Skip to Main Content

ANAL FISSURES

Anal fissures are linear or rocket-shaped ulcers that are usually less than 5 mm in length (eFigure 15–40). Most fissures are believed to arise from trauma to the anal canal during defecation, perhaps caused by straining, constipation, or high internal sphincter tone. They occur most commonly in the posterior midline, but 10% occur anteriorly. Fissures that occur off the midline should raise suspicion for Crohn disease, HIV/AIDS, tuberculosis, syphilis, or anal carcinoma. Patients complain of severe, tearing pain during defecation followed by throbbing discomfort that may lead to constipation due to fear of recurrent pain. There may be mild associated hematochezia, with blood on the stool or toilet paper. Anal fissures are confirmed by visual inspection of the anal verge while gently separating the buttocks. Acute fissures look like cracks in the epithelium. Chronic fissures result in fibrosis and the development of a skin tag at the outermost edge (sentinel pile). Digital and anoscopic examinations may cause severe pain and may not be possible. Medical management is directed at promoting effortless, painless bowel movements. Fiber supplements and sitz baths should be prescribed. Topical anesthetics (5% lidocaine; 2.5% lidocaine plus 2.5% prilocaine) may provide temporary relief. Healing occurs within 2 months in up to 45% of patients with conservative management. Chronic fissures may be treated with topical 0.2–0.4% nitroglycerin, diltiazem 2% ointment, or nifedipine 0.5% (1 cm of ointment) applied twice daily just inside the anus with the tip of a finger for 4–8 weeks or injection of botulinum toxin (20 units) into the internal anal sphincter. All of these treatments result in healing in 50–80% of patients with chronic anal fissure, but headaches occur in up to 40% of patients treated with nitroglycerin. Botulinum toxin may cause transient anal incontinence. Fissures recur in up to 40% of patients after treatment. Chronic or recurrent fissures benefit from lateral internal sphincterotomy; however, minor incontinence may complicate this procedure.

eFigure 15–40.

A linear anal fissure is visible at 1 o’clock. (Used, with permission, from A. Huang.)

+
Dat  A  et al. Botulinum toxin therapy for chronic anal fissures: where are we at currently? ANZ J Surg. 2017 Sep;87(9):E70–3.
[PubMed: 26423046]
+
Jamshidi  R. Anorectal complaints: hemorrhoids, fissures, abscesses, fistulae. Clin Colon Rectal Surg. 2018 Mar;31(2):117–20.
[PubMed: 29487494]
+
Kyriakakis  R  et al. What predicts successful nonoperative management with botulinum toxin for anal fissure? Am J Surg. 2019 Oct 11. [Epub ahead of print]
[PubMed: 31679653]
+
Newman  M  et al. Anal fissure: diagnosis, management, and referral in primary care. Br J Gen Pract. 2019 Aug;69(685):409–10.
[PubMed: 31345824]
+
Sahebally  SM  et al. Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta-analysis of randomized controlled trials. Colorectal Dis. 2018 Jan;20(1):6–15.
[PubMed: 29166553]

PERIANAL ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.