Small linear tear in anal mucosa

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• Small linear tear in anal mucosa
• Majority occur in posterior midline
• In women 10 found in anterior midline less than
  1 in males

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Diagnosis

• 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.

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Examination

• Gentle retraction of buttocks pain is noted as
  fissure is exposed.
• Edematous 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
• Digital exam may be attempted with very well
  lubricated finger pushing away from fissure.
• Overhanging edges suggest chronicity

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Etiology

• 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

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Non 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

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• Diltiazem used in recent years as means of
  chemical 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

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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