<prompt> Anal fissure best diagnosed by:AnoscopyHistory and superficial clinic examinationPR examinationUSG  <response>: Fissure-in-Ano- Location of dentate line - usually 2cm below the anal verge.- Longitudinal split in the anoderm from anal verge to the dentate line- Location - In posterior midline at 6o clock position - Fissure is of two types Acute fissures Chronic fissures - Chronic fissures - Characterized by Triad CANOE- SHAPED ULCER SENTINEL PILE aka skin tag Hyperophied papilla Pathophysiology- Spasm of Internal Anal sphincter- Patients have constipation- During excessive straining at the time of defecation, the fecal matter passing throughinternal anal sphincter injures the pain sensitive mucosa of anal canal.Tear split in the anoderm Decreased vascularity Healing of Tear decreases due to ischemia - Principle of treatment is based on relaxing the spasm- Fissure in Ano is similar to Achalasia cardia Clinical features- Serve pain during defecation- Streaking of blood over stool- In fissure in Ano - Digital rectal examination is contraindicated.- Examine the gluteal region, find the longitudinal spilt in posterior midline Management- Initially conservative management Sitz bath Stool softener- Medical Treatment CCB - 2 Diltiazem Gel - Local application Nitrates - 0.2 nitroglycerine Botox injection into sphincters Lords procedure - manual dilatation of sphincter not performed usually. TOC - NOTARAS lateral sphincterotomy divide internal anal sphincter laterally Anal advancement flap 