anal fissure
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Etiology
- passage of hard stool
- receptive anal intercourse, enemas, or lower GI endoscopy[5]
- idiopathic
Pathology
- painful longitudinal mucosal tears in the anal canal[5]
Clinical manifestations
- acute onset of pain during defecation
- pain commonly persists for 15-30 minutes following a bowel movement[9]
- very painful
- pain spreading buttocks for visualization of perianal region[5]
- pain may be worsened by sitting
- variable bleeding with bowel movements or wiping[5]
- difficult to heal
Diagnostic procedures
- Anoscopy
- elliptical tear in the mucous membrane of the anus usually midline & posterior
- majority (90%) are located in the posterior midline[9]
- minority (25% of females & 8% of males) are located in the anterior midline
- lateral fissures should raise concern for Crohn's disease or granulomatous disease[9]
- elliptical tear in the mucous membrane of the anus usually midline & posterior
Management
- outpatient management*
- stool softeners, psyllium
- analgesics, topical anesthetics, topical diclofenac
- sitz baths
- nitroglycerin ointment (Reactiv) 0.2% or 0.4%[4]
- calcium channel blocker (diltiazem, nifedipine)[10] (MKSAP19)
- surgery for chronic fissures
- botulinum toxin injections
- fissurectomy
- advancement flaps
- internal lateral anal sphincterotomy[9]
- prognosis
- spontaneous resolution generally within 2-3 weeks
* see lower gastrointestinal hemorrhage Management section for indications for hospitalization[5]
More general terms
References
- ↑ Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 360
- ↑ Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
- ↑ The American Society of Colon and Rectal Surgeons (ASCRS) has updated: Practice parameters for the management of anal fissure http://www.fascrs.org/associations/1843/files/pp_1204.pdf
- ↑ 4.0 4.1 Prescriber's Letter 19(1): 2012 Rectiv (Nitroglycerin 0.4% Ointment) for Anal Fissure Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=280105&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ Perry WB, Dykes SL, Buie WD et al Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum. 2010 Aug;53(8):1110-5 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20628272
- ↑ Beaty JS, Shashidharan M. Anal Fissure. Clin Colon Rectal Surg. 2016 Mar;29(1):30-7. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26929749 Free PMC Article
- ↑ Lu Y, Kwaan MR, Lin AY Diagnosis and Treatment of Anal Fissures in 2021. JAMA. 2021;325(7):688-689 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33591336 https://jamanetwork.com/journals/jama/fullarticle/2776317
- ↑ 9.0 9.1 9.2 9.3 9.4 Villanueva Herrero JA, Henning W, Sharma N, Deppen JG. Internal Anal Sphincterotomy. 2020 Nov 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan PMID: https://www.ncbi.nlm.nih.gov/pubmed/29630265 Free Books & Documents. Review.
- ↑ 10.0 10.1 Stewart DB Sr, Gaertner W, Glasgow S, et al. Clinical practice guideline for the management of anal fissures. Dis Colon Rectum. 2017;60:7-14. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27926552