Updated: 12/15/2021

Anal Fissure

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  • Snapshot
    • A 33-year-old woman with irritable bowel syndrome (constipation type) presents to her primary care physician for evaluation of severely painful bowel movements. She reports that onset occurs during the bowel movement and may persist for hours afterward causing significant fear of having bowel movements. She also notes small amounts of bright red blood on the toilet paper.
  • Introduction
    • Clinical definition
      • linear tear of the distal anal canal
      • acute or chronic
    • Associated conditions
      • inflammatory bowel disease
      • sexually transmitted infections
      • acquired immunodeficiency syndrome
      • squamous cell carcinoma of the anus
  • Epidemiology
    • Demographics
      • equal in males and females
      • younger and middle-aged
    • Risk factors
      • low fiber diet
      • constipation
      • chronic diarrhea
      • prior anal surgery
      • hypertonicity of the internal anal sphincter
  • ETIOLOGY
    • Pathogenesis
      • trauma to the distal anal canal
        • most often from a hard bowel movement
      • anal sphincter spasm and increase in anal sphincter pressure
  • Presentation
    • Symptoms
      • painful bowel movement
      • bright red blood on toilet paper or stool
    • Physical exam
      • tear of the anal epithelium and mucosa
        • most often at the midline, posterior more than anterior
      • sentinel pile or skin tag, if chronic
  • IMAGING
    • Anoscopy or proctosigmoidoscopy
      • if poor healing or recurrent to evaluate for other pathologies
      • if chronic, hypertrophied papilla above the fissure
  • STUDIES
    • Diagnostic testing
      • perianal examination
        • direct visualization of the anal fissure is diagnostic
          • if chronic, sentinel pile or skin tag below the fissure
          • if typical, no additional tests necessary
          • if atypical (off midline, multiple, non-healing), further testing is indicated for underlying associated conditions
      • if lateral to midline
        • must rule out alternative cause
          • HIV, syphilis, tuberculosis
          • malignancy
          • inflammatory conditions (Crohn disease)
  • Differential
    • External hemorrhoid
      • distinguishing factor
        • hemorrhoid visualized on exam
    • Anal cancer
      • distinguishing factor
        • off midline location
        • bulky appearance
  • Treatment
    • First-line
      • Medical management
        • fiber supplementation and stool softeners
          • soften and form stool
        • topical lidocaine and sitz bath
          • symptomatic management
        • nitroglycerin ointment and calcium channel blockers
          • relax the internal anal sphincter muscle
          • may cause hypotension
    • Second-line
      • interventional
        • botulinum toxin injection to the anal sphincter
      • surgical
        • lateral internal sphincterotomy
  • Complications
    • Chronic anal fissure
    • Fecal bacterial infection of wound

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Questions (4)

(M2.GI.16.41) A 4-year-old boy is brought into your office by his parents who state that the boy has been noncompliant with his toilet training and passes stools every 4 days. They describe his stool as hard pellets. They deny any problems during pregnancy and state that he was born at a weight of 7 lbs and 10 oz. They state that he remained in the hospital for one day after his delivery. Since then, he has not had any problems and was exclusively breast fed for the first six months of his life. On physical exam, there is a shallow tear in the posterior verge of his anus. Which of the following is the best treatment?

QID: 104583

Colonoscopy

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Proctoscopy

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Fiber supplementation

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(3/7)

Laxatives and stool softeners

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(4/7)

Sigmoidoscopy and biopsy

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(0/7)

M 7 E

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(M2.OMB.43) A 22-year-old woman presents to her primary care physician with severe rectal pain and painful bowel movements. She states that defecating has become so painful that she now avoids it, and her last bowel movement was 5 days ago. Sometimes, she notices a small amount of blood on the toilet paper. These symptoms have progressively worsened over the past month. The patient smokes 1-2 cigarettes a week for the past year and has 2 male sexual partners. Her temperature is 99.2°F (37.3°C), blood pressure is 120/85 mmHg, pulse is 72/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam reveals a small linear skin tear in the posterior midline right next to the anus. Which of the following is the most likely diagnosis?

QID: 216439

Anal cancer

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Anal fissure

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Crohn disease

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Perianal abscess

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Thrombosed external hemorrhoid

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M 10

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(M2.OMB.42) A 32-year-old man presents to the emergency department with pain upon defecation. His symptoms started a few weeks ago but have been worsening. Sometimes he notes blood on the toilet paper. He has to strain to have bowel movements and has trouble defecating secondary to pain. He is generally healthy and does not smoke. The patient is a software engineer and enjoys hiking, going to nightclubs, and dancing. His temperature is 98.1°F (36.7°C), blood pressure is 112/83 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam reveals a small, superficial fissure that is lateral to the anus and lateral to the midline. Which of the following is the most appropriate management for this patient?

QID: 216438

CT scan of the abdomen and pelvis

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Incision, drainage, ciprofloxacin, and metronidazole

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Surgical excision

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Testing for HIV, fecal occult blood, and sexually transmitted diseases

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Topical lidocaine, sitz baths, and fiber supplements

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M 10

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