![]() The goal of this is once again, to effect relaxation of the internal anal sphincter. This is indicated when a trial of medical treatment has failed to produce any significant healing of the fissure, which is most commonly manifested as a persistence of pain. The comprehensive Cochrane review has found that the success rates of topical nitrates are only marginally better than placebo in the management of chronic anal fissures. In addition, patients on Sildanefil (Viagra) should avoid this form of treatment in view of the increased risk of hypotension. These commonly occur about 30 minutes following application. Patients must be warned of the reported 20-30% incidence of headaches as a side effect. ![]() Application around the perianal skin 2 to 3 times a day usually suffices. Alternatively, commercially available preparations e.g. Most pharmacies are able to custom prepare these on request. These are prepared in the form of a glyceryl trinitrate (GTN) paste or ointment at a 0.2% concentration. Topical NitratesThese have been shown to improve the local blood flow and reduce the pressure exerted by the internal anal sphincter, thereby increasing the likelihood of healing. To maintain the passage of soft stools in order to minimize further trauma to the mucosa around the fissure.To promote internal anal sphincter relaxation.The main intents of medical therapy are threefold:.The following serves to summarize the treatment options the current available evidence on their efficacy. It is therefore imperative that physicians be cognizant of the evidence that is available for each one of these. The medical literature is filled with numerous studies addressing the efficacy of non-surgical treatments for anal fissures. Again, most fissures can be diagnosed by simple parting of the perianal skin. Attempting this in a patient with anal fissure is almost impossible without inflicting severe pain. Non prolapsing internal hemorrhoids can only be diagnosed through an anoscopic or proctoscopic examination. Although this may be difficult at times, a properly performed physical examination of the perianal region is often revealing. It is imperative that the examining physician attempt to differentiate between anal fissures and hemorrhoids. Fibrosis of the exposed internal anal sphincter fibres.Sentinel tag - these are hypertrophic skin tags at the distal edge ofthe fissure and are very commonly mistaken as external hemorrhoids and hence the misnomer 'sentinel pile'.These fissures will have developed secondary changes which include the following: Chronic Anal FissureA fissure which fails to heal after 4 weeks is considered chronic. Located between the anal verge and the dentate line, these tears may deepen to expose the underlying internal anal sphincter. This is a superficial tear in the vertical axis of the squamous lining of the anal canal. Symptoms of pruritus or perianal skin irritation may also be present. This is usually accompanied by bright red per rectal bleeding. Patients with anal fissures present with a very classical history of a 'searing' or 'tearing' type of pain which is associated with each bowel movement.
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