Anal Fissure

Aka: Anal Fissure

1. Pathophysiology
   1. Usually follows trauma or Diarrheal illness
   2. Chronic increase in resting anal pressure
      1. Increased anodermal blood flow causes fissures
2. Epidemiology
   1. Affects young and middle-aged adults
   2. Men and women are equally affected
3. Symptoms
   1. Onset after forced hard Bowel Movement
   2. Bright red rectal bleeding
   3. Pain during Bowel Movement
      1. Cut with sharp glass sensation
      2. Pain persists for an hour after stooling
4. Signs
   1. See Anorectal Exam
   2. Avoid Anoscopy if possible
      1. Painful and usually not needed
      2. Use Local Anesthesia if performed
   3. Crack or crevice in anoderm at anal verge
      1. Usually in canal midline (anterior or posterior)
      2. Lateral suggests other diagnosis (see below)
      3. Best seen with lateral traction on opposite buttock
   4. Sentinel pile (distal Skin Tag)
      1. Tag-like swelling of fissure end
      2. Results from infection and edema
5. Differential Diagnosis
   1. See Anorectal Pain
   2. Conditions resulting in lateral Anal Fissure
      1. Inflammatory Bowel Disease (e.g. Crohn's Disease)
      2. HIV Infection
      3. Tuberculosis
      4. Syphilis
      5. Leukemia
      6. Anorectal cancer
6. Management
   1. Early Management
      1. Bulk Dietary Fiber
      2. Increase fluid intake
      3. Sitz baths
      4. Topical Hydrocortisone (e.g. Proctofoam HC)
      5. Xylocaine 5%
      6. Glyceryl Trinitrate ointment 0.2% to 0.4% bid for 6 weeks
         1. See Rectal Nitroglycerin (Glyceryl Trinitrate, Rectiv)
   2. Late Management (>3 months)
      1. Difficult to treat if persistent beyond 3 months
      2. Topical Nifedipine 0.3% and Lidocaine 1.5% ointment
         1. Apply twice daily for 6 weeks
         2. Resulted in 94.5% rate of healing
         3. Perrotti (2002) Dis Colon Rectum 45:1468-75
      3. Invasive procedures
         1. Surgery: Lateral sphincterotomy (preferred)
         2. Botulin toxin injection
            1. Unclear long term efficacy
         3. Adverse effects
            1. Short term fecal Incontinence in 5-7%
            2. Long term flatus Incontinence is uncommon
         4. References
            1. Arroyo (2005) Am J Surg 189:429-34
7. References
   1. Madoff (2003) Gastroenterology 124:235-45