الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Anal fissure is a linear ulcer in the lining of the squamous epithelium in the anal canal distal to the mucocutaneous junction (dentate line). Approximately 90% of anal fissures in both men and women are located posteriorly in the midline. Anterior fissures occur in 10% of patients, more commonly women (Zaghiyan and Fleshner , 2011). Less than 1% of fissures are located off a midline position or are multiple in number. These atypical fissures may be associated with Crohn’s disease, sexually transmitted diseases, anal cancer, or tuberculosis (Zaghiyan and Fleshner , 2011). The principle aim of therapy for anal fissures is to relax the internal anal sphincter, provide symptomatic relief and heal the fissure. Nearly 90% of acute anal fissures will heal using conservative measures alone. By contrast, only 20% of chronic fissures are likey to heal by conservative therapy (Keighley and Williams , 2008). Pharmacological treatment involves the use of muscle relaxants, commonly topical and occasionally oral agents.These agents include nitrates (isosorbide dinitrate ”ISDN” or glyceryl trinitrate ”GTN”), calcium channel blockers, botulinum toxin, alpha adrenoreceptor antagonists, beta adrenoreceptor agonists and muscarinic agonists (Poh et al., 2010). Lateral internal sphincterotomy is the gold standard for the operative management of anal fissures secondary to hypertonicity or hypertrophy of the internal anal sphincter. An alternative procedure, the Y-V advancement flap, is generally described for recurrent fissures or fissures that are not associated with hypertrophy and hypertonicity of the internal anal sphincter. Previously described procedures, such as anal dilatation and posterior midline internal sphincterotomy, are rarely used because of the high rates of incontinence, recurrence, and longer time for wound healing (Poh et al., 2010)..