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anal fissure

Etiology: - passage of hard stool Pathology: - painful longitudinal mucosal tears in the anal canal [5] Clinical manifestations: 1) acute onset of pain during defecation - pain commonly persists for 15-30 minutes following a bowel movement [9] 2) very painful - pain spreading buttocks for visualization of perianal region [5] 3) variable bleeding 4) difficult to heal 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] Management: outpatient management* 1) stool softeners, psyllium 2) analgesics, topical anesthetics, topical diclofenac 3) sitz baths 4) nitroglycerin ointment (Reactiv) 0.2% or 0.4% [4] 5) calcium channel blocker (diltiazem, nifedipine) [10] (MKSAP19) prognosis - spontaneous resolution generally within 2-3 weeks surgery for chronic fissures - botulinum toxin injections - fissurectomy - advancement flaps - internal lateral anal sphincterotomy ]9] * see lower gastrointestinal hemorrhage Management section for indications for hospitalization [5]

General

dermal fissure anorectal disease

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 360
  2. Stedman's Medical Dictionary 27th ed, Williams & Wilkins, Baltimore, 1999
  3. 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. Prescriber's Letter 19(1): 2012 Rectiv (Nitroglycerin 0.4% Ointment) for Anal Fissure Detail-Document#: 280105 (subscription needed) http://www.prescribersletter.com
  5. Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2021.
  6. 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: 20628272
  7. Beaty JS, Shashidharan M. Anal Fissure. Clin Colon Rectal Surg. 2016 Mar;29(1):30-7. Review. PMID: 26929749 Free PMC Article
  8. Lu Y, Kwaan MR, Lin AY Diagnosis and Treatment of Anal Fissures in 2021. JAMA. 2021;325(7):688-689 PMID: 33591336 https://jamanetwork.com/journals/jama/fullarticle/2776317
  9. 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: 29630265 Free Books & Documents. Review.
  10. 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: 27926552