Anal fissure

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Anal fissure is linear tear in the anal skin. Historically, there is description of anal fissure by Louis Lemonnier in his “Traité de la fistule de l’anus ou du fondement” (1689). Anal fissures can be divided into primary and secondary anal fissures based on etiology, posterior and anterior anal fissures based on location, and acute and chronic anal fissures based on the duration of symptoms.The exact pathogenesis of anal fissure is not fully understood but constipation or anal trauma was supposed to instigate the fissure. It is understood that anal fissure is the result of either anal trauma (by hard stools/diarrhea), perfusion defects with ischemia caused due to increased anal pressures and decreased blood flow or increased anal sphincter tone. In 90% of the patients, anal fissures are found in posterior midline. A small tear is seen that extends from dentate line to anal verge due to ischemia/poor perfusion of the area by inferior rectal artery (during increased sphincter tone). Anal fissure are caused due to severe and chronic constipation, watery diarrhea and Crohn’s disease. Anal fissures are common in women after childbirth, and following constipation in infants. Other less common causes include tuberculosis, sarcoidosis, anal intercourse, HIV , Human papillomavirus, and syphilis. Anal fissure are caused due to severe and chronic constipation, watery diarrhea and Crohn’s disease. Anal fissures are common in women after childbirth, and following constipation in infants. Other less common causes include tuberculosis, sarcoidosis, anal intercourse, HIV , Human papillomavirus, and syphilis. The incidence of anal fissure is approximately 1100 per 100,000 individuals in US which is about 7.8% lifetime risk. The incidence is 30-50% in patients with Crohn’s disease. Women in adolescence and child bearing group and males of middle aged group are commonly affected. Females are more affected than males. The symptoms of anal fissure can develop in infants as well as in adults following episodes of severe and chronic constipation and diarrhea. If left untreated, the unhealed fissures can get complicated to chronic fissures, anal abscess, anal fistula and fecal incontinence. The prognosis is generally excellent and 90% spontaneously heal or with dietary and medical measures. Patients with anal fissure have a history of painful bowel movements and bleeding per rectum which can be seen as blood on tissue paper following a bowel movement. They usually have a history of constipation too but also some patients may report frequent episodes of watery diarrhea.They also have symptoms of painful defecation.Some patients may also have associated itching and irritation. Patients with anal fissure usually appear in pain. Physical examination of patients with anal fissure is usually remarkable for painful skin laceration, skin tags in the chronic anal fissure. Most common cause of anal fissure is straining when constipated. For treatment of constipation, click here. Anal fissures in infants usually self-heal without anything more than frequently changing diapers and treating constipation if it is the cause. The topical therapy is the first line of treatment along with dietary and other conservative measures. Analgesia with lidocaine and vasodilators like nitroglycerin and nifedipine are chiefly used for the topical management. Botulinum toxin can be effective in 89% cases. It is reserved for the people who can’t undergo surgery for high risk of incontinence. Surgery is the option after trying the conservative and medical measures and its done in patients not responding to them, with chronic anal fissures and where fissures are complicated by fistulas and abscess. Lateral internal sphincterotomy is the procedure of choice. The complications of the surgery include fecal incontinence and therefore contraindicated in the patients having fecal incontinence. In these patients, anal advancement flap or Botulinum toxin is used.

There is description of anal fissure by Louis Lemonnier in his “Traité de la fistule de l’anus ou du fondement” (1689). In 1989, Klosterhalfen et al discovered a scarcity of small arteriolar collaterals between the end branches of the left and right inferior rectal artery dorsally during post-mortem angiographic studies. Botulinum toxin injection, administered by colorectal surgeons to relax the sphincter muscle and its use for this condition was first investigated in 1993.In 1994, Shouten et al discovered the association between anal pressure and the anodermal blood flow indicating development of anal fissure. This work also showed that there is significantly lower blood flow at the fissure site than other places.

Anal fissures can be divided into primary and secondary anal fissures based on etiology, posterior and anterior anal fissures based on location, and acute and chronic anal fissures based on the duration of symptoms.

The exact pathogenesis of anal fissure is not fully understood but constipation or anal trauma was supposed to instigate the fissure. It is understood that anal fissure is the result of either anal trauma (by hard stools/diarrhea), perfusion defects with ischemia caused due to increased anal pressures and decreased blood flow or increased anal sphincter tone. In 90% of the patients, anal fissures are found in posterior mid line. A small tear is seen that extends from dentate line to anal verge due to ischemia/poor perfusion of the area by inferior rectal artery (during increased sphincter tone).

Anal fissure are caused due to severe and chronic constipation, watery diarrhea and Crohn’s disease. Anal fissures are common in women after childbirth, and following constipation in infants. Other less common causes include tuberculosis, sarcoidosis, anal intercourse, HIV , Human papillomavirus, and syphilis.

Anal fissure must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoids, rectal prolapse and perianal abscess, anal fistula and anal cancer.

The incidence of anal fissure is approximately 1100 per 100,000 individuals in US which is about 7.8% lifetime risk. The incidence is 30-50% in patients with Crohn’s disease. Women in adolescence and child bearing group and males of middle aged group are commonly affected. Females are more affected than males.

The common risk factors for anal fissure include people with chronic constipation, frequent diarrhea, anal trauma, labor complication to the mother, Crohn’s disease. Less common risk factors include infants, elderly adults, and people having HIV.

There is insufficient evidence to recommend routine screening for anal fissure.

The symptoms of anal fissure can develop in infants as well as in adults following episodes of severe and chronic constipation and diarrhea. If left untreated, the unhealed fissures can get complicated to chronic fissures, anal abscess, anal fistula and fecal incontinence. The prognosis is generally excellent and 90% spontaneously heal or with dietary and medical measures.

Patients with anal fissure have a history of painful bowel movements and bleeding per rectum which can be seen as blood on tissue paper following a bowel movement. They usually have a history of constipation too but also some patients may report frequent episodes of watery diarrhea.They also have symptoms of painful defecation.Some patients may also have associated itching and irritation.

Patients with anal fissure usually appear in pain. Physical examination of patients with anal fissure is usually remarkable for painful skin laceration, skin tags in the chronic anal fissure. A tear is usually seen in the posterior part of anal canal(90)% and in anterior or middle part(10%). Patient usually resists use of anoscope due to the pain. Acute anal fissures appear as fresh laceration while chronic have raised margins.

Primary anal fissure is usually diagnosed and confirmed by clinical history and physical examination. Laboratory findings are needed to rule out the causes of secondary anal fissures e.g. Crohn’s disease,tuberculosis, sarcoidosis and HIV which include Leukocytosis– lymphocytosis,Enzyme linked immunosorbent assay (ELISA).

There are no other imaging findings associated with anal fissure.

There are no other diagnostic studies associated with anal fissure.

Most common cause of anal fissure is straining when constipated. For treatment of constipation, click here. Anal fissures in infants usually self-heal without anything more than frequently changing diapers and treating constipation if it is the cause. The topical therapy is the first line of treatment along with dietary and other conservative measures. Analgesia with lidocaine and vasodilators like nitroglycerin and nifedipine are chiefly used for the topical management. Botulinum toxin can be effective in 89% cases. It is reserved for the people who can’t undergo surgery for high risk of incontinence.

Surgery is the option after trying the conservative and medical measures and its done in patients not responding to them, with chronic anal fissures and where fissures are complicated by fistulas and abscess. Lateral internal sphincterotomy is the procedure of choice. The complications of the surgery include fecal incontinence and therefore contraindicated in the patients having fecal incontinence. In these patients, anal advancement flap or Botulinum toxin is used.

Effective measures for the primary prevention of anal fissure include frequent diaper change in infants and preventing constipation. In adults, the approach is to prevent constipation and treating it appropriately by adopting dietary measures like eating diet rich in fibers , drinking water and also stool softener if needed. Treating diarrhea and to prevent straining in the toilet. Keeping anal hygiene and avoiding anal intercourse.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

There is description of anal fissure by Louis Lemonnier in his “Traité de la fistule de l’anus ou du fondement” (1689). In 1989, Klosterhalfen et al. discovered a scarcity of small arteriolar collaterals between the end branches of the left and right inferior rectal artery dorsally during post-mortem angiographic studies. Botulinum toxin injection, administered by colorectal surgeons to relax the sphincter muscle and its use for this condition was first investigated in 1993.In 1994, Shouten et al. discovered the association between the anal pressure and the anodermal blood flow indicating development of anal fissure. This work also showed that there is significantly lower blood flow at the fissure site than other places.

• There is description of anal fissure by Louis Lemonnier in his “Traité de la fistule de l’anus ou du fondement” (1689).^[1][2]
• Raphael B. Sabatier has mentioned anal fissures in his “De la Médecine opératoire” (1824).^[1][2]
• In 1989, Klosterhalfen et al. discovered a scarcity of small arteriolar collaterals between the end branches of the left and right inferior rectal artery dorsally during post-mortem angiographic studies.^[3]
• Botulinum toxin injection, administered by colorectal surgeons to relax the sphincter muscle and its use for this condition was first investigated in 1993.^[4]
• In 1994, Shouten et al. discovered the association between anal pressure and the anodermal blood flow indicating development of anal fissure. This work also showed that there is significantly lower blood flow at the fissure site than other places.^[5]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Anal fissures can be divided into primary and secondary anal fissures, based on etiology; posterior and anterior anal fissures based on location; and acute and chronic anal fissures based on the duration of symptoms.

Anal fissures are divided into different categories according to different classification systems:^[1][2][3][4]

• Anal fissure may be classified according to causative factors into 2 subtypes:
  • Primary anal fissure- caused due to local trauma such as hard stools, prolonged diarrhea, vaginal delivery, repetitive injury or penetration. These are usually posterior and anterior in location.
  • Secondary anal fissure- caused due to previous surgical procedures in the anal area, inflammatory bowel disease, tuberculosis, sarcoidosis, HIV/AIDS, syphilis. They are usually multiple and lateral in position.

• Anal fissure may be classified into several subtypes based on location:
  • Posterior anal fissures- it is found in 90% cases.
  • Anterior anal fissures- seen in 10% of cases.

• Based on the duration of symptoms, an anal fissure may be classified as either acute (4-8 weeks), or chronic.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

The exact pathogenesis of anal fissure is not fully understood but constipation or anal trauma was supposed to instigate the fissure. It is understood that anal fissure is the result of either anal trauma (by constipation/diarrhea), perfusion defects with ischemia caused due to increased anal pressures and decreased blood flow or increased anal sphincter tone. In 90% of the patients, anal fissures are found in posterior midline. A small tear is seen that extends from dentate line to anal verge due to ischemia/poor perfusion of the area by inferior rectal artery (during increased sphincter tone).

An anal fissure is a linear tear or superficial ulcer of the anal canal, extending from just below the dentate line to the anal margin.

• Although constipation or anal trauma was supposed to instigate the fissure,the exact pathogenesis of anal fissure is not fully understood.^[2]
• It is understood that anal fissure is the result of either anal trauma (by hard stools/diarrhea), perfusion defects with ischemia caused due to increased anal pressures and decreased blood flow or increased anal sphincter tone.
• In 90% of the patients, anal fissures are found in posterior midline. A small tear is seen that extends from dentate line to anal verge.^[3]
• This is believed due to ischemia/poor perfusion of the area by inferior rectal artery (during increased sphincter tone).^[4][5][6][7]
• Some studies in 1970-80 have suggested the increased tone of intenal sphincter as the basis of anal fissure genesis.^[8][9][10]
• The increased internal sphincter tone also leads to decreased perfusion.^[2]
• Use of anal manometry have suggested hypertonia of internal sphincter as a cause of anal fissure, and also relaxation in chronic anal fissures.^[11][12]

• Crohn’s disease
• Syphilis
• HIV/AIDS
• Previous anal surgery
• Anal cancer
• Tuberculosis

• On microscopic histopathological analysis, the following are characteristic findings of anal fissure:
  • Presence of fibrosis at the base of the fissure when compared to normal internal anal sphincter.^[13]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Anal fissure are caused due to severe and chronic constipation, watery diarrhea and Crohn’s disease. Anal fissures are common in women after childbirth, and following constipation in infants. Other less common causes include tuberculosis, sarcoidosis, anal intercourse, HIV, Human papillomavirus, and syphilis.

• Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no life-threatening causes of anal fissure, however complications resulting from untreated anal fissure is common.

Anal fissures may be caused by:^[1]

• Severe and chronic constipation
• Severe watery diarrhea
• Difficult labor^[2]
• Crohn’s disease
• Infants- constipation^[3]

Less common causes of disease name include:^[1]

• Tuberculosis
• Sarcoidosis
• Anal intercourse
• HIV
• HPV
• Syphilis

List the causes of the disease in alphabetical order.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Anal fissure must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoids, rectal prolapse and perianal abscess, anal fistula and anal cancer.

Anal fissure must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoids, rectal prolapse and perianal abscess.

Disease	History	Physical exam findings	Sample image
Anal fissure	Anal fissure usually presents with tearing pain with every bowel movement.[1] Pain usually lasts for minutes to hours after every bowel movement. Patient is typically afraid of going to the bathroom to avoid the pain, which leads to a viscious cycle. The fissure worsens the constipation and the constipation (hard stool) aggravates the fissure. About two-thirds of the patients present with bright red blood streaks on toilet papers or on the surface of stools. May be accompanied by pruritis and discharge.	Most fissures occur in the posterior midline of the anal canal.[2] Skin tags in the perianal area may accompany chronic anal fissures.
Hemorrhoids	External hemorrhoids External hemorrhoids are painful as the skin below the punctate line is sensitive to pain.[1] Blood clots may form in external hemorrhoids. Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus. When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch. Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse. Internal hemorrhoids The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement. Internal hemorrhoids that are not prolapsed are usually not painful. Prolapsed hemorrhoids often cause pain, discomfort, and anal itching.	Skin examination Inspection of the anal verge may show scratch marks and skin tags. Inspection also may reveal external hemorrhoids or prolapsed internal hemorrhoids. Digital rectal examination Digital rectal examination reveals the size and location of hemorrhoids. Thrombosed hemorrhoids are tender to palpation. Internal hemorrhoids are not palpable by digital rectal examination and the use of anoscope is mandatory.
Rectal prolapse	Rectal prolapse most commonly occurs in multiparous females over 40 years old.[5] Appears as a progressive mass protrusion from the anus. The protrusion first appears with straining and defecation, then progresses to the degree when it is no longer replaced back. It presents with abdominal discomfort and incomplete defecation. Fecal incontinence and anal discharge. Pain is not usually present.	Mass protruding from the anus.[6] Concentric mucosal rings are characteristic of rectal prolapse.
Perianal abscess	Perianal abscess presents with severe, continuous, dull, aching pain in the perianal area.[8] Pain is exacerbated with bowel movements, but is not exclusive to it. Constipation due to fear of bowel movements. Fever, headache, and chills may accompany the pain. If the abscess starts to drain, discharge of purulent or bloody fluid may be noticed.	Flatulent, erythematous, and tender area of skin overlying the abscess. If abscess is deep, tenderness is elicited with digital rectal examination.
Anal cancer	Rectal bleeding is the most common presentation.[9] Mass sensation in the anus. Mucoid discharge may occur. Patient may give a history of anal condyloma (especially homosexual men).[10] Fecal incontinence.	On digital rectal examination, solid hemorrhagic mass that is firmly fixed to the surrounding structures is noted. Femoral and inguinal lymph nodes may show lymphadenopathy secondary to spread of cancer.
Condylomata acuminata	Patient may give a history of unprotected anal sex with an infected partner. Having multiple sexual partners is a risk factor and should be investigated.[12] Condyloma acuminata presents with painless warts that vary in size, shape, and color. Pruritis and discharge may accompany the warts.	Anal condyloma acuminata may be accompanied by cervical, vaginal, or even ororpharyngeal warts, so the patient should be examined thoroughly.[13]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

The incidence of anal fissure is approximately 1100 per 100,000 individuals in US which is about 7.8% lifetime risk. The incidence is 30-50% in patients with Crohn’s disease. Women in adolescence and child bearing group and males of middle aged group are commonly affected. Females are more affected than males.

• The incidence of anal fissure is approximately 1100 (700-1700) per 100,000 individuals in US which is about 7.8% lifetime risk.^[1]
• The incidence in patients with Crohn’s disease is approximately 30-50%.
• Each year 235,0000 new cases are reported for anal fissure.^[2]

• Patients of all age groups may develop anal fissure.
• Anal fissure commonly affects women in adolescence and child bearing age group
• Anal fissure commonly affects men in the middle age group.^[1]

• There is no racial predilection to anal fissure.

• Females are more commonly affected by anal fissure than males.
• Females have higher incidence of 1140 cases per 100,000 as compared to males who have 1070 per 100,000. ^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

The common risk factors for anal fissure include people with chronic constipation, frequent diarrhea, anal trauma, labor complication to the mother, Crohn’s disease. Less common risk factors include infants, elderly adults, and people having HIV.

• Common risk factors in the development of anal fissure include:^[1]
  • Chronic constipation
  • Frequent diarrhea
  • Anal trauma
  • Women who just gave birth
  • People with Crohn’s disease

• Less common risk factors in the development of anal fissure include:^[1]
  • Infants
  • Elderly adults
  • HIV

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

There is insufficient evidence to recommend routine screening for anal fissure.

There is insufficient evidence to recommend routine screening for anal fissure.

​​ Template:WS Template:WH

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

The symptoms of anal fissure can develop in infants as well as in adults following episodes of severe and chronic constipationand diarrhea. If left untreated, the unhealed fissures can get complicated to chronic fissures, anal abscess, anal fistula and fecal incontinence. The prognosis is generally excellent and 90% spontaneously heal or with dietary and medical measures.

• The symptoms of anal fissure can develop in the childhood in children having frequent diarrhea or severe constipation.
• In adults, severe and chronic constipation leads to increased straining efforts which ultimately leads to anal fissure.
• If left untreated, they become chronic anal fissure which frequently have an anal tag and unhealed fissures can get complicated to anal fistula and anal abscess.

• Common complications of anal fissure include:^[1][2]
  • Failure to heal and become chronic fissures
  • Anal abscess or fistula
  • Fecal incontinence after surgery

• Prognosis is generally excellent and the patients with acute anal fissure is approximately 90% spontaneously heal or with dietary and medical measures.^[3]
• Fecal incontinence occurs in 56.5% of patients undergoing surgery.

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