Page 3 - 01- Anal Fissure

GENERAL PREVENTION
All measures to prevent constipation; avoid straining and prolonged sitting on toilet.

COMMONLY ASSOCIATED CONDITIONS
Posterior midline location: Constipation, irritable bowel syndrome; other locations: Crohn
disease, tuberculosis, leukemia, and HIV

DIAGNOSIS

HISTORY
Severe, sharp rectal pain, often with and following defecation but can be continuous; some
patients will see bright red blood on the stool or when wiping.
Occasionally, anal pruritus or perianal irritation

PHYSICAL EXAM
Gentle spreading of the buttocks with close inspection of the anal verge will reveal a tender,
smooth-edged tear in the anodermal tissue, typically posterior midline, occasionally anterior
midline, rarely eccentric to midline. Digital rectal exam and anoscopy are painful and can be
deferred if inspection confirms the diagnosis.
Minimal edema, erythema, or bleeding may be seen.
Chronic fissures may demonstrate rolled edges, exposed muscle fibers, hypertrophic papillae at
proximal end, and a sentinel pile (tag) at distal end.

DIFFERENTIAL DIAGNOSIS
Thrombosed external hemorrhoid: swollen, painful mass at anal verge
Perirectal abscess: tender, warm erythematous induration or fluctuance
Perianal fistula: abnormal communication between rectum and perianal epithelium with
feculent or purulent drainage
Pruritus ani: shallow excoriations and erythema rather than true fissure
DIAGNOSTIC TESTS & INTERPRETATION
Diagnostic Procedures/Other
Avoid anoscopy/sigmoidoscopy initially unless necessary for other diagnoses or chronic
fissures.
Due to pain, some patients may require exam under anesthesia in order to confirm the
diagnosis.

TREATMENT

The goal of treatment is to avoid repeated tearing of the anal mucosa with resultant spasm of the
internal anal sphincter by decreasing the patient’s high sphincter tone and addressing its
underlying cause.

GENERAL MEASURES
Wash area gently with warm water; consume high-fiber diet, increase fluids, add daily fiber
supplement; avoid constipation, maintain healthy weight.