INITIAL MANAGEMENT OF TYPICAL FISSURES > 의학

INITIAL MANAGEMENT OF TYPICAL FISSURESFor patients with a typical anal fissure (ie, a single posterior or anterior fissure with no evidence of Crohn disease), we recommend prescribing a combination of supportive measures (fiber, sitz bath, topical analgesic) and one of the topical vasodilators (nifedipine or nitroglycerin) for one month (algorithm 1). In addition, patients who are constipated should receive a stool softener or laxative. The treatment goal is to relax the internal anal sphincter, initiate and maintain atraumatic passage of stool, and relieve pain.

Although medical therapy is less effective than surgery, especially for chronic anal fissures, it should be offered first because of its wide availability, better tolerance, and lack of severe complications (ie, fecal incontinence) [3,4]. The best data come from a trial that randomly assigned 54 patients with anal fissures to receive either a lateral internal sphincterotomy (surgery) or 0.2% nitroglycerin ointment (medical therapy) for 10 weeks; all patients received warm sitz baths and a fiber-bulking agent [5]. Compared with the medicine group, the surgery group achieved higher rates of fissure healing (96 versus 67 percent at 5 weeks and 100 versus 89 percent at 10 weeks) at the expense of a significantly higher rate of minor fecal incontinence (44 versus 0 percent). Fifteen percent of patients who underwent surgery had residual fecal incontinence after two years.