Percutaneous tibial nerve stimulation (PTNS): an alternative treatment option for chronic therapy resistant anal fissure

Abstract

Background The aim of the present study was to evaluate percutaneous tibial nerve stimulation (PTNS) for treatment resistant chronic anal fissure. Methods Consecutive patients with chronic anal fissure were treated with neuromodulation via the posterior tibial nerve between October 2013 and January 2014. Patients had PTNS for 30 min on 10 consecutive days. All patients had failed conventional medical treatment. The visual analogue scale (VAS) score, St. Marks score, Wexner’s constipation score, Brief Pain Inventory (BPI-SF), bleeding and mucosal healing were evaluated before treatment, at termination, after 3 months, and then yearly for 3 years. Results Ten patients (4 males and 6 females; mean age 49.8 years) were identified but only 9 were evaluated as one patient’s fissure healed before PTNS was started. At 3-year follow-up, fissures had remained completely healed in 5 out of 9 patients. All patients stopped bleeding and were almost completely pain-free at 3 years (VAS p = 0.010) and pain relief improved from 50% at completion to 90% at 3 years. The patients’ Wexner constipation scores improved significantly ( p = 0.007). Conclusions In this small series, PTNS enhanced healing of chronic anal fissure and reduced pain and bleeding with an associated improvement in bowel function.

Percutaneous Tibial Nerve Stimulation in Chronic Post-Surgical Anorectal Pain: A Case Report

“…PTNS has been more extensively studied in the treatment of pelvic organ dysfunctions commonly associated with CPP. Recent reviews show promising results both in lower urinary tract dysfunction [11], FI [13], and as a treatment option for CAF [8]. However, larger-scale studies are needed and there is no published evidence of PTNS efficacy on chronic anorectal pain.…”

“…Studies show that sacral nerve stimulation (SNS) is an effective alternative therapeutic option for CAF in patients who choose not to pursue more invasive surgical interventions [7]. The effect of SNS on anorectal function occurs at the pelvic afferent or central level via the S2–S4 nerves which contain fibres of the pudendal nerve and afferent sensory fibres from the anal sphincter and pelvic floor [8]. Based on this, Altunrende et al [9] investigated the effect of a less invasive treatment with transcutaneous tibial nerve stimulation (TTNS) in patients with CAF.…”

“…It is postulated that it exerts its effect through indirect modulation of the sacral plexus via the posterior tibial nerve which contains sensory, motor, and autonomic fibres from the fourth lumbar to third sacral roots. Its mechanisms of action are yet to be fully understood, but extrapolation from SNS evidence suggests sensory and motor neuromodulatory effects [8].…”

Electro-Neuromodulation for Colonic Disorders—Review of Meta-Analyses, Systematic Reviews, and RCTs

“…For constipation, PTNS had little success (141, 142) or some effect (143) and stimulation at ST36 (knee) may be more effective than across the ankle (144). PTNS enhanced healing of anal fissures (145–147).…”

Evaluation of the Mechanical Properties of Anorectal Tissues and Muscles by Shear Wave Elastography in Anal Fıssure Disease

“…In anal fissure pathophysiology, internal anal sphincter muscle spasm and tissue ischemia are thought to play a role. 6 Ischemia recovery occurs with fibrosis.…”