Recovery from hemorrhoids and anal fissure without surgery.

BACKGROUND/AIMS: An anal fissure (AF) is a linear tear in the distal anal canal and is one of the most common causes of anal pain. Hemorrhoidal disease (HD) is a symptomatic growth and distal displacement of normal anal cushions. Numerous studies have addressed the contributing factors of these conditions, yet the results remain controversial. In this study, we hypothesize that increasing patients' awareness of hidden risk factors could reduce the rate of HD and AF. MATERIALS AND METHODS: A questionnaire-based controlled study was planned. After power analysis, patients with HD (n=60) and AF (n=60) were enrolled consecutively into the study group and compared with the control group (n=60) of healthy individuals. The survey was designed to assess the participants' toilet and dietary habits and anxiety risk. Odds ratios were calculated and a binary logistic regression model was constructed to identify associated factors. RESULTS: Hard stools, spending more than 5 minutes in the toilet, frequent straining during defecation, and increased spice intake were more frequent in the patients with HD; and hard fecal consistency, time elapsed in toilet greater than 5 min, straining during defecation, and high anxiety risk were more frequent in the patients with AF as compared to the control group (p<0.05). CONCLUSION: Possible associations were identified between habitual factors or conditions (i.e., fecal consistency, the time elapsed in the toilet, straining during defecation) and anxiety and benign anorectal diseases (i.e., HD and AF). Patients should be advised about these hidden threats.

Hypertrophied anal papillae and fibrous anal polyps, should they be removed during anal fissure surgery?

AIM: Hypertrophied anal papillae and fibrous anal polyps are not given due importance in the proctology practice. They are mostly ignored being considered as normal structures. The present study was aimed to demonstrate that hypertrophied anal papillae and fibrous anal polyps could cause symptoms to the patients and that they should be removed in treatment of patients with chronic fissure in anus. METHODS: Two groups of patients were studied. A hundred patients were studied in group A in which the associated fibrous polyp or papillae were removed by radio frequency surgical device after a lateral subcutaneous sphincterotomy for relieving the sphincter spasm. Another group of a hundred patients who also had papillae or fibrous polyps, were treated by lateral sphincterotomy alone. They were followed up for one year. RESULTS: Eighty-nine percent patients from group A expressed their satisfaction with the treatment in comparison to only 64% from group B who underwent sphincterotomy alone with the papillae or anal polyps left untreated. Group A patients showed a marked reduction with regard to pain and irritation during defecation (P = 0.0011), pricking or foreign body sensation in the anus (P = 0.0006) and pruritus or wetness around the anal verge (P = 0.0008). CONCLUSION: Hypertrophied anal papillae and fibrous anal polyps should be removed during treatment of chronic anal fissure. This would add to effectiveness and completeness of the procedure.

Long-term results and quality-of-life outcomes in patients with transsphincteric fistulas after muscle-filling procedure.

PURPOSE: This study was designed to evaluate long-term results and quality-of-life outcomes after the muscle-filling procedure for posterior transsphincteric fistulas. METHODS: A questionnaire was mailed to 207 patients who had been treated by the muscle-filling procedure for posterior transsphincteric fistulas with cryptoglandular origin at the Social Health Insurance Hospital during a ten-year period. One hundred fifty-one patients who returned their questionnaires were included in this retrospective study. Information regarding fistula recurrence, time required for wound healing, postoperative incontinence, overall satisfaction with the procedure, and quality-of-life data were surveyed from the returned questionnaires. RESULTS: One hundred fifty-one patients (140 males) with a mean age of 48 (range, 17-75) years were analyzed. The mean follow-up was 70 (range, 12-131) months. Fistulas recurred in seven patients (4.6 percent). Fifty-eight patients (38 percent) healed within 3 months, and 52 (34 percent) healed within 6 months. Eighty-four patients (56 percent) reported some reduction in their sense of sphincter-tightening ability after surgery. Seventy-eight patients (52 percent) reported some degree of incontinence. One hundred thirty-three patients (88 percent) were satisfied or very satisfied with their outcomes. Of the 18 patients (12 percent) who reported unsatisfactory or very unsatisfactory results, 7 experienced recurrence. Thirty-seven patients (25 percent) indicated one or more lifestyle alterations, including social activities (11 percent), travel (12 percent), sports (5 percent), diet (4 percent), housework (1 percent), or sexual activities (1 percent), because of incontinence after surgery. Eighteen patients (12 percent) had more than one restriction in their quality-of-life parameters. CONCLUSION: The muscle-filling procedure is a viable option in the treatment of transsphincteric fistulas, with a favorable recurrence rate and an overall patient satisfaction rate above 88 percent.

Treatment of anal fissure with glyceryl trinitrate in patients referred for surgical management.

BACKGROUND: A number of recent studies indicate that anal fissure may be treated by applying glyceryl trinitrate (GTN) ointment. The present study aims to determine the effectiveness and patient acceptability of GTN treatment for patients referred to a consultant surgeon. METHODS: A prospective study of 65 consecutive patients referred to one surgeon (ALP) over a 12-month period was undertaken. All patients were offered 0.2% GTN ointment to be applied intra-anally four times daily for 4 weeks. Informed consent was obtained and review planned for 4 weeks. RESULTS: Fourteen patients declined treatment and nine of the 14 (64%) subsequently underwent lateral sphincterotomy. Twelve of the 51 patients (18.5%) who accepted treatment could not complete it due to headache or persisting severe anal pain. Thirty-nine of the 51 patients (77%) were able to complete 4 weeks of treatment. Twenty-two of the 39 reported an improvement in symptoms. A total of 22 patients (43%) who started GTN treatment subsequently underwent lateral sphincterotomy. CONCLUSIONS: Evidence from the present study suggests that GTN ointment has a place in the management of referred patients with severe and/or chronic anal fissure, but sphincterotomy remains an important treatment option for the majority.

Results of behavioral treatment (biofeedback) for solitary rectal ulcer syndrome.

BACKGROUND: Treatment of solitary rectal ulcer syndrome with behavioral techniques (biofeedback) has been shown to be successful in a majority of patients in the short term. We aimed to determine the longer-term outcome of patients treated with this therapy. PATIENTS AND METHODS: Thirteen consecutive patients (3 male; median age, 34 years) with solitary rectal ulcer who had been treated by biofeedback and assessed a median of nine months after treatment were reassessed by questionnaire. Three patients were also examined using rigid sigmoidoscopy. RESULTS: Median follow up was 36 (range, 32-59) months after initial biofeedback treatment. One patient (previously reported as failing biofeedback therapy) was lost to follow-up. Of the four patients previously reported as asymptomatic, one remained asymptomatic, one maintained marked improvement, and another slight improvement; one had reverted to pretreatment status. Of the three patients previously reported as having marked improvement, one maintained moderate improvement, and two had reverted to pretreatment status. The patient previously reporting slight improvement had reverted to pretreatment status. Of the five previously reported failures, two patients experienced no improvement after further courses of biofeedback. At the three different times of review (pretreatment vs. 9 months vs. 36 months after biofeedback), reported bowel function was as follows: the need to strain (12 vs. 5 vs. 9 patients), anal digitation (10 vs. 3 vs. 8 patients), laxative use (9 vs. 4 vs. 4 patients), median time spent in the toilet per attempt at defecation (30 vs. 10 vs. 25 minutes), median visits to the toilet (5.5 vs. 2 vs. 4 per day), and ability to maintain employment (3 vs. 7 vs. 6 patients). CONCLUSION: Improvement in symptoms of solitary rectal ulcer syndrome after biofeedback retraining deteriorates in some patients with time. Half the patients with an early clinical response to retraining, however, can be expected to have ongoing clinical benefit at a median of three years.