Acute fissure

Linear defect in the epithelial lining of the anal canal distal to the dentate line

Chronic fissure

•           When failed to heal within 6-8 weeks

•           Exposed internal anal sphincter muscle fibre

•           Skin tag

•           Internal hypertrophied anal papilla

It most commonly occurs in the midline posteriorly. Most cases are idiopathic and may be due to trauma, inflammatory bowel diseases and sexually transmitted disease.

Salient features

•           There is severe pain on defecation.

•           Bleeding is usually small and occurs as a streak by the side of stools.

•           On examination, a longitudinal ulcer is seen in the midline posteriorly that may be covered by a skin tag. There is local inflammation and induration.

Treatment

The aim of the treatment is to obtain complete relaxation of the sphincter and provide relief from pain.

A.  Medical therapy

Breaking the cycle of pain, spasm, ischemia.

•           Warm sitz bath

•           Stool- bulking agents

•           200-500mg of 0.2% Nitroglycerin paste locally (34% headache, 60% heals at 8 wks)

•           Calcium channel blocker locally— Diltiazem (2%), Nifedipine

•           Botulinum toxin -temporary muscle paralysis (73% heals at 8 wks)

•           Steroids/ topical creams are of limited utility.

B.  Surgery

Lateral anal sphincterotomy.

Anal dilatation - Discouraged (incontinence rate -12.5% to 24.3%).

C.  Patient education

Local care of the region and sitz bath should be regularly taken.

Avoid constipation by the use of high fiber diet and use of purgatives.