The Practices and Preferences of Turkish Surgeons in the Treatment of Anal Fissure

Abstract

Objective

Despite different medical and surgical options for the treatment of anal fissure no international consensus has been reached. The aim of this study was to determine current practices and preferences of Turkish surgeons when treating anal fissure.

Methods

Two groups were formed according to numbers of anal fissure patients treated per year (0-50 or >50 patients) and were then compared in respect of responses to questions about diagnosis, treatment and clinical approaches to anal fissure.

Results

A total of 300 Turkish surgeons completed the questionnaire: 50.7% in Group 1 (0-50 patients per year) and 49.3% in Group 2 (>50 patients per year). The leading diagnostic method was reported to be physical examination (84.0%). The first approach in treatment was support treatment + topical medical treatment together (82.0%), and when this does not provide recovery, the next option is lateral internal sphincterotomy (LIS) (54.5%). Botulinium toxin injection (BTI) was preferred more by the Group 2 respondents (13.8% vs.23.0%). The use of phlebotonic drugs was lower in Group 2 (45.4% vs.33.1%, p = 0.029). Fetal incontinence is considered in the decision for LIS (82.8%). Limited application of BTI was reported (38.7%) and 17.0% stated that in healthcare facilities in Türkiye there was no institutional treatment protocol for anal fissure.

Conclusion

Main lines of anal fissure treatment in daily practice in Türkiye are in parallel with current international practice. For the updating and standardization of anal fissure treatment, national meetings and studies must be increased and a national anal fissure treatment algorithm should be prepared.

Keywords

anal fissure - lateral internal sphincterotomy - anal fissure treatment - Botulinium toxin injection - national survey

Introduction

Anal fissure is a benign anorectal entity that presents with severe pain and bleeding during defecation.[1] A linear tear develops in the anal mucosa due to the passage of wide and hard stools. Pain and limited bleeding occur during defecation, the internal anal sphincter contracts, and resting pressure does not decrease.[2] As muscle relaxation does not develop in the anal canal, limited ischaemia occurs and therefore, mucosal recovery is delayed. This situation creates a self-perpetuating vicious circle with pain during and after defecation causing painful contraction and the continuation of ischaemia.[3]

In treatment, it is first attempted to eliminate the causes of anal fissure. Supportive treatment is applied, including a fiber-rich diet, laxatives, and hot sitz baths.[4] Topical medical treatment using spasmolytic ointments such as calcium channel blockers and nitric oxide donors are applied in the continuation of treatment.[5] [6] The most effective treatment is surgical treatment, the first option of which is lateral internal sphincterotomy (LIS).[7] Interventional treatment options include botulinium toxin injection(BTI), fissurectomy, and anal flap surgery.[8] Full recovery is obtained at rates > 90% with LIS, but fecal incontinence(FI) of different degrees may occur. The most feared complication in anal fissure treatment is FI.[9] [10] Therefore, there is sometimes deviation from the treatment algorithm. Some surgeons accept unwilling anal fissure patients while some may not recommend surgical treatment even for cases that are not responsive to long-term topical medical treatment. In contrast, some surgeons may recommend surgical treatment as the first option.

Although there are various medical and surgical treatment options available for the treatment of anal fissure, no international consensus has been reached on a common treatment. Treatment protocols and trends vary in different countries.[11] [12] The aim of this study was to determine the current trends and preferences of Turkish surgeons in the treatment of anal fissure, and to compare these with the trends and algorithms of other countries. Information about the clinical trends and practices could open the door to new perspectives and recommendations and be of guidance for subsequent researchers.

Material and Methods

A questionnaire to investigate the tendencies and preferences of Turkish surgeons in anal fissure treatment was prepared based on current algorithms, previous questionnaires about anal fissure and the clinical experience of the authors. The first 6 items on the questionnaire were to elicit information about age, experience, institution where working and title of the respondents, and the other questions investigated the diagnosis of anal fissure, medical treatment, surgical interventions and associated clinical approaches to these. The study included general surgeons and surgeons in auxiliary branches (surgical oncology, gastroenterological surgery) with different levels of experience (specialist, resident) working in all regions of Türkiye. An online questionnaire was prepared and then through digital and face-to-face communication, participants were invited to enroll in the study in April and May 2024.

The study participants were separated into two groups according to how many patients with anal fissure they treated per year (0-50 or >50 patients), and these two groups were compared.

Approval for the study was granted by the Institutional Clinical Research Ethics Committee (decision no: AEŞH-BADEK-2024-194, dated: 20.03.2024).

Data obtained in the study were analyzed statistically using SPSS 26.0 software (SPSS Inc., Chicago, IL, USA). The distribution of numerical variables was examined with visual (histogram, probability graphs) and analytical methods (Kolmogorov-Smirnov test/ Shapiro-Wilk test). Descriptive statistics were stated as median, minimum and maximum values for continuous variables not showing normal distribution, and as number (n) and percentage (%) for categorical variables. Pearson's Chi-square test was used in the comparison of categorical data. The value of p < 0.05 was accepted as statistically significant.

Results

A total of 300 Turkish surgeons participated in the study. Information about the participants is presented in [Table 1]. The median age of the surgeons was 30 years, and they were found to have a median 11 years of surgical experience. The participants comprised 235 (78%) specialists and 65 (21.7%) residents, and 61.0% were working in university hospitals. The branches of surgery were recorded as general surgery specialism for 265 (88.3%) and auxiliary branches (surgical oncology, gastroenterological surgery) of general surgery for 35 (11.7%). The surgeons were asked approximately how many cases of anal fissure they treated per year; 148 (49.3%) stated that they treated more than 50 patients per year and 152 (50.7%) stated that they treated fewer than 50 cases of anal fissure per year. The surgeons were separated into two groups, such as those who treated 0-50 anal fissure patients per year (Group 1) and those who treated >50 anal fissure patients per year (Group 2). Data was compared between these two groups.

Table 1 Information about the surgeons participating in the study

	Study participants - n = 300
Surgical experience (years)*	11.00 (1.00–49.00)
Age (years)*	38.00 (25.00–72.00)
Title
Resident	65 (21.7%)
Specialist	235 (78.3%)
Place of work
University hospital	183 (61.0%)
Public hospital	81 (27.0%)
Private hospital	36 (12.0%)
Area of specialism
General Surgery	265 (88.3%)	265 (88.3%)
Surgical Oncology	16 (5.3%)	Fellowship total 35 (11.7%)
Gastroenterological Surgery	19(6.3%)
Number of patients treated per year
0–10	60 (20.0%)	0–50 patients total 152 (50.7%)
10–50	92 (30.7%)
> 50	148 (49.3%)	148 (49.3%)

^* median (min – max).

The clinical approaches of the surgeons to anal fissure treatment are shown in [Table 2]. The primary diagnostic method in anal fissure was physical examination as stated by 252 (84.0%) surgeons and this rate showed no difference between the groups. Physical examination was also stated by 205 (68.3%) to be the most important method for the differentiation of acute and chronic anal fissure. There is very limited use (5.3%) of anorectal manometry in anal fissure in Türkiye, and the rate was similar in both groups. The first approach in the treatment of anal fissure was accepted by the vast majority in both groups to be the combination of supportive treatment (fiber-rich diet, laxatives, hot sitz baths) and topical medical treatment (Group 1: n = 122, 80.3%; Group 2: n = 124, 83.3%; Total: n = 246, 82.0%). When recovery was not obtained with supportive treatment + topical medical treatment, the next option preferred was LIS (Group 1: 60.5%; Group 2: 48.0%; Total: 54.5%). There was determined to be a higher rate of BTI by the surgeons in Group 2 (n = 38, 23.0%) with the experience of treating more patients compared to Group 1 (n = 21, 13.8%).

Table 2 The clinical practices and preferences of the study participants in the treatment of anal fissure

	Group 1: n = 152 (50.7%) 0-50 patients per year	Group 2: n = 148 (49.3%) >50 patients per year	Total: n = 300	p value
Primary diagnostic methods in anal fissure				0.264
History	20 (13.2%)	18 (12.2%)	38 (12.7%)
Physical examination	125 (82.2%)	127 (85.8%)	252 (84.0%)
Proctoscopy	1 (0.7%)	2 (1.4%)	3 (1.0%)
Physical examination under anaesthesia	6 (3.9%)	1 (0.7%)	7 (2.3%)
The most frequently used methods in the differentiation of acute and chronic anal fissure				0.408
Duration of symptoms	49 (32.2%)	41 (27.7%)	90 (30.0%)
Physical examination	99 (65.1%)	106 (71.6%)	205 (68.3%)
Proctoscopy	3 (2.0%)	1 (0.7%)	4 (1.3%)
Non-response to medical treatment	1 (0.7%)	0 (0%)	1 (0.3%)
Do you use anorectal manometry in anal fissure? Yes	10 (6.6%)	6 (4.1%)	16 (5.3%)	0.331
First approach to anal fissure treatment				0.721
Supportive treatment (fibre-rich diet, laxatives, hot sitz baths)	29 (19.1%)	23 (15.5%)	52 (17.3%)
Supportive treatment + local medical treatment	122 (80.3%)	124 (83.8%)	246 (82.0%)
Lateral internal sphincterotomy	1 (0.7%)	1 (0.7%)	2 (0.7%)
Botilinum toxin injection	0 (0%)	0 (0%)	0 (0%)
Subcutaneous fissurectomy	0 (0%)	0 (0%)	0 (0%)
Anal flap surgery	0 (0%)	0 (0%)	0 (0%)
Options available when recovery is not obtained with supportive treatment + local medical treatment				0.115
Follow-up with supportive treatment + local medical treatment	38 (25.0%)	42 (28.4%)	80 (26.7%)
Lateral internal sphincterotomy	92 (60.5%)	71 (48.0%)	163 (54.4%)
Botilinum toxin injection	21 (13.8%)	34 (23.0%)	55 (18.3%)
Subcutaneous fissurectomy	1 (0.7%)	1 (0.7%)	2 (0.7%)
First approach in the treatment of chronic anal fissure				0.116
Supportive treatment (fibre-rich diet, laxatives, hot sitz baths)	14 (9.2%)	6 (4.1%)	20 (6.7%)
Supportive treatment + local medical treatment	83 (54.6%)	89 (60.1%)	172 (57.3%)
Lateral internal sphincterotomy	44 (28.9%)	46 (31.1%)	90 (30.0%)
Botilinium toxin injection	7 (4.6%)	7 (4.7%)	14 (4.7%)
Subcutaneous fissurectomy	4 (2.6%)	0 (0%)	4 (1.3%)
Anal flap surgery	0 (0%)	0 (0%)	0 (0%)
The most frequently used local medical treatment agent				0.129
Calcium channel blockers	75 (48.7%)	85 (57.4%)	159 (53.0%)
Nitric oxide donors	78 (51.3%)	62 (42.6%)	141 (47.0%)
Duration of local medical treatment				0.791
1 month	64 (22.1%)	60 (40.5%)	124 (41.3%)
2 months	58 (38.2%)	54 (36.5%)	112 (37.3%)
Until symptoms recover	30 (19.7%)	34 (23.0%)	64 (21.3%)
Is there a place for phlebotonic agents in anal fissure treatment? Yes	69 (45.5%)	49 (33.1%)	118 (39.3%)	0.029
Do you perform LIS[a] in anal fissure treatment?				0.034
It is one of my treatment options	139 (91.4%)	127 (85.8%)	266 (88.7%)
It is my first treatment option	11 (7.2%)	10 (6.8%)	21 (7.0.%)
I never perform LIS[a]	2 (1.3%)	11 (7.4%)	13 (4.3%)
Does the risk of fecal incontinence affect the decision for LIS[a]? Yes	128 (84.2%)	118 (81.4%)	246 (82.8%)	0.518
In what conditions do you avoid LIS[a]?				0.032
I perform LIS[a] for all anal fissures	7 (4.6%)	16 (11.4%)	23 (7.9%)
I avoid LIS[a] in patients at high risk of fecal incontinence*	144 (95.4%)	124 (88.6%)	268 (92.1%)
In what percentage of patients on whom you have performed LIS[a] have you encountered anal incontinence?				0.194
< 5%	148 (97.4%)	140 (94.6%)	288 (96.0%)
5%-10%	4 (2.6%)	5 (3.4%)	9 (3.0%)
> 10%	0 (0%)	3 (2.0%)	3 (1.0%)
Which method do you use in LIS[a]? Open	137 (91.3%)	132 (91.0%)	269 (91.2%)	0.928
What should be the breadth in LIS[a]?				0.513
According to the fissure length.	108 (71.1%)	100 (67.6%)	208 (69.8%)
As far as the dentate line.	44 (28.9%)	48 (32.4%)	92 (30.7%)
Do you administer botulinum toxin injection in anal fissure treatment? Yes	60 (39.5%)	56 (37.8%)	116 (38.7%)	0.771
At what stage of anal fissure treatment do you prefer botulinum toxin injection?				0.882
When supportive treatment + local medical treatment is not successful	86 (68.3%)	75 (65.2%)	161 (66.8%)
When LIS is not successful	38 (30.2%)	38 (33.0%)	76 (31.5%)
First choice	2 (1.6%)	2 (1.7%)	4 (1.7%)
Do you perform anal flap surgery in anal fissure treatment? Yes	17 (11.2%)	23(15.5%)	40 (13.3%)	0.267
At what stage of anal fissure treatment do you perform anal flap surgery?				0.675
When supportive treatment + local medical treatment is not successful	5 (4.8%)	3 (2.9%)	8 (3.9%)
When LIS[a] is not successful	51 (49.0%)	50 (49.1%)	101 (49.0%)
If there are risk factors for anal incontinencei*	47 (45.0%)	49 (48.0%)	96 (46.0%)
First choice	1 (1.0%)	0 (0%)	1 (0.5%)
Does your institution have an institutional training program and treatment protocol for the treatment of anal fissure? Yes	26 (17.1%)	25 (16.9%)	51 (17.0%)	0.961

^* Advanced age, history of multiple vaginal births, history of anal surgery.

[a]Lateral internal sphincterotomy.

In the treatment of chronic anal fissure, supportive treatment +topical medical treatment remained the most common approach (n = 172, 57.3%), followed by a significant increase in LIS (n = 90, 30.0%), with no difference seen between the groups. Ointments containing calcium channel blockers (diltiazem) and nitric oxide donors (glyceril trinitrate) are refunded by the national social security institution in Türkiye. The comparisons between topical medical treatment agents showed that they are used at similar rates (p = 0.129). It was stated that topical medical treatment should continue for 1 month by 41.3% of the surgeons, for 2 months by 37.3%, and until the symptoms recovered by 21.3%. The rates were similar in both groups. The use of phlebotonic agents in anal fissure treatment was statistically significantly different between the groups, with use reported by 33.1% of Group 2 and 45.4% of Group 1 (p = 0.029).

The application of LIS was accepted as a treatment option by the surgeons in both groups (91.4%, 85.8%, respectively), but there were significantly more participants who never performed LIS in Group 2 than in Group 1 (1.3% vs 7.4%, p = 0.034). The risk of fetal incontinence was considered when making the decision for LIS by 82.8%, and 92.1% of the total study sample avoided LIS in patients at high risk of fetal incontinence (advanced age, history of multiple vaginal births, history of anal surgery). The surgeons in Group 2 behaved more boldly than those in Group 1 in terms of LIS (applied to all anal fissures: Group 1 - 4.6% vs Group 2 - 11.4%, p = 0.032). It was reported by 96% of the participants that anal incontinence occurred in <5% of LIS cases. LIS was performed with an open approach at the rate of 91.2%. The extent of LIS was said to depend on the length of the fissure (69.8%) or was applied as far as the dentate line (30.7%) and there was no difference determined between the groups ([Table 2]).

BTI was administered in treatment by 38.7% of the study participants. This was applied as first choice by 1.7%, when LIS was unsuccessful by 31.5%, and as second-line treatment when supportive treatment + topical medical treatment was unsuccessful by the majority (66.8%), and the rates were similar in both groups.

Anal flap surgery was seen to be very limited in the treatment of anal fissure in Türkiye (13.3%), and when it is selected it is performed in most cases as a second step if there are anal incontinence risk factors (46.0%) or if LIS has been unsuccessful (49.0%). It was stated by 51 (17.0%) surgeons in the study that in healthcare institutions in Türkiye there is generally no institutional treatment protocol for the treatment of anal fissure ([Table 2]).

Discussion

There is an extensive pool of treatment options for anal fissure extending from dietary recommendations to topical ointments, and from BTI to various surgical interventions.[13] Algorithms have been published by various associations and national research has been conducted in different countries to investigate their own practices.[11] [14] [15] [16] [17] [18] [19] This is the first study to have evaluated current trends and preferences in anal fissure treatment in Türkiye.

Patients who are present with anal fissure are generally thought to have hemorrhoidal disease because of bleeding and pain in the anal region. Therefore, in addition to history, physical examination is of critical importance for the differentiation of anal fissure from other diseases of the perianal region.[14] In the current study, 84.0% of the surgeons stated that diagnosis was made from physical examination. Although the duration of symptoms is important in terms of whether the anal fissure is acute or chronic, there are also physical examination findings such as the formation of skin tag and visibility of the internal sphincter.[20] According to the results obtained in this study, 68% of Turkish surgeons trust physical examination findings when making this differentiation, and 30% give priority to the anamnesis. Anorectal manometry is not generally used in anal fissure diagnosis unless there are FI risk factors in acute and chronic anal fissures.[15] In patients who are candidates for surgical treatment when there has been no benefit from supportive treatment together with topical treatment, anorectal manometry is considered at advanced stages because of the risk of fetal incontinence, and in parallel with current practice, anorectal manometry was reported to be used by 5.3% of the surgeons in this study.[21]

According to current algorithms for acute anal fissure treatment, the first step is to apply supportive treatments such as high-fiber foods, laxatives, and hot sitz baths to eliminate hard and large stools that have caused anal fissure.[11] [14] [15] According to the current study, 82% of the participants stated that they provided immediate supportive treatment together with topical medical treatment, and only 17.3% provided supportive treatment only. A similar result showing that supportive treatment together with topical agents was the first step was reported in a national study in Spain.[18] The first stage of treatment for acute anal fissure in Türkiye differs from international algorithms.

Although the recommendation in the past has been for LIS when recovery is not obtained with the application of supportive treatment+ topical ointments (calcium channel blockers or glyceril trinitrate), there is information in the literature about the benefit obtained from BTI.[11] [22] [23] The responses to the current questionnaire showed that in these conditions treatment was continued with LIS at the rate of 54%, and with BTI at 18%. In the comparisons between the groups, it was striking that the rate of surgeons in Group 2 administrating BTI was 23%, and in Group 1 this rate was 13.8%. Thus, the surgeons who treated a greater number of patients showed a greater preference for injections, demonstrating increased use of BTI in advanced centres in Türkiye where there is more intense treatment of anal fissure. It can be considered that an increase in in-service training programs and easier availability of BTI will both decrease LIS rates and increase rates of BTI.

In parallel with current algorithms topical calcium channel blockers or glyceril trinitrate are used together with supportive treatment first for chronic anal fissure.[6] [24] The topical treatment agents in Türkiye are the calcium channel blocker diltiazem and the nitric oxide donor, glyceril trinitrate. Although the treatment efficacy has been shown to be similar in literature, patient adherence to glyceril nitrate is low because of the side-effect of headache. The preference of surgeons in Türkiye for diltiazem was greater, but not to a statistically significant level (53.0% vs. 47.0%).

Treatment with phlebotonic drugs (calcium dobesilate, diosmin + hesperidin) is not included in the current treatment algorithms for anal fissure, but can be seen in daily practice inn Türkiye and throughout the world.[11] [14] [16] [17] In a study by Balla et al., it was reported that phlebotonic agents were used less by colorectal surgeons than by general surgeons.[16] Similarly in the current study, there was seen to be less phlebotonic use by the Group 2 surgeons. This shows that adherence to the algorithms increased together with increased interest in anal fissure and proctological diseases.

The current study results showed that 88.7% of the participants considered LIS as one of the treatment options, whereas anal flap surgery or fissurectomy had very limited application. In parallel with these findings for Türkiye, previous questionnaires in Italy and Spain have shown that LIS was performed after non-surgical treatments, whereas recently published studies in the Netherlands and France have shown that fissurectomy is preferred before LIS.[12] [16] [18] [25] Current algorithms are in parallel with the approach in Türkiye.[11] [14] [15]

More surgeons in Group 2 than in Group 1 stated that they never performed LIS, and 11.4% stated that they could perform LIS on every patient (including those with FI risk factors). These results were attributed to the Group 2 surgeons with greater anal fissure experience having more experience of alternative methods to LIS and that they were bolder and more experienced about LIS complications. In the current algorithms, it is recommended to adjust the extent of LIS according to the anal fissure length to cause a moderate decrease in FI rates.[10] [11] [26] Of the surgeons in the current study performing LIS, 69.8% stated that they took fissure length into consideration.

BTI is a topical treatment modality showing similar results to those of the topical application of glyceril trinitrate and calcium channel blockers.[14] [27] It is one of the alternative methods that can be attempted before LIS. However, it was only applied by 38.7% of the current study participants, and 66.8% of those stated that they applied BTI when supportive treatment + topical ointments remained insufficient. There is a need for further studies and scientific meetings in Türkiye to examine the place of BTI in the treatment of anal fissure.

Anal flap surgery or fissurectomy after unsuccessful topical treatments have not been shown to be superior to LIS and are not a strong recommendation in current algorithms.[11] [14] [28] Only 13.3% of the current study participants performed anal flap surgery, and of these, 46.0% stated that it was only performed if there were FI risk factors. This result was in parallel with current algorithms. New topical agents have been developed, advances have been made about BTI, and anal fissure remains a subject for which there is debate about the transition from conservative treatment to surgical treatment. There was reported to be an institutional anal fissure treatment protocol by 17.0% of the study participants. Therefore, it is essential that healthcare institutions prepare anal fissure training programs and treatment protocols to be able to follow current literature and standardize treatment.

Anal fissure treatment is a detailed subject with medical and surgical steps. Questions related to the details of medical treatment and the surgical techniques could have been added to the questionnaire. However, questions with many response options can prevent the emergence of more comprehensive responses. These constitute limitations of this study, and the scope of the study could not be extended from the current form of 26 questions, as a longer and more complicated questionnaire would have decreased participation.

Conclusion

The main lines of anal fissure treatment in Türkiye are in parallel with current international practice. However, the immediate transition to topical drugs in addition to supportive treatment in the first step of treatment does not conform to international algorithms. The application of BTI in treatment remains limited compared to the international approach. Therefore, to be able to standardize anal fissure treatment and deliver equal high-quality healthcare services to all citizens, there is a need for national meetings and studies to be increased, and a national anal fissure treatment algorithm should be established.

Conflict of Interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.

Ethical Statement

All authors declare that the study was conducted in accordance with the Declaration of Helsinki and followed the ethical standards of Türkiye. Approval was granted by the Ethics Committee of Ankara Etlik City Hospital (Date:20.03.2024, No: AEŞH-BADEK-2024-194).

Authors' Contributions

ÜO, NTB, AS: material preparation, data collection, data analysis. ÜO: writing – original draft. All authors contributed to the conception and design of the study, critical review of the manuscript, and final approval.

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Publikationsverlauf

Eingereicht: 11. März 2025

Angenommen: 16. Juli 2025

Artikel online veröffentlicht:
10. September 2025