrued and randomized to 0.25 percent nitroglycerin ointment t.i.d. or lateral internal sphincterotomy. In 2004, a telephone survey of trial participants was conducted to determine symptom recurrence, the need for further medical and/or surgical treatment, and patient satisfaction. Furthermore, patients were assessed for symptoms of fecal incontinence using the Jorge and Wexner Fecal Incontinence Score and the Fecal Incontinence Quality of Life questionnaire.
Overall, 51 of the original 82 patients (62 percent, 27 nitroglycerin, 24 lateral internal sphincterotomy) completed our survey. Mean follow-up was 79 (+/-1) months. Sphincterotomy patients were less likely to have experienced fissure symptoms within the past year (0 vs. 41 percent; P = 0.0004) and were less likely to require subsequent surgical treatment (0 vs. 59 percent; P < 0.0001) than patients treated with nitroglycerin. Patients in the lateral internal sphincterotomy group were more likely to say that they were "very" or "moderately" satisfied with their treatment (100 vs. 56 percent; P = 0.04) and that they would choose the same treatment again (92 vs. 63 percent; P = 0.02) than patients in the nitroglycerin group. Finally, the fecal incontinence and fecal incontinence quality of life scores at six-year follow-up were similar in both groups.
After six years of follow-up, it seems that lateral internal sphincterotomy is a more durable treatment for chronic anal fissure compared with topical nitroglycerin therapy and does not compromise long-term fecal continence. Thus, sphincterotomy continues to be a good treatment for patients with chronic anal fissure.
Anal canal pressures are low in women with postpartum anal fissure
- Corby