Anorectal: Anal Fissure

Basics

• Tear in Anoderm from Straining
• Sentinel Pile – Thickened Mucosal Papilla at the Distal End of Chronic Fissures

Location

• Posterior Midline – Most Common (90%)
  • Where the Greatest Mechanical Stress is Placed
• Anterior Midline – More Common in Females (Posterior Still More Common Overall)
• Lateral Sites – Prompt Concern for Other Pathology

Symptoms

• Pain – Worse with Defecation
• Bleeding

Atypical Features

• Atypical Features Raise Concern for Other Pathology (IBD, Cancer, HIV or HPV)
• Atypical Features:
  • Lateral Site
  • Multiple Sites
  • Nonhealing
  • Recurrence
  • Painless Fissures

Treatment

• Initial: Conservative Management
  • Sitz Baths – A Bath with Shallow Warm Water in Which Only the Buttock/Hips are Emerged & Soaked
  • Adequate Hydration
  • Fiber Supplements
    • Daily Goal: 20-25 g for Women, 25-30 g for Men
  • Stool Softeners
• If Conservative Management Fails: Topical Creams
  • Calcium Channel Blockers (Diltiazem/Nifedipine)
  • Nitroglycerin
  • Lidocaine
• If Topical Creams Fail: Botulinum Toxin Injection
  • The Most Effective Medical Treatment
  • Surgical Sphincterotomy is Contraindicated If Patient Develops Fecal Incontinence After Botox Injection
• If Medical Management Fails: Lateral Internal Anal Sphincterotomy
  • *See Anorectal: Lateral Internal Anal Sphincterotomy
  • The Most Effective Treatment
    • Success: 88-100%
  • Highest Risk for Fecal Incontinence
  • Avoid Surgical Management in Patients with Crohn’s Unless Absolutely Necessary