1. Anal Fissure: the Facts (Are there any?) Tamzin Cuming Colorectal Consultant Homerton University Hospital

2. Classic fissure in ano 90% posterior < 6 weeks: acute > 6 weeks + sentinel pile + visible sphincter = chronic

3. When is a fissure not a fissure? Be suspicious multiple or lateral – Crohn’s

4. ?fissure Post-childbirth woman – ‘low-pressure fissure’ – Anterior – Weak pelvic floor – rectocele

5. ?fissure In an old person – Cancer: – anal cancer even – (esp if HIV+)

6. ?fissure In someone with bad skin Eczema, psoriasis, dermatitis

7. OK some facts 90% are the fissures you are thinking of – Young man – High pressure anus – Split is posterior Because the blood supply is worst at the back The pain is from anal spasm

8. Management Acute Lignocaine, Fybogel and sympathy (90% cure) Chronic ALL THE TREATMENTS (except one) TREAT THE SPASM and let the body heal the fissure

9. Anal spasm treatment I Give it nitrous oxide – GTN0.4% >0.2% 25% headache (cling film) Cure 60% 1 Recurrence 50% 2 – Diltiazem 2% 15% pruritis Cure: 75% 3 RRecurrence 0.66 4 Why not block the Ca 2+ channels? – nifedipene top/oral 1 2006 Cochrane Review Nelson 2 DCR 2004;47:422-431 3 Steele SR 2006 Aliment Pharm 4 Sajid MS Colorectal Dis 2013

10. Anal Spasm treatment II Paralyse it! At least Botox wears off Clinical conviction Less expensive than 5 years ago Cochrane review Healing rate variable: 75% Recurrence rate 50% at 4 yrs 10% temporary incontinence No better than GTN 0.2% More expensive than NO (£77/pt) Works for NO-resistant Nelson 2012; NICE ESUOM14; Lindsey DCR 2004

11. Anal spasm treatment CUT IT! – Lateral anal (internal) sphincterotomy – FINALLY! A CURE! 95% – 5% up to 47% ‘mild’ incontinence forever No longer Posterior sphincterotomy: key-hole deformity Lord’s anal stretch

12. If all else fails Histology to exclude odd things plus DOSH Advancement flap anoplasty – 48% cure with 0% incontinence – Also a treatment for low pressure fissures – recur if pelvic floor dysfunction not addressed

13. Anoplasty options V-Y or rotational island advancement flap Mucosal advancement flap Cutaneous advancement flap using sentinel pile (SCAFA) Probably fail due to same high pressure ischaemia – Botox AND anoplasty if high pressures – LAS and anoplasty

14. Conclusion If it’s not at the back in a young man: worry – (but you don’t need to do a PR) If it is: Diltiazem is good Botox is good LAS short term good long term bad and Anoplasty can be good if desperate