• Sentinel piles may be seen at the distal end of the ssure.

Anal manometry is employed to measure the resting anal pressure. Anal ssure patients have a higher resting pressure [31].

The management of ssure include

They act by decreasing the intracellular availabil­ity of calcium [42]. The topical nifedipine reduces anal sphincter tone, which helps in promoting blood ow and faster healing. Nifedipine com­bined with 2% lidocaine jelly produces a dual effect as lidocaine causes numbness of the area but does not heal the ssure. Diltiazem promotes muscular sphincter relaxation by inhibiting cal­cium channels in smooth muscles [8]. According to studies, topical nifedipine has a greater healing rate than diltiazem [43].

The patient is positioned in the left lateral or lithotomy position. An insulin syringe with a needle is used for injecting. The injection is given into the internal anal sphincter at 5 and 7 o’clock on both sides of the ssure [45]. The total dose given is 30–40units.

• Fissurectomy

It aims to successfully “freshen” the ssure mar­gins and convert a chronic ssure into an acute one [52].

created with the closed approach, but both tech­niques are equally effective.

The results of the anal advancement ap are

However, many surgeons have combined tech­niques or modied anoplasty to enhance effec­tiveness [61].

Lateral internal sphincterotomy with laser can be performed either by open or closed technique. The principle and the basic technique remains the same as in open or closed lateral internal sphinc­terotomy. The only difference is that instead of scissors or cautery, a laser ber is used for sphinc­ter division. The cutting by laser is precise and immediate hemostasis is achieved.

• If the anal tone is normal, sphincterotomy should never be performed. The treatment of choice is the anal advancement ap.

eral internal sphincterotomy, Gupta etal. dis­covered that 4.4% of open lateral sphincterotomy patients had delayed postop­erative recovery. The closed method resulted in a lower mean pain score and a short stay in the hospital [58].

• Miles, in 1919 treated ssures by “pec-

The mainstay of treatment is the control of CD4 count [73]. Lateral internal sphincterotomy results are approximately 92%.

It is widely accepted that lateral internal sphinc­terotomy is the best modality for treating anal s­sures. The mainstay of anal ssure is less blood supply in the posterior commissure. As a result, an ischemic ulcer is formed, which does not heal. Medical management with laxatives and topical applications using GTN or calcium channel blockers is effective. Most of the ssures heal within 6 weeks. However, the ssures may relapse.

Mr. B, 52, a male patient, presented with pain dur­ing defecation and pus discharge from the anal area. To start with, the patient had only pain during defecation. He was diagnosed to be a case of s­sure in ano and treated conservatively by one of my colleagues. Later, the pus started coming out from the ssure site, and a diagnosis of acute ssure in ano with suppuration was made. The conservative management was continued, but the patient had no relief. After a month-long treatment, he came to me for consultation as the pain worsened. Local exam­ination revealed a chronic ssurewith a small peri­anal abscess at 6 o’clock. On digital rectal examination, there was noticeable discomfort at 6 o’clock, and pus could be seen oozing out when the nger was inserted. It was a case of ssure in the ano (midline posterior) with a small perianal abscess and a communicating low intersphincteric stula. Proctoscopy was not signicant. The MRI revealed a stulous tract with an internal opening at 6–7 o’clock. The patient was taken for surgery. To my surprise, when methylene blue and hydrogen peroxide were injected through the abscess, the dye could be seen coming out of the two internal open­ings, one below the dentate line and the other at the dentate line. As the patient had a ssure with a small perianal collection and a communicating low intersphincteric stula, a stulectomy was done, with excision of the ssure and the abscess (Fig.

The patient’s presenting complaints were pain dur­ing defecation which was due to an anal ssure. A thorough examination revealed perianal collection with communicating intersphincteric stula. As already mentioned, the anal gland lying below the ssure can become infected, leading to a stula. Moreover, it is known that sphincterotomy at 6 o’clock can lead to a keyhole deformity. However, in this case, there was no option except to do a low-end stulectomy at the 6 o’clock position due to the presence of both stula and ssure.