Anal Fissure: Symptoms, Diagnosis and Treatment

What is Anal Fissure?

Anal fissure is one of the most common diseases of the anal region. The most characteristic feature is that it causes severe anal pain and fresh bleeding. During defecation, it may hurt as if it were cut with a knife or as if a piece of glass was coming out. It may bleed in the form of fresh red blood on the stool or fresh red blood in the form of dripping after defecation. In advanced cases, enlarged skin fold is one of the typical findings. Although it improves with hot water bath and some medications in the early period, this treatment does not benefit when it becomes chronic. Surgical treatment or Botox injection can be used as a treatment method in advanced, chronic disease.

Incidence: It is especially common in the middle-aged group. Although the incidence of the diseases of this region is low because of embarrassment, the rate of going to the doctor was found to be extremely high. Over 200,000 new cases are detected each year in the United States. When this rate is adapted to our country, it corresponds to approximately 60,000 new cases per year (Madalinski MH. Identifying the best therapy for chronic anal fissure. World J Gastrointest Pharmacol Ther 2011; 2:9).

Anal Fissure Pathogenesis:

It may develop after increased anal pressure in the distal part of the anal canal or due to trauma due to forced defecation. This tear/crack leads to a vicious cycle of recurrent anal pain, bleeding and anal spasm, leading to the chronicity of the disease. Nearly 40% of the patients have chronic anal fissure disease. The exposed internal sphincter muscle at the base of the crack causes pain and bleeding. Excessive spasm in the internal sphincter disrupts the blood supply and prevents the healing of the fissure. Anal pressure is mostly increased in patients with anal fissures compared to healthy individuals.

90% of anal fissures are posterior in the prone position, that is, on the side of the coccyx. Crohn’s disease should be kept in mind in lateral or multiple fissures (Stewart DB Sr, Gaertner W, Glasgow S, et al. Clinical Practice Guideline for the Management of Anal Fissures. Dis Colon Rectum 2017; 60:7. Lund JN, Scholefield JH. Aetiology and treatment of anal fissure. Br J Surg 1996; 83:1335.)

Anal Fissure Etiology:

Anal fissure may develop due to causes such as constipation, diarrhea, vaginal delivery and anal sex, which generally cause anal trauma, or it may develop due to crohn, cancer, granulomatous diseases.

Anal Fissure Symptoms:

The most typical symptom of anal fissure is severe pain during defecation. The pain is typically tearing or

Primary chronic fissures, respond to medical management, while chronic fissures more often require surgical intervention [1,7,12,13]. The medical and surgical management of anal fissure is discussed in detail separately. (See ‘Anal fissure: Medical management’ and ‘Anal fissure: Surgical management’.)

Secondary fissures require a detailed evaluation for and treatment of the underlying condition causing them (eg, Crohn disease). Those conditions are discussed separately. (See ‘Perianal Crohn disease’ and ‘Cutaneous manifestations of tuberculosis’, section on ‘Metastatic tuberculous abscesses’.)

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