‡ Small linear tear in anal mucosa

‡ Majority occur in posterior midline

‡ In women 10% found in anterior midline;
less than 1% in males
 `iagnosis
‡ History alone usually renders dx. w/
symptoms of tearing, knife-like pain w/ or
w/o bleeding, usually associated with
forceful hard stool or diarrhea.
‡ Pain starting w/ defecation lasts minutes to
hours
‡ Fear of symptoms often causes pt. to
withhold stooling, exacerbating
constipation, impaction and pain.
 xamination
‡ Gentle retraction of buttocks; pain is noted as
fissure is exposed.
‡ dematous sentinel tag may be present
‡ White fibers of internal sphincter may be seen in
base of fissure or may be covered by thin
epithelium which may hide the fissure
‡ `igital exam may be attempted with very well
lubricated finger pushing away from fissure.
‡ Overhanging edges suggest chronicity
 tiology
‡ Linear tear along the longitudinal axis of
overlying epithelium covering internal sphincter.
‡ Higher resting internal sphincter pressures are
found in people with fissures
‡ Shouten and associates have suggested decrease in
blood flow as cause of fissures, accounting for the
pain
‡ Because increased resting anal pressure is
associated with decreased mucosal blood flow-
two may be related
 ðon operative treatment
‡ Mainstay of tx. Is avoidance of straining at stool
and use of sitz baths multiple times a day
‡ Hydrocortisone creams and local anesthetic
ointments such as lidocaine may help
‡ Botulinum toxin injected into external anal
sphincter on both sides of fissure
‡ Topical nitroglycerin ointment ranging fr. 0.15%
to 0.8% three to four times a day; concentration
greater than 0.2% required to decrease MRAP by
25% but headaches increase accordingly
‡ `iltiazem used in recent years as means of
³chemical sphincterotomy´. Best used as
2% topical preparation. Side effects
generally less frequent vs. nitroglycerin
‡ Anal dilatation incl. controlled dilation with
rectosigmoid balloon under anorectal loval
anesthesia
 Operative techniques
‡ Most sphincterotomies done as outpatient
procedures with sedation and IV anesthesia.
‡ Intersphincteric groove palpated laterally.
Radial incision no more than 5mm is made