Manometry in Chronic Anal Fissures: Clinical and Therapeutic Correlation

Abstract

Objective: The aim of this study is to determine the clinical and therapeutic relevance of manometric findings in patients with chronic anal fissure. Methods: Descriptive, prospective study of 139 patients with chronic anal fissure (CAF) treated with Isosorbide Dinitrate 2% cream (Master Formula) for 6 to 8 weeks with a maximum of 2 treatment cycles. Physical exam findings were recorded prior to treatment, which included location of the fissure(s) and rectal sphincter tone. One week after beginning treatment, High resolution Anal Manometry (HRAM) was performed discriminating the rest pressure (RP) in low (<40 mmHg), normal (40-70 mmHg), and increased (> 70 mmHg) sphincter pressure. The increased (>70 mmHg) category was further subclassified as: mildly increased (71 -100 mmHg), moderately increased (101-150 mmHg) and severely increased (> 150 mmHg) with the intention of further describing the associations between the patients’ therapeutic evolution and their HRAM pressures. Results: Mean age 42 ± 13 and 51.8% of patients were female. Posterior fissures were present in 87.8% of patients. 61 patients were found to have moderately increased RP (43.9%). 46% of patients with normal RP were classified as hypertonic on digital rectal examination (p = 0.01). Mean healing rate was 80% with medical treatment, this percentage was positively correlated with higher RP (p = 0.004). 20% underwent surgery, with the surgical technique depending on the RP, without reports of complications or fecal incontinence. Conclusions: HRAM is a guiding tool in the evolution of the CAF, finding that the higher the RP is, the better the response to medical treatment. Additionally, in non-responders patients, to reduce complications, surgical management can and should take the RP into consideration and not only to the physical examination.