Pathophys:Once started, perpetuated by firm bowel movements. Assoc w and perpetuated by spasm of internal (not external) anal sphincter (Nejm 1999;341:65)
Sx:Rectal pain
Si:Posterior (90%) fissure/ulcer between anal verge and dentate line; skin tag at anal verge; prominent proximal papilla
r/o inflammatory bowel disease, esp if not posterior
Rx:
(Nejm 1999;341:65)
1st: Nitroglycerine 0.2% ointment (nitropaste diluted × 10) bid × 6 wk; 60% cure; adv effects: headache
2nd: Botulinum toxin injections (Nejm 1998;338:217) 20 U in each side of anal sphincter, 96% cure
3rd: Surgical lateral internal sphincterotomy; 90-95% cure; cmplc: permanent weakness of anal sphincter w gas, mucus, and rarely stool leakage