1.Lifestyle and toilet habit
If you are constipated you need to increase the amount of fibre in your diet, which means eating enough fruit and vegetables. You should exercise regularly and drink enough water.
It may also mean that you need some laxatives. It is important that you avoid straining or spending more than a few minutes on the toilet.
Take simple pain relief such as paracetamol before you open your bowels. Avoid using fragranced wet wipes. Regularly washing the area with plain water will also help.
2. Medical treatment
Your doctor may recommend the application of an ointment. This is 0.2% GTN (glyceryl tri-nitrate), which may give you a headache as a side effect which can be relieved by taking paracetamol half an hour before using the cream. GTN cream works by dilating the blood vessels in the anus, which promotes healing and relives spasm within the anal canal.
Second line treatment is a cream called Diltiazem, which may cause an itchy bottom. Typically treatment will be needed for 6 to 8 weeks, and occasionally a second course of treatment is needed.
About 7 out of 10 patients will get better with these simple measures.
If you don’t recover your doctor may recommend a Botox injection. This is typically given under general anaesthetic. It works by paralysing one of the muscles in the bottom, which eases spasm and promotes blood flow to the injured area. The medicine lasts for three to four months and then wears off. It is safe, with limited side effects. However, Botox will only work in about 50% of cases and there is a risk of temporary incontinence or infection or the need for further treatment.
Surgery is reserved for patients in whom these simple measures don’t work. This is known as a “lateral sphincterotomy”. The aim is to cut one of the muscles in the bottom and to permanently reduce the spasm in the anal sphincter muscles. It works in about 90% of patients. This is performed under general anaesthetic as a day case procedure. Most patients will recover in about two to four weeks. Although effective, 1 in 20 patients will experience some symptoms of incontinence. This is usually to wind or liquid motions and in most cases this is temporary.
Very resistant or chronic fissures may require more complex treatment with surgery called “advancement flaps”. This procedure creates a flap of healthy tissue which is taken from the skin around the bottom which is then stitched over the area of the fissure. This is a complex procedure which requires discussion with your surgeon.