Anal Fissure

Question 1

Define anal fissure

Answer 1

Tear in the lower anal canal (sensitive, skin-lined region)

Question 2

What are the causes/risk factors of anal fissures?

Answer 2

• Idiopathic
• IBD
• Passage of hard stool (constipation)
• Opiate analgesia (increased risk of constipation)
• Pregnancy

Question 3

What are the symptoms of anal fissures?

Answer 3

• Pain on defecation (like passing broken glass)
• Tearing sensation on passing stool
• Fresh PR bleeding
• Anal spasm

Question 4

What are the signs of anal fissures?

Answer 4

• Visible fissure

* Anal spasm

Question 5

What investigations are carried out for anal fissures?

Answer 5

• Clinical diagnosis (history and examination consisting of inspection only)
• DRE is too painful to perform
• Proctoscopy and sigmoidoscopy – exclude other anorectal disease in severe cases
• Anal manometry (patients with resistant fissures – low resting pressure)
• Anal ultrasound (suspected anal sphincter defects)

Question 6

What is the management for anal fissures?

Answer 6

Conservative
• High fibre diet
• Adequate fluid intake
• Topical analgesia
• Stool softeners

Adjuncts
• 0.4% GTN ointment
• 2% diltiazem ointment

Chronic or severe cases
• Botulinum toxin
• Lateral subcutaneous internal sphincterotomy

Question 7

What are the complications of anal fissures?

Answer 7

• Chronic anal fissure
• Recurrence
• Perianal abscess or anal fistula in IBD