Ischaemic nature of anal fissure

Microvascular perfusion of the anoderm was assessed by laser Doppler flowmetry in 27 patients with anal fissure. Anal pressure was recorded simultaneously. Both measurements were repeated 6 weeks after lateral internal sphincterotomy and compared with those obtained from 27 controls. Mean(s.d.) maximum anal resting pressure was significantly higher in those with a fissure than in controls (121.07(24.48) versus 68.78(16.97) mmHg, P<0.001). Anodermal blood flow at the fissure site was significantly lower than at the posterior commissure of the controls (0.46(0.20) versus 0.76(0.28) V, P<0.001). The fissure healed in 24 patients within 6 weeks of sphincterotomy. In these patients a significant pressure decrease was noted (35 per cent) which was accompanied by a consistent rise in blood flow (65 per cent) at the original fissure site. The increased internal sphincter tone in patients with a fissure reduces anodermal blood flow at the posterior midline. Reduction of anal pressure by sphincterotomy improves anodermal blood flow at the posterior midline, resulting in fissure healing. These findings provide evidence for the ischaemic nature of anal fissure.