Anal fissure

Background

Superficial linear tear of anal canal from at/below dentate line to anal verge
- May be due to passage of hard stool, frequent diarrhea, or abuse
Most common cause of painful rectal bleeding
In >90% of cases anal fissures occur in the midline posteriorly
- Nonhealing fissure or one not located in midline suggests alternative diagnosis

Acute sharp, cutting pain most severe during and immediately after bowel movement
- Subsides between bowel movements (distinguishes fissure from other anorectal disease)
Bright red bleeding, small in quantity (usually noticed only on toilet paper)
Lateral to anus often indicates associated systemic illness such as Crohns, HIV, Leukemia, TB, syphillis

Having patient bear down may make fissure more noticable
Sentinel pile, located at distal end of fissure, along with deep ulcer suggests chronicity
- Often misdiagnosed as an external hemorrhoid

Hot sitz baths 15 min TID-QID and after each bowel movement
1. Provides symptomatic relief and relieves anal sphincter spasm
Topicals
1. Pain control with lidocaine
2. Vasodilators such as nitroglycerin ointment
3. Hydrocortizone
High-fiber diet
1. Prevents stricture formation by providing a bulky stool
Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
Surgical referral indicated if healing does not occur in a reasonable amount of time