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

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.

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

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

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

Diltiazem used in recent years as means of “chemical sphincterotomy” 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

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