Anal Fissure

Presentation

In most patients, the symptoms are so characteristic that they are nearly diagnostic. Initial onset of pain often occurs during or after defecation, usually after passing a large, hard bowel movement or following an explosive bout of diarrhea. Later, patients complain of severe intense pain with subsequent defecation. It can be described as knifelike, cutting, or tearing in character. This pain can persist for a few minutes to hours, with a tight, throbbing quality followed by relative comfort prior to the next bowel movement. Often patients will complain of constipation that predates their anal symptoms. Occasionally patients have diarrhea or an alternating pattern of constipation and diarrhea.

Bright red bleeding with defecation may occur but is usually slight, only staining the toilet tissue. Mucous discharge may increase perineal moisture and cause itching. Examination of the anus reveals a radial tear or ulceration of the posterior midline 95% of the time (the fissure is anterior in 10% of women but only 1% of men) ( Fig. 66.1 ). If the condition becomes chronic (>8 weeks), the skin distal to the fissure becomes edematous and enlarged and may form a fibrous skin tag called a sentinel pile.