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The role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure: a systematic review

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Abstract

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.

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Data Availability

Data available on request from the authors.

References  

  1. Dykstra MA, Buie WD (2019) Anal fissures. CMAJ 191:E737. https://doi.org/10.1503/cmaj.190074

    Article  PubMed  PubMed Central  Google Scholar 

  2. Beaty JS, Shashidharan M (2016) Anal fissure. Clin Colon Rectal Surg 29:30–37. https://doi.org/10.1055/s-0035-1570390

    Article  PubMed  Google Scholar 

  3. Lu Y, Kwaan MR, Lin AY (2021) Diagnosis and treatment of anal fissures in 2021. JAMA 325:688. https://doi.org/10.1001/jama.2020.16705

    Article  PubMed  Google Scholar 

  4. Youssef T, Youssef M, Thabet W et al (2015) Randomized clinical trial of transcutaneous electrical posterior tibial nerve stimulation versus lateral internal sphincterotomy for treatment of chronic anal fissure. Int J Surg 22:143–148. https://doi.org/10.1016/j.ijsu.2015.08.033

    Article  PubMed  Google Scholar 

  5. Altunrende B, Sengul N, Arisoy O, Yilmaz EE (2013) Transcutaneous electrical posterior tibial nerve stimulation for chronic anal fissure: a preliminary study. Int J Colorectal Dis 28:1583–1589. https://doi.org/10.1007/s00384-013-1743-4

    Article  PubMed  Google Scholar 

  6. Menteş BB, Tezcaner T, Yilmaz U et al (2006) Results of lateral internal sphincterotomy for chronic anal fissure with particular reference to quality of life. Dis Colon Rectum 49:1045–1051. https://doi.org/10.1007/s10350-006-0527-0

    Article  PubMed  Google Scholar 

  7. Emile SH, Abdel-Razik MA, Elshobaky A et al (2020) Topical 5% minoxidil versus topical 0.2% glyceryl trinitrate in treatment of chronic anal fissure: a randomized clinical trial. Int J Surg 75:152–158. https://doi.org/10.1016/j.ijsu.2020.01.143

    Article  PubMed  Google Scholar 

  8. Pinsk I, Czeiger D, Lichtman D, Reshef A (2020) The long-term effect of standardized anal dilatation for chronic anal fissure on anal continence. Ann Coloproctol. https://doi.org/10.3393/ac.2020.03.16

    Article  PubMed  PubMed Central  Google Scholar 

  9. Yilmaz G, Tanrikulu Y (2020) Short-term results of platelet-rich plasma in the treatment of chronic anal fissure: randomized controlled clinical study. Dis Colon Rectum Publish Ah: https://doi.org/10.1097/DCR.0000000000001903

    Article  Google Scholar 

  10. D’Orazio B, Geraci G, Famà F, et al (2020) Long term outcomes of fissurectomy and anoplasty for chronic anterior anal fissure without hypertonia: low recurrences and continence conservation. Ann Ital Chir 9

  11. Alawady M, Emile SH, Abdelnaby M et al (2018) Posterolateral versus lateral internal anal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. Int J Colorectal Dis 33:1461–1467. https://doi.org/10.1007/s00384-018-3087-6

    Article  PubMed  Google Scholar 

  12. Boland PA, Kelly ME, Donlon NE et al (2020) Management options for chronic anal fissure: a systematic review of randomised controlled trials. Int J Colorectal Dis 35:1807–1815. https://doi.org/10.1007/s00384-020-03699-4

    Article  CAS  PubMed  Google Scholar 

  13. Griffin N, Acheson AG, Tung P et al (2004) Quality of life in patients with chronic anal fissure. Colorectal Dis 6:39–44. https://doi.org/10.1111/j.1463-1318.2004.00576.x

    Article  CAS  PubMed  Google Scholar 

  14. Nasr M, Ezzat H, Elsebae M (2010) Botulinum toxin injection versus lateral internal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. World J Surg 34:2730–2734. https://doi.org/10.1007/s00268-010-0736-5

    Article  PubMed  Google Scholar 

  15. Valizadeh N, Jalaly NY, Hassanzadeh M et al (2012) Botulinum toxin injection versus lateral internal sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial. Langenbeck’s Arch Surg 397:1093–1098. https://doi.org/10.1007/s00423-012-0948-2

    Article  Google Scholar 

  16. de Rosa M, Cestaro G, Vitiello C et al (2013) Conservative versus surgical treatment for chronic anal idiopathic fissure: a prospective randomized trial. Updates Surg 65:197–200. https://doi.org/10.1007/s13304-013-0217-0

    Article  PubMed  Google Scholar 

  17. Aslam MI, Pervaiz A, Figueiredo R (2014) Internal sphincterotomy versus topical nitroglycerin ointment for chronic anal fissure. Asian J Surg 37:15–19. https://doi.org/10.1016/j.asjsur.2013.07.004

    Article  PubMed  Google Scholar 

  18. Cakir C, Idiz UO, Aydin I et al (2020) Comparison of the effectiveness of two treatment modalities for chronic anal fissure: Botox versus sphincterotomy. Turkish J Surg 36:264–270. https://doi.org/10.47717/turkjsurg.2020.4492

  19. Muñoz-Duyos A, Lagares-Tena L, Delgado-Rivilla S (2017) Treatment of chronic anal fissure with sacral neuromodulation: a pilot study. Tech Coloproctol 21:761–762. https://doi.org/10.1007/s10151-017-1683-z

    Article  PubMed  Google Scholar 

  20. Yakovlev A, Karasev SA (2010) Successful treatment of chronic anal fissure utilizing sacral nerve stimulation. WMJ 109:279–282

    PubMed  Google Scholar 

  21. Yakovlev A, Karasev SA, Dolgich OY (2011) Sacral nerve stimulation: a novel treatment of chronic anal fissure. Dis Colon Rectum 54:324–327. https://doi.org/10.1007/DCR.0b013e318202f922

    Article  PubMed  Google Scholar 

  22. Hunter CW, Falowski S (2021) Neuromodulation in treating pelvic pain. Curr Pain Headache Rep 25:9. https://doi.org/10.1007/s11916-020-00927-y

    Article  PubMed  Google Scholar 

  23. Hernández-Hernández D, Padilla-Fernández B, Castro Romera M et al (2021) Long-term outcomes of sacral nerve stimulation in pelvic floor dysfunctions. Int Neurourol J. https://doi.org/10.5213/inj.2040364.182

    Article  PubMed  PubMed Central  Google Scholar 

  24. Enomoto H, Nishizawa Y, Inamori K et al (2021) Sacral neuromodulation for the prevention of a permanent stoma in patients with severe defecation disorder following intersphincteric resection. Surg Today. https://doi.org/10.1007/s00595-021-02233-5

    Article  PubMed  Google Scholar 

  25. Fält UA, Lindsten M, Strandberg S et al (2019) Percutaneous tibial nerve stimulation (PTNS): an alternative treatment option for chronic therapy resistant anal fissure. Tech Coloproctol 23:361–365. https://doi.org/10.1007/s10151-019-01972-5

    Article  PubMed  PubMed Central  Google Scholar 

  26. Ruiz-Tovar J, Llavero C (2017) Percutaneous posterior tibial nerve stimulation vs perianal application of glyceryl trinitrate ointment in the treatment of chronic anal fissure: a randomized clinical trial. Dis Colon Rectum 60:81–86. https://doi.org/10.1097/DCR.0000000000000736

    Article  PubMed  Google Scholar 

  27. Moya P, Arroyo A, Del Mar AM et al (2016) Percutaneous posterior tibial nerve stimulation in the treatment of refractory anal fissure. Tech Coloproctol 20:197–198. https://doi.org/10.1007/s10151-015-1417-z

    Article  CAS  PubMed  Google Scholar 

  28. Mentes BB, Yüksel O, Aydin A et al (2007) Posterior tibial nerve stimulation for faecal incontinence after partial spinal injury: preliminary report. Tech Coloproctol 11:115–119. https://doi.org/10.1007/s10151-007-0340-3

    Article  CAS  PubMed  Google Scholar 

  29. Koel G, Houghton PE (2014) Electrostimulation: current status, strength of evidence guidelines, and meta-analysis. Adv wound care 3:118–126. https://doi.org/10.1089/wound.2013.0448

    Article  Google Scholar 

  30. Brégeon J, Coron E, Da Silva ACC et al (2016) Sacral nerve stimulation enhances early intestinal mucosal repair following mucosal injury in a pig model. J Physiol 594:4309–4323. https://doi.org/10.1113/JP271783

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement. PLoS Med 6:e1000097. https://doi.org/10.1371/journal.pmed.1000097

    Article  PubMed  PubMed Central  Google Scholar 

  32. Higgins JPT, Cochrane Collaboration (2019) Cochrane handbook for systematic reviews of interventions, 2nd Editio. Wiley-Blackwell Publishing Ltd

  33. Sterne JAC, Savović J, Page MJ et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 366:l4898. https://doi.org/10.1136/bmj.l4898

    Article  PubMed  Google Scholar 

  34. National Heart Lung and Blood Institute (2019) Quality assessment tool for observational cohort and cross-sectional studies. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools

  35. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13. https://doi.org/10.1186/1471-2288-5-13

    Article  PubMed  PubMed Central  Google Scholar 

  36. Nelson RL (2016) Chronic Anal Fissures. Am Fam Physician 93:498–499

    PubMed  Google Scholar 

  37. Ebinger SM, Hardt J, Warschkow R et al (2017) Operative and medical treatment of chronic anal fissures-a review and network meta-analysis of randomized controlled trials. J Gastroenterol 52:663–676. https://doi.org/10.1007/s00535-017-1335-0

    Article  PubMed  Google Scholar 

  38. Davis TJ, Schon LC (1995) Branches of the tibial nerve: anatomic variations. Foot ankle Int 16:21–29. https://doi.org/10.1177/107110079501600105

    Article  CAS  PubMed  Google Scholar 

  39. Kowalska B, Sudoł-Szopińska I (2012) Normal and sonographic anatomy of selected peripheral nerves. Part III: Peripheral nerves of the lower limb. J Ultrason 12:148–63. https://doi.org/10.15557/JoU.2012.0003

  40. Granger CJ, Cohen-Levy WB (2021) Anatomy, bony pelvis and lower limb, posterior tibial nerve

  41. Wienert V, Raulf F, Mlitz H (2017) Problems of defining chronic anal fissure. Anal fissure. Springer International Publishing, Cham, pp 51–54

    Chapter  Google Scholar 

  42. Rodríguez Carrillo R, Ruiz Carmona MD, Alós Company R et al (2019) Evaluation of the anorectal motor response after percutaneous stimulation of the posterior tibial nerve in patients with fecal incontinence. Tech Coloproctol 23:987–992. https://doi.org/10.1007/s10151-019-02092-w

    Article  PubMed  Google Scholar 

  43. Moya P, Parra P, Arroyo A et al (2016) Sacral nerve stimulation versus percutaneous posterior tibial nerve stimulation in the treatment of severe fecal incontinence in men. Tech Coloproctol 20:317–319. https://doi.org/10.1007/s10151-016-1443-5

    Article  CAS  PubMed  Google Scholar 

  44. Haas S, Brock C, Krogh K et al (2016) Does sacral nerve stimulation improve continence through enhanced sensitivity of the anal canal? A pilot study. Dis Colon Rectum 59:1039–1046. https://doi.org/10.1097/DCR.0000000000000677

    Article  CAS  PubMed  Google Scholar 

  45. Dudding TC, Parés D, Vaizey CJ, Kamm MA (2010) Sacral nerve stimulation for the treatment of faecal incontinence related to dysfunction of the internal anal sphincter. Int J Colorectal Dis 25:625–630. https://doi.org/10.1007/s00384-010-0880-2

    Article  PubMed  Google Scholar 

  46. Abramowitz L, Bouchard D, Souffran M et al (2013) Sphincter-sparing anal-fissure surgery: a 1-year prospective, observational, multicentre study of fissurectomy with anoplasty. Colorectal Dis 15:359–367. https://doi.org/10.1111/j.1463-1318.2012.03176.x

    Article  CAS  PubMed  Google Scholar 

  47. Evans J, Luck A, Hewett P (2001) Glyceryl trinitrate vs. lateral sphincterotomy for chronic anal fissure: prospective, randomized trial. Dis Colon Rectum 44:93–97. https://doi.org/10.1007/BF02234828

    Article  CAS  PubMed  Google Scholar 

  48. Carapeti EA, Kamm MA, McDonald PJ et al (1999) Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate. Gut 44:727–730. https://doi.org/10.1136/gut.44.5.727

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Chen H-L, Woo X-B, Wang H-S et al (2014) Botulinum toxin injection versus lateral internal sphincterotomy for chronic anal fissure: a meta-analysis of randomized control trials. Tech Coloproctol 18:693–698. https://doi.org/10.1007/s10151-014-1121-4

    Article  PubMed  Google Scholar 

  50. Kenefick NJ, Emmanuel A, Nicholls RJ, Kamm MA (2003) Effect of sacral nerve stimulation on autonomic nerve function. Br J Surg 90:1256–1260. https://doi.org/10.1002/bjs.4196

    Article  CAS  PubMed  Google Scholar 

  51. Emmanuel AV, Kamm MA (1999) Laser Doppler measurement of rectal mucosal blood flow. Gut 45:64–69. https://doi.org/10.1136/gut.45.1.64

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Mendell LM (2014) Constructing and deconstructing the gate theory of pain. Pain 155:210–216

    Article  PubMed  Google Scholar 

  53. Pereira PJS, Lerner EA (2017) Gate control theory springs a leak. Neuron 93:723–724

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Kemler MA, Barendse GAM, Van Kleef M, Oude Egbrink MGA (2000) Pain relief in complex regional pain syndrome due to spinal cord stimulation does not depend on vasodilation. Anesthesiology 92:1653–1660. https://doi.org/10.1097/00000542-200006000-00024

    Article  CAS  PubMed  Google Scholar 

  55. Kabay S, Kabay SC, Yucel M, Ozden H (2009) Efficiency of posterior tibial nerve stimulation in category IIIB chronic prostatitis/chronic pelvic pain: a Sham-Controlled Comparative Study. Urol Int 83:33–38. https://doi.org/10.1159/000224865

    Article  PubMed  Google Scholar 

  56. Istek A, Ugurlucan FG, Yasa C et al (2014) Randomized trial of long-term effects of percutaneous tibial nerve stimulation on chronic pelvic pain. Arch Gynecol Obstet 290:291–298. https://doi.org/10.1007/s00404-014-3190-z

    Article  PubMed  Google Scholar 

  57. Duelund-Jakobsen J, Buntzen S, Laurberg S, Lundby L (2020) Improved longevity and efficacy of sacral nerve stimulation by simple adjustments at follow-up. Color Dis 22:310–318. https://doi.org/10.1111/codi.14874

    Article  CAS  Google Scholar 

  58. Queralto M, Portier G, Cabarrot PH et al (2006) Preliminary results of peripheral transcutaneous neuromodulation in the treatment of idiopathic fecal incontinence. Int J Colorectal Dis 21:670–672. https://doi.org/10.1007/s00384-005-0068-3

    Article  CAS  PubMed  Google Scholar 

  59. Gallas S, Michot F, Faucheron JL et al (2011) Predictive factors for successful sacral nerve stimulation in the treatment of faecal incontinence: results of trial stimulation in 200 patients. Colorectal Dis 13:689–696. https://doi.org/10.1111/j.1463-1318.2010.02260.x

    Article  CAS  PubMed  Google Scholar 

  60. Douven P, Assmann R, Breukink SO et al (2020) Sacral neuromodulation for lower urinary tract and bowel dysfunction in animal models: a systematic review with focus on stimulation parameter selection. Neuromodulation 23:1094–1107. https://doi.org/10.1111/ner.13245

    Article  PubMed  PubMed Central  Google Scholar 

  61. Knowles CH, Horrocks EJ, Bremner SA et al (2015) Percutaneous tibial nerve stimulation versus sham electrical stimulation for the treatment of faecal incontinence in adults (CONFIDeNT): a double-blind, multicentre, pragmatic, parallel-group, randomised controlled trial. Lancet (London, England) 386:1640–1648. https://doi.org/10.1016/S0140-6736(15)60314-2

    Article  Google Scholar 

  62. Altunrende B, Sengul N, Arisoy O, Yilmaz EE (2013) Transcutaneous electrical posterior tibial nerve stimulation for chronic anal fissure: a preliminary study. Int J Colorectal Dis 28:1583–9. https://doi.org/10.1007/s00384-013-1743-4

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, University Hospital of Larissa, Mezourlo, 41110, Larissa, Greece

    Konstantinos Perivoliotis, Ioannis Baloyiannis & Konstantinos Tepetes

  2. Faculty of Medicine, University of Thessaly, Mezourlo, 41110, Larissa, Greece

    Dimitrios Ragias, Nikolaos Beis, Despoina Papageorgouli & Emmanouil Xydias

Authors
  1. Konstantinos Perivoliotis
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  2. Ioannis Baloyiannis
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  3. Dimitrios Ragias
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  4. Nikolaos Beis
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  5. Despoina Papageorgouli
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  6. Emmanouil Xydias
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  7. Konstantinos Tepetes
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Contributions

Conception and design of the study: perivoliotis, acquisition of data: beis, xydias, papageorgouli, Drafting the article: perivoliotis, ragias, Critical revision: baloyiannis, tepetes, Final approval: perivoliotis, tepetes.

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Correspondence to Konstantinos Perivoliotis.

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Perivoliotis, K., Baloyiannis, I., Ragias, D. et al. The role of percutaneous tibial nerve stimulation (PTNS) in the treatment of chronic anal fissure: a systematic review. Int J Colorectal Dis 36, 2337–2346 (2021). https://doi.org/10.1007/s00384-021-03976-w

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