CAFA with lower anal pressure are more likely to heal following treatment with 20 units of botulinum toxin. But medical therapy in CAF is marginally better than placebo, and far less effective than surgery. Only external perineal pressure was used for haemostasis.Ĭhronic anal fissure is treated by a variety of medications which may include botulinum toxin as local injection and bran as laxative. The sentinel piles and papilloma ( Figure 2d) excision completed the procedure. With the guidance of left index finger in the anorectal lumen, the tight felt internal sphincter was hooked out side ( Figure 2c) and transected. 2-3 mm incision was made and dilated with a curved haemostat ( Figure 2b). UIS was done at 3 ‘O’ clock and BIS at 3 and 9 ’O’ clock position.

Any sentinel papilloma if present was excised. In lithotomy position, digital examination and proctoscopy was done to confirm the diagnosis ( Figure 2a) and rule out any other pathology. The surgeries were done under local infiltration of a mixture of 10 ml 2% Xylocaine, 10 ml 0.5% Bupivacaine, 5 ml of 7.5% sodium bicarbonate and 10 ml Normal saline, supplemented with 2 mg/Kg of intra-venous Propofol as initial dose followed by aliquots of 10 mg subsequently if required. Randomization was done by by sealed envelope method. The nature of study was explained to the patients and the study was received consent from the ethics committee. Diagnosis was based on clinical anal examination.

The exclusion criteria were: previous ano-rectal surgery, oral medication of nitrates and calcium channel blockers, as they are known agents for internal sphincter relaxation, and multi-parous women with old perineal tear. This combination therapy will heal almost all fissures.220 cases were recruited from 01 Jan 04 to 31 Aug 06 (Figure 1, Consort Flow chart) Eligibility criteria were: Adult patients > 18 years with a history of CAF for more than oneyear. Our anal fissure treatment with custom topical compounds, stool softeners, sitz baths, and ligation of enlarged hemorrhoids is very successful. Patient should be aware there is a slight chance of incontinence with surgery, but this usually improves with time. It is done in an operating room under anesthesia. This operation is called an internal sphincterotomy. In the rarest and most severe cases of anal fissures, surgery that involves cutting the underlying muscle may be required. These tags may be excised, which can be done under local anesthesia in the office. Our doctors have high quality custom compound ointments that they can prescribe.Īs the body tries to heal the fissure it may form a lump in the skin around the outside of the fissure, a sentinel pile. The ointment is continued for at least 8 weeks to prevent recurrence of the fissure. The ligation of associated hemorrhoids also lowers the rectal pressure which aides in the healing of the fissure. Under normal conditions, anal fissures are treated with topical smooth muscle relaxer ointment, stool softeners, and tub baths. These types of fissures treatments lower the pressure of the rectal muscle, making it easier for the fissure to heal. Muscle relaxation injections may be occasionally injected for difficult cases. Your doctor may recommend topical medications (smooth muscle relaxers) that relax smooth muscle. Relaxation of the internal sphincter allows for the fissure to heal. Do not agree to a possible unnecessary operation until you have tried our non-surgical office treatment. We have found most fissures respond to our non-operative treatment.

This is not necessary and may lead to incontinence. In the past doctor’s frequently recommended surgery for fissures. It lies under the fissure and in response to irritation goes into spasm leading to severe pain. The internal sphincter aids in continence. The internal sphincter is a smooth muscle similar to the heart. We are frequently told it is a “miracle”. Our treatment can lead to very rapid improvement. The combination of hemorrhoids and fissures can be very painful. Fissures are frequently associated with internal hemorrhoids. Self-help measures include warm water baths, stool softeners, and lubrication.

Sentinel pile or skin tag