A 22yo woman with longstanding constipation has severe ano-rectal pain on defecation. Rectal
exam: impossible due to pain and spasm. What is the most probable dx?
a. Anal hematoma
b. Anal fissure
c. Anal abscess
d. Protalgia fugax
e. Hemorrhoids
answer: B
Definition
• tear of anal canal below dentate line (very sensitive squamous epithelium)
• 90% posterior midline, 10% anterior midline
• if off midline: consider other possible causes such as IBD, STDs, TB, leukemia, or anal carcinoma
• repetitive injury cycle after first tear:
ƒ sphincter spasm occurs preventing edges from healing and leads to further tearing
ƒ ischemia may ensue and contribute to chronicity
Etiology
• forceful dilation of anal canal: large, hard stools and irritant diarrheal stools
• tightening of anal canal secondary to nervousness/pain leads to further tearing
• others: habitual use of cathartics, childbirth
Clinical Features
• acute fissure
ƒ very painful bright red bleeding especially after bowel movement, sphincter spasm on limited DRE
ƒ treatment is conservative: stool softeners, bulking agent, sitz baths (heals 90%)
• chronic fissure (anal ulcer)
ƒ triad: fissure, sentinel skin tags, hypertrophied papillae
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