(See also Evaluation of Anorectal Disorders Evaluation of Anorectal Disorders The anal canal begins at the anal verge and ends at the anorectal junction (pectinate line, mucocutaneous junction, dentate line), where there are 8 to 12 anal crypts and 5 to 8 papillae. The... read more .)
Anal fissures are believed to result from laceration by a hard or large stool or from frequent loose bowel movements. Trauma (eg, anal intercourse) is a rare cause.
The fissure may cause internal sphincter spasm, decreasing blood supply and perpetuating the fissure.
Symptoms and Signs of Anal Fissure
Anal fissures usually lie in the posterior midline but may occur in the anterior midline. Those off the midline may have specific etiologies, particularly Crohn disease Crohn Disease Crohn disease is a chronic transmural inflammatory bowel disease that usually affects the distal ileum and colon but may occur in any part of the gastrointestinal tract. Symptoms include diarrhea... read more . An external skin tag (the sentinel pile) may be present at the lower end of the fissure, and an enlarged (hypertrophic) papilla may be present at the upper end.
Fissures cause pain and bleeding. The pain typically occurs with or shortly after defecation, lasts for several hours, and subsides until the next bowel movement. Examination must be gentle but with adequate spreading of the buttocks to allow visualization.
Chronic fissures must be differentiated from anal cancer Anal Cancer Anal cancer accounts for an estimated 9760 cases and about 1870 deaths in the United States annually ( 1). The main symptom is bleeding with defecation. Diagnosis is by endoscopy. Treatment... read more , primary lesions of syphilis Syphilis Syphilis is caused by the spirochete Treponema pallidum and is characterized by 3 sequential symptomatic stages separated by periods of asymptomatic latent infection. Common manifestations... read more , tuberculosis Tuberculosis (TB) Tuberculosis is a chronic, progressive mycobacterial infection, often with an asymptomatic latent period following initial infection. Tuberculosis most commonly affects the lungs. Symptoms include... read more , and ulceration caused by Crohn disease Crohn Disease Crohn disease is a chronic transmural inflammatory bowel disease that usually affects the distal ileum and colon but may occur in any part of the gastrointestinal tract. Symptoms include diarrhea... read more .
Infants may develop acute fissures, but chronic fissures are rare.
Diagnosis of Anal Fissure
Diagnosis of anal fissure is made by inspection. Unless findings suggest a specific cause or the appearance and/or location is unusual, further studies are not required.
Treatment of Anal Fissure
Stool softeners, fiber supplements
Protective ointments, sitz baths
Nitroglycerin ointment, topical calcium channel blocker, or botulinum toxin type A injection
(See also the American Society of Colon and Rectal Surgeons’ 2016 clinical practice guideline for the management of anal fissures.)
Fissures often respond to conservative measures that minimize trauma during defecation (eg, stool softeners, psyllium, fiber).
Healing is aided by use of protective zinc oxide ointments or bland suppositories (eg, glycerin) that lubricate the lower rectum and soften stool. Topical anesthetics (eg, benzocaine, lidocaine) and warm (not hot) sitz baths for 10 or 15 minutes after each bowel movement and as needed give temporary relief.
Topical nitroglycerin 0.2% ointment, nifedipine 0.2% cream, and diltiazem 2% gel or injections of botulinum toxin type A into the internal sphincter relax the anal sphincter and decrease maximum anal resting pressure, allowing healing.
When conservative measures fail, surgery (internal anal sphincterotomy) is needed to interfere with the cycle of internal anal sphincter spasm.
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
American Society of Colon and Rectal Surgeons: Clinical practice guideline for the management of anal fissures (2016)
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|Fiber Therapy, GenFiber , Geri-Mucil, Hydrocil , Konsyl, Metamucil, Metamucil MultiHealth, Mucilin , Natural Fiber Laxative, Natural Fiber Therapy, Reguloid|
|Aquaphor 3 IN 1 Diaper Rash, Aquaphor Baby Fast Relief Diaper Rash, Aquaphor Fast Relief Diaper Rash, Balmex, Boudreaux Butt Paste, Boudreauxs Rask, Carlesta, Coppertone, COZIMA, DermacinRx Zinctral, Desitin, Desitin Maximum Strength, Desitin Rapid Relief, Diaper Rash , Dr. Smith Adult Barrier, Dr. Smith's, Dr. Smith's Diaper Rash, Dr. Smith's Rash + Skin, DynaShield, Eucerin Baby Sunscreen Sensitive Mineral , Eucerin Sunscreen Sensitive Mineral, Flanders Buttocks , Medi-Paste, Novana Protect, PanOxyl AM, Triple Paste, Triple Paste Adult Incontinence, Z-Bum|
|Colace Glycerin, Fleet, Fleet Pedia-Lax, HydroGel, Introl , Lubrin, Orajel Dry Mouth, Osmoglyn, Sani-Supp|
|Advocate Pain Relief Stick, Americaine, Anbesol, Anbesol Baby , Anbesol Jr , Banadyne-3, Benzodent, Benz-O-Sthetic, Boil-Ease, Cepacol Sensations, Chloraseptic, Comfort Caine , Dry Socket Remedy, Freez Eez, Little Remedies for Teethers, Monistat Care, Orabase, OraCoat CankerMelts, Orajel, Orajel Baby, Orajel Denture Plus, Orajel Maximum Strength, Orajel P.M., Orajel Protective, Orajel Severe Pain, Orajel Swabs, Orajel Ultra, Oral Pain Relief , Oticaine , Otocain, Outgro, Pinnacaine, Pro-Caine, RE Benzotic, Topex, Topicale Xtra, Zilactin-B|
|7T Lido, Akten , ALOCANE, ANASTIA, AneCream, Anestacon, Aspercreme with Lidocaine, Astero , BenGay, Blue Tube, Blue-Emu, CidalEaze, DermacinRx Lidogel, DermacinRx Lidorex, DERMALID, Ela-Max, GEN7T, Glydo, Gold Bond, LidaMantle, Lidocan, Lidocare, Lidoderm, LidoDose, LidoDose Pediatric, Lidofore, LidoHeal-90, LIDO-K , Lidomar , Lidomark, LidoReal-30, LidoRx, Lidosense 4 , Lidosense 5, Lidosol, Lidosol-50, LIDO-SORB, Lidotral, Lidovix L, LIDOZION, Lidozo, LMX 4, LMX 4 with Tegaderm, LMX 5, LTA, Lydexa, Moxicaine, Numbonex, ReadySharp Lidocaine, RectaSmoothe, RectiCare, Salonpas Lidocaine, Senatec, Solarcaine, SUN BURNT PLUS, Tranzarel, Xyliderm, Xylocaine, Xylocaine Dental, Xylocaine in Dextrose, Xylocaine MPF, Xylocaine Topical, Xylocaine Topical Jelly, Xylocaine Topical Solution, Xylocaine Viscous, Zilactin-L, Zingo, Zionodi, ZTlido|
|Deponit, GONITRO , Minitran, Nitrek, Nitro Bid, Nitrodisc, Nitro-Dur, Nitrogard , Nitrol, Nitrolingual, NitroMist , Nitronal, Nitroquick, Nitrostat, Nitrotab, Nitro-Time, RECTIV, Transdermal-NTG, Tridil|
|Adalat, Adalat CC, Afeditab CR, Nifediac CC, Nifedical XL, Procardia, Procardia XL|
|Cardizem, Cardizem CD, Cardizem LA, Cardizem SR, Cartia XT , Dilacor XR, Dilt-CD , Diltia XT, Diltzac, Matzim LA, Taztia XT, TIADYLT ER, Tiamate, Tiazac|