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Anal Fissure

REF:
Web MD:  http://www.webmd.com/digestive-disorders/tc/anal-fissure-treatment-overview  
http://www.medicinenet.com/anal_fissure/article.htm  
http://www.medicinenet.com/anal_fissure/page3.htm

What are anal fissures?

An anal fissure is a cut or tear occuring in the anus (the opening through which stool passes out of the body) that extends upwards into the anal canal. Fissures are a common condition of the anus and anal canal and are responsible for 6-15% of the visits to a colonic and rectal (colorectal) surgeon.

Anal fissures are fairly common and usually heal without treatment or with nonsurgical treatments.
Most short-term anal fissures can heal with home treatment in 4 to 6 weeks.
Pain during bowel movements usually goes away within a couple of days of treatment.

What causes anal fissures?

Anal fissures are caused by trauma to the anus and anal canal. The cause of the trauma usually is a bowel movement, and many patients can remember the exact bowel movement during which their pain began. The fissure may be caused by a hard stool or repeated episodes of diarrhea. Occasionally, the insertion of a rectal thermometer, enema tip, endoscope, or ultrasound probe (for examining the prostate gland) can result in sufficient trauma to produce a fissure.

What are the treatments for anal fissures?

Home treatment for Acute Anal Fissure:

• Sitz bath (sitting in warm water) for 20 minutes 2 times a day,
• Increasing fiber and fluids in the diet, and
• Stool softeners or laxatives to have pain-free bowel movements.
• Topical hydrocortisone cream to help reduce any inflammation & to ease discomfort.  
• Topical or Oral Pain med if needed for severe pain
  - Anesthetics and steroids. Topical anesthetics (e.g., Xylocaine, lidocaine, tetracaine, pramoxine) are recommended especially prior to a bowel movement to reduce the pain of defecation. Often, a small amount of a steroid is combined in the anesthetic cream to reduce inflammation.
  The use of steroids should be limited to two weeks because longer use will result in thinning of the anoderm (atrophy), which makes it more susceptible to trauma.

Chronic Anal Fissure Treatment:
A fissure that has not healed after 6 weeks is considered long-term, or chronic, and may need additional treatment.

Treatment:

1. A 0.2% (not 2%) nitroglycerin cream can reduce the pressure in the internal anal muscle (sphincter) and allow the fissure to heal. A pea-sized dot of cream is massaged into the fissure and the surrounding area.
   - Do not use a larger amount at one time, because this medicine can cause headaches, lightheadedness, or fainting from low blood pressure. It is a good idea to either wear gloves when applying the nitroglycerin cream or wash your hands right after.
   - One randomized, controlled trial has demonstrated the healing of anal fissures in 68% of patients with nitroglycerin as compared to 8% of patients treated with placebo (inactive treatment). Other studies have shown a 33-47% recurrence rate of fissures following treatment with nitroglycerin.
2. The calcium channel blockers nifedipine and diltiazem also may help healing, also by reducing the pressure in the internal anal sphincter. These two medicines are available as pills.
   Nifedipine ointment (2%) is applied in a manner similar to nitroglycerin ointment, but seems to produce fewer side effects.
3. Botulinum toxin (Botox) may be injected into the internal anal sphincter. Botox causes temporary paralysis of muscle, which can reduce muscle tension and help the anal fissure heal.
4. Surgery - lateral internal sphincterotomy  
   - Surgery may be done when more conservative treatments fail to heal an anal fissure.

2008