Controlled digital anal dilatation under total neuromuscular blockade for chronic anal fissure: a justifiable procedure

Background: There is widespread antipathy to digital dilatation of the anus (DDA) for medically resistant anal fissure. A retrospective study was ther efore undertaken to test the validity of the criticism of this technique. Methods: Some 273 patients who underwent DDA for fissure between November 1 982 and July 1997 were sent a questionnaire and/or telephoned. Those with i mpaired control were offered investigation. In addition, routine clinic fol low-up data were scrutinized in the 302 available notes of the 307 patients who had undergone DDA for fissure to determine its efficacy. Results: Some 241 patients (88.3 per cent) were contacted successfully a me dian of 7.8 years after operation. Follow-up records showed the fissure to have healed in 89.1 per cent of 302 patients. No patient was rendered incon tinent. Fifteen patients indicated persistently impaired control in the que stionnaire, nine (3.8 per cent) as a result of the DDA and six preceding it . All 23 patients who had experienced either temporary or permanent impairm ent, whether or not pre-existing, were invited to attend for ultrasonograph y and manometric measurements, of whom 18 accepted. No sphincteric fragment ation was seen, and resting and squeeze pressures did not differ from norma l. Conclusion: A single DDA appears to heal 89 per cent of chronic anal fissur es. Consequent impairment of control is infrequent and minor if the procedu re is performed carefully and with the patient paralysed.