Management of Fissure Medical Management & Surgical by Dr Govind Kodwani

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Management of Fissure Medical Management
 
Anal fissure medical management
Anal fissures are tears in the lining of the anus, often caused by hard or bulky stools, straining during bowel movements, or chronic diarrhea. Medical management focuses on conservative treatments to promote healing and relieve symptoms, primarily through softening the stool and relaxing the anal sphincter muscles. 
 
1. Initial and conservative measures
  • Dietary Modifications:
    • Increase fiber intake: Consume a diet rich in fiber (25-35 grams daily) from fruits, vegetables, whole grains, and legumes to soften stools and facilitate passage.
    • Stay hydrated: Drink plenty of fluids, especially water (8-10 glasses daily), to prevent constipation and keep stools soft.
    • Avoid trigger foods: Reduce consumption of spicy foods, processed foods, excessive dairy, caffeine, and alcohol, as they can irritate the digestive system and contribute to constipation or diarrhea.
  • Lifestyle Changes:
    • Sitz Baths: Soaking the affected area in warm water for 10-15 minutes several times a day can relieve pain, reduce muscle spasms, and promote healing by improving blood flow.
    • Avoid Straining: Take your time during bowel movements and avoid excessive straining. Using a footstool can help achieve a more natural squatting position.
    • Proper Hygiene: Clean the anal area gently with warm water or unscented wipes after each bowel movement, and pat dry with a soft towel.
    • Regular Exercise: Engage in moderate physical activity like walking or yoga to promote healthy digestion and prevent constipation.
  • Over-the-counter medications:
    • Stool Softeners: Docusate sodium or fiber supplements like psyllium can help soften stools and make them easier to pass.
    • Topical Analgesics: Creams or ointments containing lidocaine or hydrocortisone can relieve pain and reduce inflammation. 
 
2. Pharmacological treatments
If conservative measures are insufficient, your doctor may recommend medications to relax the anal sphincter and promote healing: 
  • Nitroglycerin Ointment (Rectiv): A vasodilator that increases blood flow to the fissure and helps relax the anal sphincter. It is generally the first-line medical treatment when conservative measures fail. Side effects may include headaches, according to the Mayo Clinic. Healing occurs in about 50% of chronic fissures.
  • Calcium Channel Blockers: Nifedipine or diltiazem ointments can also relax blood vessels and muscles in the anal area, promoting healing with potentially fewer side effects than nitroglycerin. Healing rates range from 65% to 95%.
  • Botulinum Toxin (Botox®) Injections: Botox injections into the anal sphincter muscle can temporarily paralyze the muscle, reduce spasms, and allow the fissure to heal. This is typically considered if other medical treatments are ineffective. Healing rates are around 67.5% with a 50% recurrence rate at one year. 
 
3. Surgical options
If medical treatments are not successful in healing the fissure, surgery may be considered: 
  • Lateral Internal Sphincterotomy (LIS): This procedure involves cutting a small part of the anal sphincter muscle to release tension, reduce spasm, and improve blood flow, facilitating healing. LIS is considered the gold standard surgical treatment, with success rates over 90% in curing fissures. However, there is a risk of anal incontinence, though typically minor and often temporary.
  • Fissurectomy with Anoplasty: This procedure involves removing the fissure and repairing the defect with a flap of skin or rectal mucosa. It may be combined with Botox injections to relax the sphincter. This may be preferred in patients with a higher risk of incontinence, says the Cleveland Clinic. 
It is important to consult with a healthcare professional to determine the most suitable treatment plan for your specific situation. They can guide you through the process, evaluate the severity of the fissure, and assess potential complications or underlying conditions, according to Smiles Gastroenterology. 
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