Diagnosis

Anal fissure

Etiology

Cause [n4r]

• Constipation

• Chronic diarrhea

• Sexually transmitted diseases

• Tuberculosis

• Inflammatory bowel disease

• HIV

• Anal cancer

• Childbearing

• Anal surgery

• Anal intercourse

Pathophysiology [n4r]

1. Direct trauma: either the posterior or anterior midline

   • The passage of hard stools against an elevated anal sphincter tone

     The classic "unstoppable force meets immovable object" scenario

   • Hard bowel movement --> pain --> worsening constipation

2. High sphincter pressure --> reduced blood perfusion --> delayed healing

3. Lateral fissure --> underlying etiology (HIV, tuberculosis, IBD)

Risk factors [mn3]

• Constipation

• Hypothyroidism

• Obesity

Complications [n4r]

• Infection

• Incontinence

• Fistula formation

Epidemiology

Incidence per 100.000

Approach

• Rectal exam

• Anoscopy

• Rectoscopy

Treatment

1. Exclude other underlying conditions [n4r]

2. Treat the constipation: Break the cycle (hard bowels -> pain -> constipation)

   • Fiber supplementation

   • Adequate fluid intake

   • Stool softeners: Laxatives, Mineral oil

3. Pain relief:

   • Sitz bath

   • Xylocain gel

   • Topical anti-inflammatory ointment (Scheriproct)

4. Sphincter relaxing procedures:

   • Intra-anal application of nitroglycerin

   • Botulinum toxin

   • Sphincter dilatation

   • Lateral internal sphincterotomy

Differential diagnoses

Anal cancer, Anorectal abscess, Anorectal fistula, Colorectal cancer, Crohn disease, Hemorrhoids, Tuberculosis, Ulcerative colitis