Anal fissure overview

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Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Anal Fissure from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Abdominal X Ray

CT

MRI

Ultrasound

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

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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]

Overview

Historical Perspective

Classification

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.

Pathophysiology

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).

Causes

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 tuberculosissarcoidosisanal intercourseHIV , Human papillomavirus, and syphilis.

Differentiating Anal fissure overview from Other Diseases

Anal fissure must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoidsrectal prolapse and perianal abscessanal fistula and anal cancer.

Epidemiology and Demographics

The incidence of anal fissure is approximately 1100 per 100,000 individuals in US which is about 7.8% lifetime risk. The incodence 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.

Risk Factors

Screening

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

Natural History, Complications, and Prognosis

Diagnosis

History and Symptoms

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.

Physical Examination

Laboratory Findings

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,tuberculosissarcoidosis and HIV which include Leukocytosislymphocytosis,Enzyme linked immunosorbent assay (ELISA).

Imaging Findings

There are no other imaging findings associated with anal fissure.

Other Diagnostic Studies

There are no other diagnostic studies associated with anal fissure.

Treatment

Medical Therapy

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.

Surgery

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.

Prevention

References

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