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Anal Fissure Epidemiology and Related Diseases in Children

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Anal Fissure Epidemiology and Related Diseases in Children DOI: 10.14744/scie.2018.84803 Original Article South. Clin. Ist. Euras. 2018;29(4):295-300 Anal Fissure Epidemiology and Related Diseases in Children Mustafa Yaşar Özdamar,1 Erkan Hirik2 ABSTRACT Objective: After an anal fissure (AF), patients frequently avoid defecation, even if they have 1Department of Pediatric Surgery, diarrhea, due to severe anal pain. This is particularly evident in constipated patients, however Erzincan Binali Yıldırım University the type of functional disease that causes AF is not limited to constipation or persistent Faculty of Medicine, Erzincan,Turkey diarrhea. The aim of this study was to examine the prevalence and the clinical importance 2Department of Urology, Erzincan Binali Yıldırım University Faculty of of diseases associated with AF in childhood age groups among young patients with different Medicine, Erzincan, Turkey clinical pictures. Submitted: 23.08.2018 Methods: The data related to age, sex, and the accompanying disease of AF patients were Accepted: 12.10.2018 collected from a hospital database. Of 7406 patients, 728 were identified and categorized Correspondence: in 6 distinct disease groups associated with AF: constipation; constipation with anal incon- Mustafa Yaşar Özdamar, tinence, urinary incontinence, or anal incontinence and urinary incontinence; infantile colic Erzincan Binali Yıldırım Üniversitesi Tıp Fakültesi, (IC); and diaper dermatitis (DD). The symptoms of the AF-related diseases were recorded Çocuk Cerrahisi Anabilim Dalı, and it was assessed whether AF-related symptoms were reduced after AF treatment. 24100 Erzincan, Turkey E-mail: Results: Of the 728 AF-associated patients of all groups, it was observed that 1 week [email protected] after AF therapy, 529 (72%) experienced a regression in both current disease and AF-re- lated symptoms (p<0.05; r=0.26). The improvement in the first week after treatment had a stronger correlation than the improvement in the third week (r=0.26 vs. 0.19). Conclusion: AF was associated with constipation, anal-urinary incontinence, IC, and DD, and was critically important in the targeted treatment of the related illness. The potential Keywords: Anal fissure; presence of AF should be kept in mind when planning the treatment of these 6 functional child; epidemiology; infant. disorders. INTRODUCTION gresses.[1–5] This cycle can also affect adjacent structures. The pain felt in the anal region due to the anatomical Anal fissure (AF) is a longitudinal tear or an ulcer in the closeness of the bladder and urethra to the rectum, as well anoderm of the anal canal distal to the dentate. It typically as similar innervation (S2-S4 spinal nerves) of the urethral causes anal pain during defecation that may occur with or and anal sphincters causes dysfunction in both systems without rectal bleeding. AF does not occur spontaneously; simultaneously. Consequently, AF can cause both bowel the fissure is classified according to causative factors. Pro- dysfunction, and indirectly, bladder dysfunction (bowel- longed diarrhea or hard stool causing irritation and trauma bladder dysfunction, BBD). The anal and urethral sphinc- to the anal canal are the primary and most common causes ters become affected as a result of rectal stool retention in of AF. Secondary AF can occur in patients following an anal constipation. Children with constipation and a fear of pain surgical procedure or with inflammatory bowel disease upon defecation may not achieve independent bowel emp- (e.g., Crohn’s disease, ulcerative colitis). AF affects all age tying, which then indirectly impacts bladder function.[6,7] [1–3] groups with an equal incidence in both sexes. From birth to 5 months of age, hepatic synthesis remains Once the AF has appeared, patients often avoid defeca- immature in infants, with reduced intraluminal bile acids tion, even if they have diarrhea, due to severe anal pain, and less efficient absorption of fats and other nutrients. particularly those with constipation. A vicious cycle of- This leads to a difference in the presence of the natural mi- ten begins between the pain and avoiding elimination of croflora in the gut. The naturally protectiveLactobacillus stool. AFs are classified into 2 groups: acute (superficial) and Bifidobacterium are often replaced by higher levels of and chronic fissure (complicated). Anal pain can initiate a Escherichia coli, Clostridium difficile, and Klebsiella. This spasm of the internal anal sphincter and create high anal flora status brings about increased nutrient fermentation, pressure, which leads to a reduction in anodermal perfu- more gas production, and a modified stool feature, which sion and an increase in ischemia in the AF as the event pro- irritates the gut. Therefore, the irritant fecal feature, 296 South. Clin. Ist. Euras. which causes AF, may be present in infantile colic (IC). tory as part of the determination of the cause of AF: The etiology of IC is not precisely known; however, in the Group 1: Constipation ongoing for at least 2 months, in- treatment of IC, it has been recommended that mothers cluding at least 2 of the following at least once a week in breastfeeding should eliminate potential allergens (milk, children of at least 4 years of age: 1) two or fewer defe- eggs, fish, nuts, soy, and wheat) from their diet. Some prac- cations per week, 2) at least 1 episode per week of fecal titioners have also suggested switching bottle-fed infants incontinence after acquisition of toilet training, 3) history to hydrolyzed formulas. However, the literature research of excessive stool retention, 4) history of painful or hard is inadequate regarding the role of AF in IC and whether bowel movements, 5) presence of a large fecal mass in [8–10] AF treatment is effective in suppressing IC symptoms. the rectum, 6) history of large-diameter stools that may Diaper dermatitis (DD) occurs due to irritation in the di- obstruct the toilet, and 7) history of retentive posturing aper area, as it is constantly exposed to urine and feces, or excessive volitional stool retention. Other possible generally in infants aged 7-12 months (though it may occur symptoms are irritability, decreased appetite, and/or early at any age), and is generally a Candida infection. Breastfed satiety. Concomitant symptoms disappear immediately fol- babies are less likely to experience DD.[11,12] Though the lowing defecation of a large stool.[14] causes and treatment of DD have been described in detail Group 2, 3, and 4: When symptoms of patients who in previous publications,[11,12] enough information has not meet Group 1 criteria also included anal incontinence, yet been reported in the literature about whether DD ir- urinary incontinence (daily or nocturnal), or both anal in- ritation in the perianal region causes AF. While AF, DD, continence and urinary incontinence (bowel-bladder dys- and IC share some clinical features and causes, it is not yet function; BBD), these patients were included in separate clear what relationships may exist. functional disease group (Group 2, 3, and 4, respectively). The objective of this study was to investigate some of the Group 5: Infants with IC were defined by 3 symptoms: diseases that cause AF in children, including functional dis- crying for more than 3 hours per day, more than 3 days orders, and any relationship between these diseases and AF. per week, and for a period longer than 3 weeks. An essen- tial criterion was that the baby continuously cried in the [8–10] MATERIAL AND METHODS evening without apparent provocation. Group 6: DD patients were diagnosed by examining The data of all patients aged up to 16 years who consecu- the baby’s diaper area and identifying the eruptions ob- tively presented at 1 outpatient clinic of pediatric surgery served.[11,12] between November 2013 and November 2017 and were diagnosed with AF were retrospectively analyzed. Patients Previous diagnosis and treatment history with organic diseases of the intestines and anal canal were Most of the patients (about 80%) were referred from not included. The study was approved by the Institutional other centers and had problems with gas-stool discharge Ethics Review Board for Clinical Research (2018, 24/06). despite previous treatment for IC or DD. The follow- This was a retrospective investigation of a 3-year period. ing medications had been used when the patients were Patients with incomplete data were not included in the brought to the outpatient clinic: oral laxative in Group 1; research. enema and oral laxative in Group 2;[7] anticholinergic for bladder stabilization in Group 3;[6] laxatives and enema in Diagnosis of patients with anal fistula Group 4; hypoallergenic formula, herbal tea, simethicone, Of a total of 7406 patients who presented at the outpa- dicyclomine, and methylscopolamine in Group 5;[8,15] and tient clinic, 954 (12%) were diagnosed with AF based on antifungal as well as steroid ointment in Group 6.[11,12] physical examination. The details of patient age, sex, and accompanying AF-related diseases were collected from Treatment applied to patients diagnosed with the database. The symptoms of AF-related diseases were anal fistula analyzed, as well the result of treatment for the symp- The conventional therapies for AF of a warm sitz bath, toms. AF was primarily characterized by anal itching, rectal local application of analgesic ointment (lidocaine oint- bleeding, and painful defecation.[13] ment, Anestol pomade; Sandoz International GmbH, Holzkirchen, Germany), and stool softeners in case of Identification of the study groups constipation (Lactulose oral, Osmolak oral; Biofarma İLAÇ The data analysis revealed that 6 disease groups were di- SAN. ve Ticaret A.Ş., Istanbul, Turkey) were applied. agnostically related to AF: constipation (Group 1); con- stipation with anal incontinence (Group 2), urinary in- Statistical analysis continence (Group 3), or anal incontinence and urinary The statistical analysis of the findings was performed us- incontinence (Group 4); IC (Group 5); and DD (Group 6).
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