An anal fissure AF is a tear in the epithelial lining of the anal canal.
This is a very common condition, but the choice of treatment is unclear. The use of anal dilators is effective, economic, and safe.
The aim of the study was to compare the efficacy of two conservative treatments, the use of anal dilators or a finger for anal dilatation, in reducing anal pressure and resolving anal fissures. Fifty patients with a clinical diagnosis of AF were randomly assigned to one of the treatments, self-massage of the anal sphincter group A, 25 patients or passive dilatation using dilators group B, 25 patients.
All patients were evaluated at baseline, at the end of Working the anal massage, and after 12 weeks and 6 months. Pain was measured using a visual analog scale. The use of anal self-massage with a finger appears to induce a better resolution of acute anal fissure than do anal dilators, and in a shorter time. The anal fissure is an extremely common proctologic disease, but the choice of the most appropriate therapy is still difficult.
Because of the high rate of recurrence that afflicts conservative therapy and the risk of serious complications, such as bowel incontinence and bleeding that can affect surgical therapy, it is not yet possible to determine which the best treatment is.
The conservative treatment of anal fissure relies on the observation of hygienic-dietary measures, obtaining a regular bowel movement, and the use of muscle Working the anal massage or anesthetics. The use of nitroglycerine creams or botulinum toxin appears to be a palliative treatment, with rapid loss of effectiveness, and it is often poorly tolerated because of unpleasant side effects [ 4 - 8 ].
Therefore, our group has developed a new therapeutic approach that involves anal self-massage by the patient. The purpose of this study was to evaluate the effectiveness of anal self-massage in the treatment of anal fissure, comparing it to traditional therapy with dilators. Fifty patients suffering from acute anal fissure were enrolled in this prospective randomized study. All patients Working the anal massage to be included in the study and gave their signed, informed consent to randomization.
Inclusion criteria were age ranging from 18 to 70 years, presence of anal pain during bowel movements, detection of acute posterior anal fissure.
Exclusion criteria were concomitant anal pathology anorectal fistulae, abscessesprevious surgery on the pelvic floor, inflammatory bowel disease, and therapy with nitrates. The patients were randomized using Working the anal massage number table to treatment with self-massage of the anal sphincter group A, 25 patients or passive dilatation of the anal sphincter using dilators group B, 25 patients. Patients were Working the anal massage before treatment by digital rectal examination performed with the patient in the left lateral position at rest and during different times of functional decline and straining.
Patients were also administered a personal questionnaire about their quality of life analyzing the results according to the Agachan-Wexner score [ 13 ]. The intensity of pain was assessed by visual analog scale VAS. At the end of treatment, all patients underwent a clinical revaluation physical examination, rectal examination and interviews with a standardized questionnaire regarding medical history, information on symptoms such as itching, anal pain, anal burning, bleeding, quality of life, and the VAS scale for pain.
Follow up was scheduled at the end of the treatment and at 3 and 6 months. During follow up, the following variables were taken into account: Descriptive continuous variables are expressed as mean and standard deviation SD. Of the 50 patients enrolled, 27 were women and 23 men, with a mean age of All patients had an acute posterior anal fissure.
Bowel movements were normal in 34 patients, 12 patients complained of constipation and 4 reported diarrhea.
There were no side effects in any of the two groups. The analysis of Working the anal massage questionnaire on quality of life showed an average of 6 on a scale of Table 1 summarizes the characteristics of patients and the symptoms and signs before treatment. At the end of the treatment, 20 patients in group A anal self-massage and 15 in group B showed resolution of symptoms and disappearance of the anal fissure.
At 3 months Working the anal massage the end of treatment, no patient in group A had recurrence of the disease, whereas 2 relapses were observed in group B. The subsequent evaluation was at 6 months. Recurrence was observed in one patient in group A and in 3 patients in group B.
The average quality of life was similar, being 9 in group A and 8 in group B. Table 2 summarizes the characteristics of patients and symptoms after treatment, and at 3 and 6 months after the procedure. Signs and symptoms of patients at the end of their treatment, and at 3 and 6 months after treatment. The analysis of the VAS score showed a progressive decrease during the follow up, but there were no significant differences in the two groups.
At 6 months after treatment, a significant difference in terms of reduction in anal pain was observed between the two groups A vs. There was no significant difference in the other symptoms.
The cause of this disease still remains unclear, although it is considered that an increase in the internal anal sphincter tone may lead to a local reduction in the blood flow, causing damage especially posteriorly, where the perfusion is physiologically lower than in the other areas of the anal canal.
From this perspective, the anal fissure can be regarded as an ischemic disease [ 14 - 16 ].
Hard stools can be the primary cause of this complex background. Therefore, a first therapeutic approach is habit regularization, especially as a preventive maneuver. Once, however, the anal fissure has presented, the choice of therapy to be implemented cannot be simple: Moreover, the long-term efficacy of these medical treatment has not been proven [ 17 - 20 ].
Regarding the use of botulinum toxin, a still expensive approach, the dose and the site of injection have still to be defined clearly, and its long-term efficacy is not supported by clinical evidence [ 21 ].
However, this method required a long application time and duration of treatment for effective results. To overcome these limitations, we developed a new therapeutic approach: These results show the long-term superiority in the effectiveness of the massage method.
At the end of both treatments, we obtained a statistically significant reduction in anal pain and bleeding, though the reduction in anal itching and burning did not reach statistical significance.
It is Working the anal massage that Working the anal massage itching and anal burning are less specific symptoms of anal fissure and represent accompanying symptoms, especially due to the presence of hemorrhoids.
This new approach represents an evolution of anal dilators. The success rates are higher and the rate of recurrence is lower compared with anal dilator therapy. In addition, the duration of the therapy is drastically reduced: Through anal self-massage, the patient modulates the action of dilating, making the therapy more effective and performing real biofeedback compared to therapy with anal dilators.
This approach also has a significantly lower cost. Our hypothesis is that the massage of the anal sphincter, in addition to the passive dilatation obtained by the finger, induces a relaxation of the hypertrophic and hyper-contracted anal sphincter, through a negative central feedback mechanism. From this perspective, the tactile sensitivity of the finger would have a key role.
However, the sample of the population analyzed in this study do not fully describe the applicability of the method. In fact, all randomized patients of the study could have performed anal self-massage, but problems could arise in some patients, such as the frail elderly, morbidly obese, or those with functional limitations neurological diseases, orthopedic diseases, muscular diseases, etc.
Another consideration is that cultural Working the anal massage make it impossible to apply the method in certain socio-cultural contexts. In these patients this method should not be proposed because of poor compliance. In Working the anal massage, in our study, both treatments, anal self-massage and anal dilators, were equally effective in inducing and maintaining remission of anal fissure.
However, anal self-massage involves lower treatment times and costs. To the best of our knowledge, this is the first study in the literature to describe and compare these techniques for the treatment of anal fissure. National Center for Biotechnology InformationU. Journal List Ann Gastroenterol v.
Published online May Author information Article notes Copyright and License information Disclaimer. Received Jan 17; Accepted Apr 6. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Background An anal fissure AF is a tear in the epithelial lining of the anal canal.
Methods Fifty patients with a clinical diagnosis of AF were randomly assigned Working the anal massage one of the treatments, self-massage of the anal sphincter group A, 25 patients or passive dilatation using dilators group B, 25 patients. Conclusion The use of anal self-massage with a finger appears to induce a better resolution of acute anal fissure than do anal dilators, and in a shorter time. Anal fissure, anal massage, anal dilator, proctologic disease, anal pain. Introduction The anal fissure is an extremely common proctologic disease, but the choice of the most appropriate therapy is still difficult.
Patients and methods Fifty patients suffering from acute anal fissure were Working the anal massage in this prospective randomized study. Open in a separate window.
Results Of the 50 patients enrolled, 27 were women and 23 men, with a mean age of Table 1 Patient characteristics. Table 2 Signs and symptoms of patients at the end of their treatment, and at 3 and 6 months after treatment. Working the anal massage widely held belief is that internal anal sphincter hypertonicity is a determining factor in the development of an anal fissure.
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The method is cheap, provides a simple solution to the problem, and offers higher success rates than conventional dilators, without the risk of anal continence. Footnotes Conflict of Interest: Aetiology and treatment of anal fissure.
Conservative treatment of anal fissure: Hananel N, Gordon PH. Re-examination of clinical manifestations and response to therapy of fissure-in-ano.