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International Journal of Colorectal... Jan 2022Anal fissure is a common condition that can be treated medically or surgically. Chemical sphincterotomy is often used before surgical intervention. This study aims to... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Anal fissure is a common condition that can be treated medically or surgically. Chemical sphincterotomy is often used before surgical intervention. This study aims to evaluate the effectiveness of topical agents for chemical sphincterotomy on healing of anal fissures and side-effects.
METHODS
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) compliant systematic review was performed using MEDLINE, EMBASE, Scopus, and CENTRAL databases. Eligible studies included randomized controlled trials which compared topical sphincterotomy agents with topical placebo agents or each other. Studies that included surgical treatments were excluded. Overall evidence was synthesized according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.
RESULTS
Thirty-seven studies met the study selection criteria. Seventeen studies show that glyceryl trinitrate (GTN) was significantly more likely to heal anal fissure than placebo (relative risk (RR) = 1.96, 95% confidence interval (95%CI) = 1.35-2.84, I2 = 80%). Eleven studies showed a marginally significant difference between healing rates for diltiazem vs GTN, RR = 1.16, (1.01-1.33) I2 = 48%. There was no significant difference in healing between diltiazem and placebo, RR = 1.65, (0.64-4.23), I2 = 92%. GTN significantly reduced pain on the visual analog scale compared to the placebo group, MD-0.97 (-1.64 to -0.29) I2 = 92%. There was high certainty of evidence that GTN was significantly more likely to cause headache than placebo (RR = 2.73 (1.82-4.10) I2 = 58%) and diltiazem RR = 6.88 (2.19-21.63) I2 = 17%.
CONCLUSION
There is low certainty evidence topical nitrates are an effective treatment for anal fissure healing and pain reduction compared to placebo. Despite widespread use of topical diltiazem, more evidence is required to establish the effectiveness of calcium channel blockers compared to placebo.
Topics: Administration, Topical; Chronic Disease; Diltiazem; Fissure in Ano; Humans; Nitroglycerin; Sphincterotomy; Treatment Outcome; Vasodilator Agents
PubMed: 34608561
DOI: 10.1007/s00384-021-04040-3 -
International Journal of Colorectal... Nov 2021This study was designed to summarize the current evidence regarding the role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure... (Review)
Review
PURPOSE
This study was designed to summarize the current evidence regarding the role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure (CAF).
METHODS
The present systematic review of the literature was conducted on the basis of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The primary endpoint of our study was the CAF recurrence rate. Quality assessment was based on the RoB 2 tool and the Case Series Quality Checklist.
RESULTS
Overall, 5 studies and 102 patients were included. A considerably heterogeneity in the neuromodulation technique and setting was identified. The pooled recurrence rate was estimated at the level of 19% (16/84). Post-interventional pain and Wexner scores were considerably reduced. The 2-month healing rate was 72% (18/25), whereas 73.6% of patients were symptom-free at 6 months.
CONCLUSIONS
PTNS is an effective alternative for the non-operative management of CAF. Due to several limitations further larger and higher quality studies are required.
Topics: Fecal Incontinence; Fissure in Ano; Humans; Quality of Life; Tibial Nerve; Transcutaneous Electric Nerve Stimulation; Treatment Outcome
PubMed: 34132862
DOI: 10.1007/s00384-021-03976-w -
European Journal of Pediatrics Jun 2021Group A Streptococcus has been associated with a perianal infection. We conducted a systematic review of the literature on childhood streptococcal perianitis in three...
Group A Streptococcus has been associated with a perianal infection. We conducted a systematic review of the literature on childhood streptococcal perianitis in three databases: Excerpta Medica, National Library of Medicine, and Web of Science. The main purposes were to document the clinical features, the tendency to recur, the association with an asymptomatic streptococcal throat carriage, the accuracy of rapid streptococcal tests, and the mechanism possibly underlying the acquisition of this infection. More than 80% of cases are boys ≤7.0 years of age with defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness. Perianitis is associated with a streptococcal tonsillopharyngitis in about every fifth case. The time to diagnosis is ≥3 weeks in 65% of cases. Recurrences occur within 3½ months in about 20% of cases. An asymptomatic group A streptococcal throat carriage occurs in 63% of cases. As compared with perianal Streptococcus A culture, the rapid streptococcal tests have a positive predictive value of 80% and a negative predictive value of 96%. It is hypothesized that digital inoculation from nasopharynx to anus underlies perianitis. Many cases are likely caused directly by children, who are throat and nasal carriers of Streptococcus A. Some cases might occur in children, who have their bottoms wiped by caregivers with streptococcal tonsillopharyngitis or carriage of Streptococcus.Conclusion: Perianitis is an infection with a distinctive presentation and a rather long time to diagnosis. There is a need for a wider awareness of this condition among healthcare professionals. What is Known: • Group A Streptococcus may cause perianitis in childhood. • Systemic antimicrobials (penicillin V, amoxycillin, or cefuroxime) are superior to topical treatment. What is New: • The clinical presentation is distinctive (defecation disorders, perianal pain, local itch, rectal bleeding, or fissure and a sharply demarcated perianal redness). • The time to diagnosis is usually ≥3 weeks. Recurrences occur in about 20% of cases.
Topics: Amoxicillin; Anal Canal; Child; Female; Humans; Male; Pharyngitis; Streptococcal Infections; Streptococcus pyogenes
PubMed: 33532889
DOI: 10.1007/s00431-021-03965-9 -
European Urology Focus Jan 2022Patients with chronic pelvic pain syndrome (CPPS) may have pain refractory to conventional management strategies. Botulinum toxin A (BTX-A) is a potential therapeutic... (Review)
Review
The Benefits and Harms of Botulinum Toxin-A in the Treatment of Chronic Pelvic Pain Syndromes: A Systematic Review by the European Association of Urology Chronic Pelvic Pain Panel.
CONTEXT
Patients with chronic pelvic pain syndrome (CPPS) may have pain refractory to conventional management strategies. Botulinum toxin A (BTX-A) is a potential therapeutic option.
OBJECTIVE
To evaluate the benefits and harms of BTX-A injections in the treatment of CPPS.
EVIDENCE ACQUISITION
A systematic review of the use of BTX-A in the treatment of CPPS was conducted (PROSPERO-ID: 162416). Comprehensive searches of EMBASE, PUBMED, Medline, and SCOPUS were performed for publications between January 1996 and May 2020. Identified studies were screened and selected studies assessed for quality prior to data extraction. The primary outcomes were improvement in pain and adverse events following treatment. Secondary outcomes included quality of life, global response assessment, sexual function, bowel function, and bladder function.
EVIDENCE SYNTHESIS
After screening 1001 abstracts, 16 studies including 11 randomised controlled trials were identified, enrolling 858 patients and covering a range of CPPS subtypes. Most studies showed high risks of bias and confounding across all domains. A narrative synthesis was performed as heterogeneity of included studies precluded a meta-analysis and calculation of pooled effect estimates of measured outcomes. BTX-A reduced pain significantly in patients with bladder pain syndrome in two studies and in patients with prostate pain syndrome in one study, but no included studies showed benefit for patients with gynaecological pelvic pain. Adverse event reporting was variable and generally poor, but no serious adverse events were described.
CONCLUSIONS
Beneficial effects of BTX-A on pain, quality of life, and functional symptoms were seen in patients with certain CPPS subtypes, but the current evidence level is too weak to allow recommendations about BTX-A use for treating CPPS.
PATIENT SUMMARY
Botulinum toxin A is used to treat different pain disorders, but current studies are of insufficient quality to determine whether it reduces pain and improves quality of life in patients with chronic pelvic pain. Further research is needed.
Topics: Botulinum Toxins, Type A; Humans; Male; Pelvic Pain; Quality of Life; Syndrome; Urology
PubMed: 33526405
DOI: 10.1016/j.euf.2021.01.005 -
International Journal of Colorectal... Oct 2020Anal fissure is the most common cause of severe anorectal pain in adults, contributing significantly to coloproctology workloads. There are a wide variety of management...
INTRODUCTION
Anal fissure is the most common cause of severe anorectal pain in adults, contributing significantly to coloproctology workloads. There are a wide variety of management options available, including topical nitrites, calcium channel blockers, botulinum toxin injection and sphincterotomy. The aim of this study was to review current options for the treatment of chronic anal fissure.
METHODS
A comprehensive search identifying randomized controlled trials comparing treatment options for anal fissure published between January 2000 and February 2020 was performed. The primary outcome assessed was healing at 8 weeks post commencing treatment. Secondary outcomes included recurrence, intolerance of treatment and complications.
RESULTS
A total of 2822 studies were identified. After removal of duplicates and non-relevant studies, we identified nine randomized controlled trials which met pre-defined criteria. There was a total of 775 patients. At 8 weeks, healing rates were 95.13% in those treated with sphincterotomy, 66.7% in the botulinum toxin group, 63.8% in the nitrate group, 52.3% for topical diltiazem and 50% for topical minoxidil. Recurrence was highest amongst those treated with botulinum toxin injection (41.7%) and lowest for sphincterotomy (6.9%). Although the absolute number is low, there was a risk of permanent incontinence with sphincterotomy.
CONCLUSION
This review of the randomized control data demonstrates that healing was significantly higher amongst those treated with sphincterotomy versus more conservative modalities. Topical nitrites had similar outcomes to botulinum toxin injection but were poorly tolerated in comparison to other treatments. The benefit of sphincterotomy was at a cost of increased complications, notably permanent incontinence.
Topics: Adult; Anal Canal; Botulinum Toxins, Type A; Chronic Disease; Fissure in Ano; Humans; Neoplasm Recurrence, Local; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 32712929
DOI: 10.1007/s00384-020-03699-4 -
Diseases of the Colon and Rectum Nov 2019Few data are published on perianal tuberculosis.
BACKGROUND
Few data are published on perianal tuberculosis.
OBJECTIVE
This study aimed to determine the best method to diagnose tuberculosis in patients with fistula-in-ano and to conduct a systematic review to determine the incidence and characteristics of tuberculosis fistula-in-ano.
DATA SOURCES
The prospective study data and existing literature were derived from PubMed, Google scholar, and Scopus STUDY SELECTION:: Prospective analysis of patients with tuberculous fistula-in-ano treated between 2014 and 2018 was conducted, and a systematic review of studies describing ≥3 patients with tuberculosis fistula-in-ano was completed.
INTERVENTION
Testing of tuberculosis was performed by histopathology or polymerase chain reaction of tissue or pus from the fistula tract.
MAIN OUTCOME MEASURES
The primary outcomes measured were the detection rate of various tests to detect tuberculosis in fistula-in-ano and the prevalence rate of tuberculosis in simple versus complex fistulas.
RESULTS
In 637 samples (410 patients) tested, tuberculosis was detected in 49 samples (43 patients). Additional samples (n = 106) sent in patients with a high index of suspicion tested positive in 14 more patients. Thus, overall, 63 samples tested positive in 57 patients (total: 743 samples in 410 patients were tested). Tuberculosis was detected in 2 of 181 patients (1.1%) in tissue (histopathology), in 28 of 341 patients (8.2%) in tissue (polymerase chain reaction), and in 19 of 115 patients (16.5%) in pus (polymerase chain reaction) samples. To detect tuberculosis, tissue (polymerase chain reaction) was significantly better than tissue (histopathology) (28/341 vs 2/181, p < 0.00001) and pus (polymerase chain reaction) was significantly better than tissue (polymerase chain reaction) (19/115 vs 28/341, p < 0.0009). Tuberculosis was significantly more common in complex fistulas than in simple fistulas (20.3% vs 7.2%, p = 0.0002). The systematic review (n = 199) highlighted that tubercular fistulas are more common in recurrent and complex fistulas and in tuberculosis endemic regions.
LIMITATIONS
The true sensitivity and specificity of each testing modality could not be determined because not all patients with tuberculosis fistula-in-ano were tested by every diagnostic modality studied.
CONCLUSIONS
The tuberculosis detection rate of polymerase chain reaction was significantly higher than histopathology. Among polymerase chain reaction, pus had higher detection rate than tissue. Tuberculosis was associated with more complex and recurrent fistulas.
Topics: Aftercare; Antitubercular Agents; Bacteriological Techniques; Female; Fissure in Ano; Humans; Incidence; India; Magnetic Resonance Imaging; Male; Middle Aged; Mycobacterium tuberculosis; Outcome Assessment, Health Care; Polymerase Chain Reaction; Rectal Fistula; Recurrence; Reproducibility of Results; Streptomycin; Surgical Procedures, Operative; Tuberculosis, Gastrointestinal
PubMed: 31596764
DOI: 10.1097/DCR.0000000000001493