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The Effect of Nonoperative Management of Chronic Anal Fissure and Hemorrhoid Disease on Bowel Function Patient-Reported Outcomes

Wilson, Matthew Z., M.D., M.Sc.1,2; Swarup, Abhishek, M.D.1,2; T. Wilson, Lauren R., M.D.1,2; Ivatury, Srinivas Joga, M.D., M.H.A.1,2

doi: 10.1097/DCR.0000000000001193
Original Contributions: Anorectal
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BACKGROUND: Nonoperative management has been reported to decrease symptoms from common anorectal conditions such as chronic anal fissures and hemorrhoids. The effects of these interventions on bowel function are unknown.

OBJECTIVE: This study aims to perform a prospective evaluation of patient-reported outcomes of bowel function on nonoperative management for chronic anal fissures and hemorrhoid disease.

DESIGN: This is a prospective, observational study.

SETTINGS: Patient-reported outcome measures were collected from the clinical practice of the division of colon and rectal surgery at a tertiary colon and rectal surgery referral center.

INTERVENTION: All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies. Those with chronic anal fissures were also prescribed topical calcium channel blockers. The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit.

MAIN OUTCOME MEASURES: The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate.

RESULTS: A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease. Incontinence, social impact, stool-related aspects, and the global score were observed to have statistically significant improvement in the aggregate group. When analyzed by diagnosis, hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects, whereas chronic anal fissure was associated with a statistically significant change in social impact, stool-related aspects, and the global score.

LIMITATIONS: This study was limited by the small cohort size and unclear patient adherence to medical management.

CONCLUSIONS: Nonoperative management of chronic anal fissures and hemorrhoid disease is associated with significant improvement in patient-reported outcome scores in several domains, suggesting that dietary counseling and medical therapy should be the first-line outpatient therapy for these diseases. See Video Abstract at

1 Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

2 Geisel School of Medicine, Lebanon, New Hampshire

Funding/Support: None reported.

Financial Disclosures: None reported.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons, Nashville, TN, May 19 to 23, 2018.

Correspondence: Srinivas Joga Ivatury M.D., M.H.A., Division Chief and Assistant Professor of Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03766. E-mail:

© 2018 The American Society of Colon and Rectal Surgeons