Anal fissure can be acute or chronic and is usually located in the midline of the anal canal, most commonly posteriorly. When a fissure is situated off the midline, other conditions, such as Crohn's disease (CD), mucosal ulcerative colitis, syphilis, tuberculosis, or leukemia, should be investigated.
The main goal of treatment is breaking the cycle of hard stool, pain, and reflex spasm. This objective can usually be achieved by increasing dietary fiber using fiber supplements, adequate liquid intake, and possibly stool softeners. Warm baths and topical anesthetics are helpful in providing symptomatic relief. The great majority of patients with acute anal fissure will respond to medical treatment. For patients with chronic anal fissure, several recently developed nonsurgical methods, including nitric oxide and botulinum toxin, are available (Utzig et al, 2003). Calcium channel blockers and a-adrenoceptor antagonists are still at the developmental stage. Nitric oxide ointment is used in a concentration of 0.2%, usually tolerable by patients, and applied in the anal canal 2 or 3 times daily for 8 weeks. Transient headache is a major side effect of this treatment, more commonly seen at higher concentrations of the compound.
Botulinum toxin injection is indicated for patients who are unresponsive to or have contraindications for nitric oxide treatment. Two, 0.1 mL doses of diluted toxin are injected beneath the anal fissure with a short, thin needle; injections can be repeated if necessary. There is a risk for minor incontinence, flatus, and soiling with this treatment. Surgical lateral sphincterotomy is associated with a greater risk of incontinence and is offered to patients who relapse or fail these newer nonsurgical methods. Sphincterotomy can be performed under local, regional, or general anesthesia as an open or closed procedure and is routinely performed on an outpatient basis.
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