Anal fissure

An anal fissure is a tear in the mucosa of the anal canal. The typical presentation of an anal fissure is pain during, and particularly after, defecation.

An anal fissure is a tear in the lining (mucosa) of the anal canal. The classical presentation of an anal fissure is pain during, and particularly after defecation. It is often described as a sharp, burning or stabbing pain. it may also present with bright red bleeding-either in the toilet bowl or on wiping.

Anal fissure can be a chronic, debilitating problem. It can be treated by both surgical and non-surgical therapies with significant improvements in quality of life.

The treatment of anal fissures is dependant on making the right diagnosis. Unfortunately there are a handful of symptoms that are shared by both serious, life threatening illness and benign self limiting diseases. You should see your GP if you have any bowel signs or symptoms and they may choose to refer you to a specialist for further evaluation.

Conservative Management

Conservative, or non surgical measures, should be the first step in management of anal fissures. The principle of management is to reduce the muscle tone in the internal anal sphincter.

This can be done using locally applied creams, such as topical nitric oxide donors (GTN) or calcium channel blockers (Nifedipine). These drugs work via slightly different routes to cause relaxation of the smooth muscle of the anal sphincter. They take between 6 – 10 weeks to work, but when used properly, result in a cure for over 60% of patients.

Botulinum toxin (Botox) also has a role in the management of anal fissures. Although botox appears as effective as topical treatments, it does have a higher recurrence rate and often requires repeated treatments for cure. Like topical creams, the benefit of botox therapy over surgery is that it does not risk permanently affecting continence.

Surgical Management

Lateral internal sphincterotomy

A lateral internal sphincterotomy (LIS) is an operation that reduces the anal tone by surgically dividing some of the internal anal sphincter. It remains the surgical procedure of choice for anal fissures with a high cure rate (>90%).

The main adverse side-efect of LIS is the small risk of incontinence associated with division of any of the internal anal sphincter, although most published literature would suggest that in the right hands, this should be less than 5%.

Surgery consistently offers better cure rates than conservative measures, and in some situations may be offered as first line therapy.

http://summaries.cochrane.org/