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JKIMSU, Vol. 5, No. 1, January-March, 2016
54
ORIGINAL ARTICLE
ISSN 2231-4261
Journal of Krishna Institute of Medical Sciences University
c
Abstract :
Background: Conservative management of anal
fissure mainly involves Sitz Bath as a treatment
modality. Considering the controversies in the
application of Sitz bath in treatment of anal fissure,
lack of adequate scientific evidence, this study is
designed to evaluate the efficacy of Sitz Bath as a
treatment modality. Aim & Objectives: The study
evaluates the efficacy of Sitz Bath in the treatment of
acute anal fissure with respect to pain relief, patient
sat i s fact i o n, heal i ng of lesi o ns and ove r all
improvement in symptomatology, as well as to assess
its effect on the Quality of Life of these patients.
Materials and Methods: This is a prospective study of
60 patients of acute anal fissure carried out over 2 years
with three groups - Group A1 (Warm Sitz Bath with
analgesics and high fiber diet), Group A2 (Cold Sitz
Bath with analgesics and high fiber diet) and Group B
(Analgesics and high fiber diet alone). Results: The
evaluation parameters were: assessment of pain,
patient satisfaction score and improvement in
sy mptomatology. Warm s itz bath res ult ed in
signif ica nt re duct ion i n pai n sco res, grea ter
im pro vement in sy mptomato log y an d patient
sat i sfact ion sco r es. Conc l usio n : An over a ll
improvement in symptomatology is evident with the
use of warm sitz bath, thereby giving more patient
satisfaction.
Keywords: Anal spasm, Anal Sphincter, Hip bath,
Thermo-sphincteric Reflex
Introduction:
Anorectal disorders include a diverse group of
pathological disorders that generate significant
patient discomfort and disability [1]. Despite the
fact that the exact nature and cause of the
conditions is known, the standard conservative
treatment options are still a matter of debate. Anal
Fissure is a linear ulcer in the squamous
epithelium of the anal canal located just distal to
the dentate line occurring usually in the posterior
midline. It causes severe pain with spasm of the
anal canal due to hypertonia of the internal anal
sphincter [2]. Sitz bath is frequently prescribed for
the management of acute anal fissure, but proper
instructions as to how to perform it are seldom
given to the patients. It is thought to relieve the
pain, and improve healing by increasing the local
blood circulation. Very little scientific evidence is
available on the issue regarding the most suitable
temperature for sitz baths [3].Considering the
controversies in the application of conservative
measures in treatment of anal fissure, lack of
adequate scientific evidence, this study is
designed to evaluate the efficacy of sitz bath as a
treatment modality in management of acute anal
fissure. The objective of the study was to evaluate
the efficacy of sitz bath in the treatment of acute
Evaluation of Different Sitz Bath Methods as a Treatment Modality
in Acute Anal Fissure
1* 1 1
Siddharth P. Dubhashi , Krishna J. Parmar , I. Rege
1Department of Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D.
Y. Patil Vidyapeeth, Pimpri, Pune-411008 (Maharashtra) India
Siddharth P. Dubhashi et.al.
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Journal of Krishna Institute of Medical Sciences University
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(Temperature being hot or cold depending on the
group allotted) for 15 minutes, twice daily,
carefully drying the area after each bath.
The evaluation parameters were: assessment of
pain (using Visual Analogue Scale) (daily),
patient satisfaction score (using Analogue Scale)
(after 7 days) and improvement in sympto-
matology (using Analogue Scale) (days 3, 5 and
7). Chi Square test, ANOVA, and Tukey's tests
were used for statistical analysis. All procedures
performed in the study were in accordance with
the ethical standards of the Institute and with the
1964 Helsinki Declaration and its later amend-
ments or comparable ethical standards.
Results:
All patients included in the study were compa-
rable for age and sex. Majority of the patients were
in the age group of 31-40 years. 55% of patients
were males. Pain during defaecation was the most
common presenting symptom, followed by hard
stools, bleeding per rectum and constipation.
The mean pain score in patients receiving warm
sitz bath (Group A1), cold sitz bath (Group A2)
and the control group (Group B), on day 1 was
7.07 and 7.33 and 7.73 respectively, and that
measured on the 7th day were 2.80, 4.67 and 5.47
respectively, with pain relief most evident with
warm sitz bath followed by cold sitz bath. The
difference in pain scores was statistically
significant on days 1-3 and highly significant on
day 4-7 (Tables 1A and 1B).
anal fissure, with reference to: pain relief, patient
satisfacti on, and ove rall i mpro vement in
symptomatology.
Material and Methods:
This is a prospective study carried out at a tertiary
care centre over a period of two years. The study
was approved by the Institute Review Board.
Sixty patients were divided into two groups
(Group A and Group B of 30 each). Group A was
further divided into Group A1 and Group A2.
0
Group A1 (15 cases) - Warm Sitz Bath (>30 C),
twice daily along with high fibre diet and
analgesics.
0
Group A2 (15 cases) - Cold sitz bath (<15 C),
twice daily along with high fibre diet and
analgesics
Group B (30 cases) - Analgesics and high fibre
diet alone.
Analgesic- Injection Diclofenac sodium.1cc I/M
12 hourly in all groups
Written informed consent was obtained from all
patients before enrollment into the study.
Patients in age group 21 to 60 years presenting
with acute anal fissure were included in the study.
Patients <15 years of age and pregnant females
were excluded from the study. The first case was
allocated to study/control group by lottery method
and subsequently cases were allotted alternately
to each group.
Sitz Bath –Patients were asked to soak their hips
and buttocks in a tub containing plain water
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JKIMSU, Vol. 5, No. 1, January-March, 2016
Table 1A: Pain Scores
Pain Score
on
GroupA1 Group A2 Group B F value p value
Mean ± SD Mean ± SD Mean ± SD D
Day 1 7.07 ± 0.96 7.33 ± 0.62 7.73 ± 0.83 3.59 <0.05
Day 2 6.60 ± 0.91 6.93 ± 0.79 7.40 ±1.07 3.63 <0.05
Day 3 6.00 ± 1.00 6.67 ± 0.90 6.92 ±1.08 4.05 <0.05
Day 4 5.07 ± 1.10 6.30 ± 0.96 6.57 ±1.08 10.34 <0.001
Day 5 4.13 ± 1.36 5.67 ± 1.17 6.12 ±1.37 11.36 <0.001
Day 6 3.60 ± 1.50 5.13 ± 1.12 5.87 ±1.28 15.13 <0.001
Day 7 2.80 ± 1.01 4.67 ± 0.98 5.47 ±1.19 29.32 <0.001
(Visual Analogue Scale; 0-10, 0: No pain, 10: Agonizing pain)
Table 1B: Pain Scores – Intergroup Comparison
Pain Score on A1 Vs A2 A1 Vs B A2 Vs B
p P p
Day 1 >0.05 <0.05 >0.05
Day 2 >0.05 <0.05 >0.05
Day 3 >0.05 <0.05 >0.05
Day 4 <0.01 <0.001 >0.05
Day 5 <0.01 <0.001 >0.05
Day 6 <0.01 <0.001 >0.05
Day 7 <0.001 <0.001 >0.05
three was 2.13, 1.60, 0.83 whereas on day seven, it
was 4, 2.47 and 1.78 in patients receiving warm,
cold and no sitz bath respectively (Tables 3A and
3B).
The overall patient satisfaction score (mean)
assessed on day 7 was 3.93 in group A1, 2.47 in
group A2 and 1.82 in group B patients (Table 2).
The improvement in symptomatology on day
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JKIMSU, Vol. 5, No. 1, January-March, 2016
Table 2: Patient Satisfaction Score
Patient
Satisfaction
Score on
Group A1
(n=15)
Group A2
(n=15)
Group B
(n=30)
F Value p Value
Mean ± SD
Day 7 3.93 ± 0.94 2.47 ± 0.52 1.82±0.48 55.78 <0.0001
Table 3A: Improvement in Symptomatology
Improvement in
symptomatology on
Group A1
(n=15)
Group A2
(n=15)
Group B
(n=30)
F Value p Value
Mean ± SD Mean± SD Mean±SD
Day 3 2.13 ±0.64 1.60±0.91 0.83 ± 0.66 17.24 <0.001
Day 5 3.07 ±0.88 2.0±0.93 1.35 ± 0.57 25.89 <0.001
Day 7 4±0.73 2.47±0.55 1.78 ±0.66 57.02 <0.001
(Visual Analogue Scale; 0-5, 0- no improvement, 5- comfortable)
Table 3B: Improvement in Symptomatology
- Intergroup Comparison
Improvement in
symptomatology on
A1 Vs A2 A1 Vs B A2 Vs B
ppp
Day 3 >0.05 <0.001 <0.05
Day 5 <0.001 <0.001 <0.05
Day 7 <0.001 <0.001 <0.05
(Visual Analogue Scale; 0-5, 0- very poor, 5- excellent)
Siddharth P. Dubhashi et.al.
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been proposed for relaxation of the internal
urethral sphincter to induce urination in patients
after anorectal operations [6]. The perceived
advantages of sitz bath include improvements in
hygiene, relief of discomfort such as burning
sensation or itching, and wound healing [7]. In
addition, sitz bath has been reported as beneficial
for limiting infectious disease and preventing
sepsis following surgery [8].
A variety of medicaments and additives have been
used and recommended with sitz bath for different
proctologic disorders. These include antiseptic
solutions, table salt, povidone iodine, potassium
permanganate, vinegar, etc. How far these
additives are useful remains an issue of debate.
The basis of sitz bath is application of variable
temperature to the ano-perineal region, and the
oth er fac t ors are s e cond ary. Addit ion of
medicaments to the water can cause various
allergic skin reactions. In general, the water is
expected to cover only the perineum and lower
pelvis. Immersing other parts of the body in warm
water could lead to systemic vasodilatation and
decreased circulation to the perianal area [9].
Cold sitz bath causes a contraction of the
cutaneous blood vessels of the area covered by the
water. This effect seems especially felt in the head,
and may on certain occasions be used to increase
cerebral activity. Superficial cold application may
cause physiologic reactions such as decrease in
local metabolic function, local oedema, nerve
conduction velocity, muscle spasm and increase in
local anaesthetic effects [10].
The hot water causes an atonic dilation in the
cutaneous blood vessels. The quantity of blood in
Discussion:
Historically, the use of sitz bath to improve the
th
blood circulation can be traced to early 19
century as part of the old European tradition.
Today, sitz bath has been a commonly used
conservative therapy for patients with acute anal
fissure to relieve symptoms like pain. Although
the effect of using sitz bath in anorectal disorders
has not been established yet, clinicians still
prescribe sitz baths for patients with anal fissure
and other anorectal disorders. The clinical impact
of sitz bath has been unclear. Patients with anal
fissure often showed improvement and fissures
healed regardless of the adherence to a strict sitz
bath regimen. There has been no rigid analysis
conducted to examine the evidence using a
systematic approach [4].
A Sitz bath, also called a hip bath is a type of bath
in which only the hips and buttocks are soaked in
wate r or saline solutio n . S i tz b aths are
recommended for their soothing effect and their
ability to relax the anal sphincter muscles. It is
frequently recommended because of the low
morbidity it carries [5].
It has been hypothesized that the pain relief after
sitz bath could be the result of internal anal
sphincter relaxation, with a resulting diminution
of the rectal neck pressure. A decrease in the
internal sphincter pressure during the sitz bath has
been observed. It is postulated that the relaxation
of the internal sphincter muscle is mediated
through sensory perianal skin receptors getting
stimulated by warm water. The decrease in the
spasm and pain relief is attributed to this 'thermo-
sphincteric reflex'. The same mechanism also has
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significant effect on overall intensity of pain (one
study), post-operative pain (two studies).
A study by Jensen [15] showed that in patients
with a first episode of acute posterior anal fissure,
simple measures such as warm sitz baths
combined with a dietary intake of unprocessed
bran may relieve symptoms significantly better
t h a n t h e a p p l i c a t i o n o f l i g n o c a i n e o r
hydrocortisone ointment to the anal canal.
Cross et al [2] have reported level 1, Grade A
evidence that conservative treatment will heal a
significant proportion of acute anal fissures.
Recurrence rates were reduced from 68 % to 16 %
at one year following continued conservative
management [16].
One study [13] has reported that patients in the sitz
bath group expressed greater satisfaction than the
patients in control group at the end of 4 weeks.
Two patients reported a perianal rash after sitz
bath. A review [4] of three studies assessing
patient satisfaction had conflicting views about
the same. One of the studies reported no
significant difference between sitz bath and
control groups. Our study showed significant
patient satisfaction with warm sitz bath. There
were no complications. Tejirian et al [5] have
reviewed the literature on the use of sitz baths in
anorectal disease and have concluded that there is
no conclusive scientific evidence and studies on
its effect. Alt hou gh the Cl inical P rac tice
Guidelines recommend the use of hot water sitz
baths for the treatment of anal pain for its known
effect on the resting anal pressure, popular belief
encourages the use of cold water sitz baths. This
has also been reported by Maestre et al [3]
the pelvis is largely increased. Hot sitz bath
relieves pain by lowering anal pressure, and
improves anal blood circulation that relieves the
congestion and oedema [11]. It is hypothesized
that hot water baths have a greater analgesic effect
than the cold water with longer durations of low
internal sphincter pressure [3,12].
A study of 24 patients of acute anal pain due to
haemorrhoidal disease/acute anal fissure rando-
mized into two groups: one receiving warm sitz
bath and the other receiving cold sitz bath has
demo nstrat e d no statis ticall y s ignifi c ant
difference in the pain scores. The variation in
maximum anorectal resting pressure measured
before and after the sitz bath also has shown no
significant difference [3].
A study by Gupta [13] compared the analgesic
effect of treatment with and without sitz bath in
patients with anal fissure through a randomised
clinical trial. It shows that there was no significant
pain relief or wound healing in patients taking
warm water sitz baths, although there was greater
overall patient satisfaction.
The benefits of hydrotherapy on different systems
of the body have been reviewed. These depend on
the temperature of the water. Though these effects
are scientifically evidence-based, there is lack of
evidence for the mechanism on how hydrotherapy
brings about an improvement in the disease
process [14].
A systemic review [4] of four studies (268
participants) was conducted. One study was a
ran domi zed con troll ed tri al with a c lear
computerized sequential randomization and
allocation concealment. Use of a sitz bath had no
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Conclusion:
The temperature of sitz bath is an important factor
in determining the outcome of the use of this
treatment method. Warm sitz bath provides
significant analgesia. An overall improvement in
symptomatology is evident with the use of warm
sitz bath, thereby giving more patient satisfaction.
In an era of industry driven treatment 'packages', it
is definitely worthwhile considering the potential
of use of a natural source like water in the
management of common surgical ailments.
The current study has attempted to evaluate the
effectiveness of sitz bath in the management of
acute anal fissure. The re sults hav e be en
statistically significant especially with reference
to pain relief and patient satisfaction. It is noted
that a lot of apprehension exists in the mind of
patients about the feasibility of the sitz bath. Space
limitations and effort involved in preparing the
sitz bath are issues often raised by them. Proper
counseling about the correct technique and
potential benefits of sitz bath will go a long way in
removing the misconceptions.
JKIMSU, Vol. 5, No. 1, January-March, 2016
9. Ng CL. Levator ani syndrome: a case study and
literature review. Aust Fam Physician 2007; 36: 449-
452.
10. Weston M, Taber C, Casagranda L, Cornwall M.
Changes in local blood volume during cold gel pack
application to traumatized ankles. J Orthop Sports Phys
Ther 1994; 19: 197-199.
11. Yang HK. Non surgical treatment of haemorrhoids.
Haemorrhoids 2014; 47-63. doi: 10.1007/978-3-642-
41798-6.
12. Shak A. 'Somatoanal' reex or 'thermosphincteric
reex? Dis Colon Rectum 2000; 43: 726-728.
13. Gupta P. Randomised controlled study comparing sitz-
bath and no-sitz-bath treatment in patients with acute
anal ssures. ANZ J Surg 2006; 76(8): 718-721.
14. Mooventhan A, Nivethitha L. Scientic Evidence
Based effects of Hydrotherapy on various systems of
the body. North Am J Med Sci 2014; 6(5):199-209.
15. Jensen SL. Treatment of rst episodes of acute anal
ssure: prospective randomized study of lignocaine
ointment versus hydrocortisone ointment or warm sitz
bath plus bran. Br Med J 1986; 292: 1167-1169.
16. Jenson SL. Maintenance therapy with unprocessed bran
in the prevention of acute anal ssure recurrence. J R
Soc Med 1987; 80: 296-298.
1. Gupta PJ .A review of ano-rectal disorders and their
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2. Cross KLR, Massey EJD, Fowler AL, Monson JRT. The
managemen t o f a nal ssure. ACPGBI Po sition
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3. Yolanda Maestre, David Pares, Silvia Salvans, Ines
Ibanez-Zafon, Esther Nve, Maria Jose Pons, et al. Cold
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randomized clinical trial. Cir Esp 2010; 88(2): 97-102.
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5. Tejirian T, Abbas MA. Sitz Bath: where is the evidence?
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References
*Author for Correspondence: Dr. Siddharth P. Dubhashi, A-2 / 103, Shivranjan Towers, Someshwarwadi, Pashan,
Pune- 411008 Email: spdubhashi@gmail.com Cell: 09881624422
