Anal Fissure

Anal fissure is a slit-like linear or rocket-shaped tear,usually <5 mm in the squamous epithelium of the anus distal to the dentate line.

-Usually they arise from trauma during defecation

-They are more common in the third through the fifth decades.

-They most commonly occur in the posterior midline (90%); 10% occur anteriorly

-Chronic fissures are those present for >6 weeks.

-Fissures that occur off the midline should lead to suspect other conditions such as syphilis, tuberculosis, HIV/AIDS, Crohn Disease, anal carcinoma

Symptoms & Signs:

Classic complaint: Severe,relentless, tearing pain during defecation followed by throbbing discomfort; May lead to constipation because of fear of recurrent pain

With chronic fissures, there is fibrosis and a skin tag at the outermost edge (sentinel pile)


Visual inspection of the anal verge while gently separating the buttocks

Sentinel pile: A skin tag at the distal end of the fissure

Anal manometry: elevation in anal resting pressure


Most primary acute anal fissures respond to medical management, while chronic fissures more often require surgical intervention

Conservative: Stool softeners, increased dietary fiber, topical anesthetics (lidocaine, prilocaine), glucocorticoids, sitz baths, nifedipine ointment, nitroglycerin ointment, diltiazem ointment, botulinum toxin injected into the internal sphincter

Surgical: anal dilatation and lateral internal sphincterotomy

Prognosis: Most simple anal fissures resolve in 2 to 4 weeks.

Q: What is the most common cause of rectal bleeding in infancy? Anal fissure

Q: What is the most common cause of painful rectal bleeding? Anal fissure

Q: What is the most common side-effect of nitroglycerin ointment? Headache

Q: What is the most common etiology of anal fissure? Anal trauma due to bowel movements

Q: What do you suspect in a child with large, irregular, multiple anal fissures? Sexual abuse

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