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Updated: Dec 15 2021

Anal Fissure

  • 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
    • 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
    • Anoscopy or proctosigmoidoscopy
      • if poor healing or recurrent to evaluate for other pathologies
      • if chronic, hypertrophied papilla above the fissure
    • 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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