Anal Fissures

Linear or rocket-shaped ulcers, usually < 5 mm

Most commonly occur in the posterior midline; 10% occur anteriorly

Arise from trauma during defecation

Severe, tearing pain during defecation followed by throbbing discomfort

May lead to constipation because of fear of recurrent pain

Mild associated hematochezia

With chronic fissures, there is fibrosis and a skin tag at the outermost edge (sentinel pile)

Diagnosis is confirmed by visual inspection of the anal verge while gently separating the buttocks

Digital and anoscopic examinations may cause severe pain and may not be possible

Fissures that occur off the midline suggest

• Crohn disease

• Syphilis

• Tuberculosis

• HIV/AIDS

• Anal carcinoma

Fiber supplements, stool softeners

Sitz baths

Topical anesthetics (5% lidocaine; 2.5% lidocaine plus 2.5% prilocaine) may provide temporary relief

Chronic fissures may be treated with

• Topical 0.2–0.4% nitroglycerin or diltiazem 2% or nifedipine 0.5% ointment (1 cm of ointment) applied just inside anus with tip of finger twice daily for 4–8 weeks

• Injection of botulinum toxin (20 units) into internal anal sphincter

• 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

Internal sphincterotomy is effective for chronic or recurrent fissures but may be complicated by minor fecal incontinence