Anal Fissure Flashcards
What is an anal fissure?
Anal fissure = split in the skin of the distal anal canal characterised by pain on defecation and rectal bleeding
Tear in the squamous lining
If chronic, often with a sentinel pile/mucosal tag externally
90% are posterior
Parturition-caused are anterior
What is the aetiology of anal fissure?
The fissure may occur during the passage of a hard stool bolus, episode of diarrhoea or spontaneously
Most are due to hard stool tearing the anal skin from the pectin (at the dentate line)
Spasm may constrict the inferior rectal artery – causing ischaemia
Can also have a deficiency in the intrinsic NO pathway
Rare: Syphilis, herpes, trauma, Crohn’s, anal cancer, psoriasis
What are the risk factors for anal fissure?
Hard stool
Pregnancy (May occur in third trimester or after delivery)
Opiate analgesia
What is the epidemiology of anal fissure?
Incidence of 1 in 350
Equally common in men and women
Often affects young adults 15-40
What are the symptoms of anal fissure?
Symptoms tend to wax and wane
Pain on defecation (Tearing sensation)
Fresh blood on stool/paper
Anal spasm
What are the signs of anal fissure?
Sentinel pile
Fissure visible on retraction of buttock
What are appropriate investigations for diagnosis of anal fissure?
Clinical diagnosis
Anal manometry
NOT DRE (Very painful for patient)
What is the management of anal fissure?
First presentation: Conservative treatment Increase dietary fibre Increase fluids Stool softener Topical lidocaine (5%) Sitz baths Topical GTN (0.2-0.4%)/diltiazem (2%)
Resistant fissures:
Botulinum toxin injection
Lateral partial internal sphincterotomy
What are the complications of anal fissure?
Chronic anal fissure
Post-surgery incontinence
Recurrence
What is the prognosis of anal fissure?
60% heal at 6-8 weeks
20% heal later with topical diltiazem
Some will relapse – and 30% will require a surgical treatment
