Anal fissure: Clinical manifestations, diagnosis, prevention
- Elizabeth Breen, MD
Elizabeth Breen, MD
- Assistant Professor of Surgery
- Harvard Medical School
- Ronald Bleday, MD
Ronald Bleday, MD
- Associate Professor of Surgery
- Harvard Medical School
- Section Editors
- Martin Weiser, MD
Martin Weiser, MD
- Section Editor — Colorectal Surgery
- Professor of Surgery
- Weill Cornell Medical College
- Memorial Sloan Kettering Cancer Center
- Lawrence S Friedman, MD
Lawrence S Friedman, MD
- Section Editor — General Gastroenterology
- Professor of Medicine
- Harvard Medical School
- Tufts University School of Medicine
An anal fissure is one of the most common benign anorectal conditions that may result from high anal pressure. Anal fissures may be acute or chronic. Acute fissures may result from local trauma or may be secondary to an underlying medical/surgical condition.
An anal fissure is a tear in the anoderm distal to the dentate line (figure 1) . By definition, an acute anal fissure typically heals within six weeks with conservative local management, while a chronic anal fissure fails conservative management and requires a more aggressive, surgical approach [1-4]. The etiology of the fissure determines if it is primary (eg, local trauma) or secondary (eg, inflammatory bowel disease, malignancy).
An anal fissure is the result of the stretching of the anal mucosa beyond its normal capacity. Once the tear occurs, it begins a cycle leading to repeated injury. The exposed internal sphincter muscle beneath the tear goes into spasm. In addition to causing severe pain, the spasm pulls the edges of the fissure apart, which impairs healing of the wound. The spasm also leads to further tearing of the mucosa with the passage of subsequent bowel movements. This cycle leads to the development of a chronic anal fissure in approximately 40 percent of patients .
It has been proposed that ischemia may contribute to the development of an anal fissure. Blood flow in the anoderm at the posterior midline, the site of most fissures, is less than one-half that in other quadrants in the anal canal [5,6]. Furthermore, the rate of perfusion is inversely related to anal pressure and, in one study, patients with chronic anal fissure had higher anal pressures than those with fecal incontinence, hemorrhoids, or other colorectal disorders, or controls . The demonstration of reduced blood flow provided the rationale for the use of topical nitroglycerin in the treatment of this disorder (see "Anal fissure: Medical management", section on 'Topical nitroglycerin').
The elevation in anal pressure in patients with chronic anal fissure may result from increased tone of the internal anal sphincter, which can be demonstrated manometrically [7-9]. In one study, for example, manometry was performed in 12 patients with chronic anal fissure and in 12 controls . The mean average resting pressure of the internal sphincter was significantly higher in patients with a chronic anal fissure (120 versus 83 mmHg).
- Zaghiyan KN, Fleshner P. Anal fissure. Clin Colon Rectal Surg 2011; 24:22.
- Madalinski MH. Identifying the best therapy for chronic anal fissure. World J Gastrointest Pharmacol Ther 2011; 2:9.
- Dykes SL, Madoff RD. Benign Anorectal: Anal Fissure. In: Wolff BG, Fleshman JW, Beck DE, Pemberton JH, Wexner SD, et al., editors. The ASCRS textbook of colon and rectal surgery. New York: Springer Science and Business Media LLC; 2007. pp. 178–191.
- Perry WB, Dykes SL, Buie WD, et al. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum 2010; 53:1110.
- Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum 1994; 37:664.
- Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum 1989; 32:43.
- Keck JO, Staniunas RJ, Coller JA, et al. Computer-generated profiles of the anal canal in patients with anal fissure. Dis Colon Rectum 1995; 38:72.
- Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fissure. Dis Colon Rectum 1994; 37:424.
- Horvath KD, Whelan RL, Golub RW, et al. Effect of catheter diameter on resting pressures in anal fissure patients. Dis Colon Rectum 1995; 38:728.
- Nelson RL, Abcarian H, Davis FG, Persky V. Prevalence of benign anorectal disease in a randomly selected population. Dis Colon Rectum 1995; 38:341.
- Oh C, Divino CM, Steinhagen RM. Anal fissure. 20-year experience. Dis Colon Rectum 1995; 38:378.
- Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg 1996; 83:1335.
- Gupta PJ. Ano-perianal tuberculosis--solving a clinical dilemma. Afr Health Sci 2005; 5:345.
- Mathew S. Anal tuberculosis: report of a case and review of literature. Int J Surg 2008; 6:e36.
- Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
- CLINICAL MANIFESTATIONS
- Patient presentation
- Physical examination
- DIAGNOSTIC EVALUATION
- DIFFERENTIAL DIAGNOSIS
- Perianal ulcers or sores
- Anorectal fistula
- Solitary rectal ulcer syndrome
- POSTDIAGNOSTIC EVALUATION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS