CONSERVATIVE TREATMENT FOR ANAL FISSURE – FOR HOW LONG? – REVIEW OF THE LITERATURE AND PERSONAL EXPERIENCE

Anal fissure (AF) is a common proctologic disease and health problem, with potential for chronicity, causing the patient a debilitating suffering. The pathogenesis, in most of the cases consists in a vicious circle of pain-internal anal sphincter (IAS) spasm-decrease blood irrigation of mucosa-delay of healing. Treatment should aim to break this mechanism by cutting or relaxing the IAS and restoring adequate blood flow to promote healing. If anal stretch is becoming history, surgical sphincterotomy has the highest rate of healing and the least percentage of recurrence, but incontinence for flatus and stool may occur so “medical or “chemical” sphincterotomy using calcium channel blockers (CCB), nitric oxide donors, botulinum toxin injection are used with success rates from 50% to over 90%, also in combination with other conservative measures like warm sitz baths, stool softeners, high fiber and more liquid daily ingestion. All of those therapeutic measures are also stated in current guidelines. The question we tried to answer in this paper is for how long we can prolong the conservative, non-operative treatment in AF. Based upon literature research and our personal experience we may state that the earlier institution of medical specific treatment (CCB, nitric oxide donors, botulinum toxin) has more chances to heal the patient and avoid surgery. Success is also dependent on the good communication with the patient, detailed explanation of the purpose of the treatment, how to assess himself the evolution, and employ botulinum toxin earlier if patient is less compliant to topic treatment. Conservative non-operative management should be pushed as long as it is correctly applied and progression is made both from subjective and objective point of view and patient is compliant and content.