Anal Fissure & Ulcer

• • Fissure: Split in the anoderm

  • Ulcer: Chronic fissure

  • Associated with skin tag (sentinel pile) once matured

  • Located in midline, distal to dentate line

  • Most commonly located posteriorly (90%)

  • Caused by forceful dilatation of anal canal, usually from defecation, leading to sphincter spasm and local anoderm ischemia

Epidemiology

• • Predisposing factors: previous anorectal surgery (hemorrhoidectomy, fistulotomy)

  • Classically, initial insult is a firm, hard bowel movement

  • -Pain resulting from the initial bowel movement may be great, leading to tendency to resist urge to defecate

    -This leads to the formation of harder stool

Symptoms and Signs

• • Pain and bleeding with defecation

  • Pain may be tearing or burning, worst during defecation, may last for hours

  • Blood may be noted on tissue or on stool but not mixed in

  • Constipation may develop secondary to fear of recurrent pain

  • May present as painless, nonhealing wounds that occasionally bleed

  • Physical exam reveals disruption of anoderm in the midline at the mucocutaneous junction

  • Sentinel skin tag or pile may be present at the inferior margin

  • Digital exam may reveal sphincter spasm

Laboratory Findings

• • No specific findings

  • Anal manometry may demonstrate increased sphincter tone

Imaging Findings

• • No specific findings

• • Crohn disease

  • Anal tuberculosis

  • Anal malignancy

  • Abscess

  • Fistula

  • Cytomegalovirus

  • Herpes

  • Chlamydiosis

  • Syphilis

  • AIDS

Rule Out

• • Anal malignancy

• • History (including previous anorectal surgery) and physical exam

  • Following diagnosis, patients should undergo anoscopy and sigmoidoscopy to evaluate for anorectal malignancy or inflammatory bowel disease

  • Nonhealing ulcers should be biopsied

When to Admit

• • Rarely, except for severe pain or bleeding leading to hemodynamic compromise, or both

• • Initial treatment is conservative with stool softeners, bulking agents, sitz baths

Surgery

Indications

• • Failure of conservative measures

  • Perform lateral internal anal sphincterotomy

Medications

• • 0.2% nitroglycerin ointment

  • Botulinum toxin infiltration into internal sphincters may aid healing

  • Stool softeners

  • Bulking agents

Treatment Monitoring

• • Follow-up physical exam

Complications

• • Sphincterotomy may result in fecal incontinence

  • Recurrence

Prognosis

• • Conservative measures will result in healing in 90% cases

  • A second episode has a 70% chance of healing with conservative treatment

  • Lateral internal anal sphincterotomy is over 90% successful

  • Recurrence rate is less than 10% after sphincterotomy

References