Editing Fissure-in-ano (section)

== '''Treatment''' ==

=== Non-specific: (give to all patients) ===

** If chronic constipation: fibre + Movicol, avoid straining, good anal hygiene
** Local NSAID or LA preparations (esp. for acute) (can try haemorrhoid creams but may not help)
** Steroids can help sometimes
** Heat of any source is likely to help with spasm of anal muscle and therefore pain e.g. hot water bottle
** Sitz baths

=== First-line: (add as initial step for all chronic fissures and many acute fissures) ===

** Six weeks of GTN cream - apply over fissure after defecation and at night, up to four times a day if needed. Warn re: headache (30% get it, but normally gets better over time).
*** In the best study so far, from 2012, GTN improved healing rates from 35% to 49%
*** Don't use with hypotension, anaemia, glaucoma, Viagra
** Can also try nifedipine 0.5% + lignocaine 0.5% cream twice daily - needs to be compounded, so more expensive and takes longer.

=== Second-line: (once failed GTN) ===

** Botox injection. Inject to inter-sphincteric plane, away from the fissure, usually at 3 and 9 o'clock, although opinions vary - some say also anterior. Works in 50%, but recurrence rates at 1 year approach 50%. Can get transient incontinence, haematoma or sepsis, but unusual.
*** Cameron's suggests 20 units at 10 and 2 o'clock anteriorly in the inter-sphincteric groove. Sabiston's just says 20-100IU. UTD says it varies depending on preparation of botox used. I think 40 units on each side is a reasonable average.
*** Typically gives relaxation for three months
*** Can be done in office, or with a bit of sedation
*** Costs up to $600 for patients if they have to pay

=== Third-line: ===

** Anal dilatation - old, now not used.
** Internal sphincterotomy. Risk of incontinence 5%. Pre-op enema. Incontinence and soiling is usually transient up to 3/12, but 20% will get flatus incontinence. Complete long-term healing rates exceed 90%. '''Used only as last resort in women''' - exclude low-pressure fissure with clinical examination and manometry prior.
*** Lateral internal sphincterotomy is preferred method, can be performed either open or closed technique, fairly equivalent results, however most modern surgeons would stay well clear of the closed technique now.
***

{| class="wikitable"
|Open
|Parkes retractor to put fibres on stretch (if struggling to identify groove, try without muscle relaxant). Small, radially-oriented incision over the intersphincteric groove at 3 or 9 o'clock (not directly under the fissure - can lead to keyhole deformity and chronic leakage), dissecting out a plane both superficial and deep to the internal sphincter muscle, grasping it with Allis forceps, and cutting in the muscle with scissors or diathermy, for 5mm (previously up to length of the fissure, but this gives a higher risk of incontinence in long fissure; classically to the level of the pectinate line). Close the incision with absorbable suture in anoderm.
|-
|Closed
|Index finger in the anal canal, insert an 11-blade scalpel in the intersphincteric groove, and cutting the muscle towards the finger
|}

** Fissurectomy, with or without advancement flap
*** Especially when patients have a low baseline sphincter resting pressure