Anal Fissure

Question 1

Define

Answer 1

A painful tear in the squamous lining of the lower anal canal

Question 2

Epidemiology

Answer 2

• Affects 1/10 people during their life time
• Both sexes are affected equally
• Can occur at any age
• Most cases occur in children and young adults: 10-30yrs

Question 3

Aetiology

Answer 3

• Most are caused by hard faeces
• Anal sphincter spasm can constrict the inferior rectal artery, causing ischaemia and impairing the healing process
• Rare causes: syphilis, herpes, trauma, Crohn’s, anal cancer, psoriasis

Question 4

Presenting Symptoms

Answer 4

• Tearing pain when passing stools
• There may be a little bit of blood in the faeces or on the paper
• Anal itching (pruritus ani)

Question 5

Signs on PE

Answer 5

• Tears in the squamous lining of the anus on examination

Question 6

Investigations

Answer 6

Examine the anus

Question 7

Management

Answer 7

• Conservative
o High-fibre diet
o Softening the stools (laxatives)
o Good hydration
• Medical
o Lidocaine ointment (local anaesthetic)
o GTN ointment (relaxes the anal sphincter and promoted healing)
o Diltiazem (relaxes the anal sphincter and promotes healing)
o Botulinum toxin injection
• Surgical
o Lateral sphincterotomy: This relaxes the anal sphincter and promotes healing but it has complications (e.g. anal incontinence) so it is reserved for patients who are intolerant or not responsive to non-surgical treatments

Question 8

Complications

Answer 8

Chronic anal fissure

Question 9

Prognosis

Answer 9

• In most people, the fissure will heal within a week or so

* Treatment revolves around easing pain by keeping the stools soft and relaxing the anal sphincter to promote healing