Anal fissures are often intensely painful due to sphincter spasm. Anaesthetic ointments and stool softening agents have been widely used, with surgery (lateral internal sphinterotomy) for severely affected cases, but this procedure can cause incontinence from loss of sphincter control. An alternative is topical application of nitrate which heals two-thirds of fissures. Preparations should be diluted to 0.2% as such use may be complicated by headache; tolerance can develop. Intrasphincteric injection of botulinum toxin has also been shown to be effective.
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