Anal fissure Is defined as crack in the skin lined part of the anal canal, which often shows considerable

reluctance to heal. Pathology Nearly always in the midline of the posterior wall of the anal canal Anterior fissures are more common in women, due to sex, pregnancy. Fissures lie in the cutaneous portion of the anal lining between the level of anal valve and the anal orifice. It is situated superficial to the lower third of the internal sphincter muscle. Swelling of the skin at the lower end of the fissure actually at the level of the anal orifice so that it form a tag like swelling the so called sentinel pile. This is due to low-grade infection and lymphatic edema. Long-standing fissure has development of fibrous induration of the lateral edges of the fissure. After several months the muscle may become fibrosed in its spastic condition so that a rather fibrotic tightly contracted internal sphincter may result. Etiology Passage of large hard motion Spasm of the sphincter spasm of the anus brings the lateral edges of the fissure together so that discharge from the crack is dammed back or pocketed and healing by granulation from the depth cannot take place.

Symptoms Pain is the chief complaint. Described as sharp, cutting, or tearing sensation during actual passage of the motion. Bleeding bleeding is quite slight and amounts to little more than a streaking of the motion. Swelling of the sentinel tag Discharge and pruritus Urinary symptoms dysuria and retention or increased frequency.

Differential diagnosis Pruritus ani with superficial cracks of the anal skin Ulcerative colitis or proctocolitis with associated anal fissure Crohns disease with anal ulceration Squamous cell carcinoma of the anus or adenocarcinoma of the rectum invading the anal canal Syphitic ulcers chancre in its initial stage may present as anal fissure. Tuberculous ulcers 1

Idiopathic stenosis of internal sphincter

Treatment Conservative treatment avoidance of constipation, use of anesthetic ointment, use of anal dilator, injection of long acting anesthetics. Operative treatment Lords procedure advantage no after care is required. Excision of anal fissure popularized by Gabriel (1948) excised the triangular portion of the anal mucosa containing the fissure and divided the internal sphincter exposed during excision. Proposed that the external drainage was better due to triangular nature of the wound and helps in better epithelization. Internal sphincterotomy Open internal sphincterotomy (lateral sphincterotomy) Closed internal sphincterotomy (Lateral subcutaneous internal sphincterotomy) Posterior sphincterotomy was not favoured as it caused high degree of anal incontinence. During the first few weeks after operation control of flatus was impaired by almost 35% and for feces by 15%. Anal discharge with resulting fecal staining of the underclothes. This was due to the longitudinal furrow that developed in the scar of the sphincterotomy wound in the posterior wall of the anal canal. Fecal matter and flatus could leak down this groove despite the action of the sphincter musculature. The lateral sphincterotomy does not cause these problems.