Clinical outcome of manual dilation of the anus (MDA), for anal fissure at Mulago Hospital

Abstract

Background: The modern treatment of chronic anal fissure is aimed at reducing the resting anal pressure. This can be achieved either by a conservative approach as the first line of clinical management or surgery, if the conservative approach is unsuccessful. Manual Dilation of the Anus (MDA) has been the mainstay of treatment for this condition for the last 160 years. It has its proponents and critics. To date there has been a variation in practice with some authorities still practicing MDA and others preferring Lateral Internal Sphincterotomy (LIS) as the treatment of choice. Both surgical options mechanically relax the internal anal sphincter, reduce the resting anal tone, improve or restore perfusion in the anoderm resulting into healing. A scientific analysis of manual anal dilation however has not been made in this population. The aim of this prospective descriptive study was to determine the outcome of standardized gentle MDA in the management of chronic fissure in this setting, and to identify the complications and the overall patient satisfaction as regards the final result. Methods: Data was prospectively collected from patients aged between 18-61 years. Recruitment, clinical evaluation and HIV screening were done and a surgical intervention (MDA) offered. Recruitment was done concurrently with follow up lasting four weeks. Postoperative status was assessed at weekly intervals for complications or improvement. Symptomatic assessment and overall patient satisfaction was then assessed on a scale at the end of the follow up period. Results: A total of forty eight (48) patients were recruited and underwent surgery, three were lost to follow up and forty five (15) were followed up. The results of 45 patients are presented. The male to female ratio was 1:2:5 The mean duration of symptoms was 30 weeks and ranged between 6-60 weeks. Over 80% of the patients had failed to improve on previous conservative therapy prior to admission. MDA completely relieved symptoms in the majority of subjects (84%) with complete resolution of symptoms of symptoms within the second and third week. No case of incontinence featured as a reason for poor result in this series of patients. The poor result was attributed to only one case that had transient disturbance of continence in the first week of follow up. Six (6%) of the patients did not show improvement and this was attributed to infection, progression to ulcer and mucosal prolapse. Overall the results of MDA were good in sixty eight (68.9%), satisfactory in 20% and poor in 11.1%. Conclusion: In view of the improvement observed and minimal cases of complications this study demonstrates a success rate of over 80%. I would still recommend MDA in our situation as a useful mode of treatment for chronic anal fissure since it is associated with minimal postoperative complications. A positive HIV status should not be a contraindication to MDA for as long as it is done gently with standard four fingers for four minutes.