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Anal fissure

Definition
  • An anal fissure is a small tear or cut in the lining of the anal canal.
Etiology
  • Constipation: Hard stools causing trauma.
  • Chronic diarrhoea.
  • Anal intercourse.
  • Childbirth trauma.
  • Inflammatory bowel diseases (less common).
Clinical Presentation
  • Severe, sharp pain during and after bowel movements.
  • Bright red blood on the toilet paper or in the stool.
  • Pruritus (itching).
  • A visible tear or cut near the anus (on inspection).
Classification
  • Acute: Less than 6 weeks’ duration.
  • Chronic: More than 6 weeks’ duration, may have an external skin tag (sentinel pile) at the distal end.
Investigations
  • Generally clinical diagnosis.
  • Anoscopy or proctoscopy: If other diagnoses are being considered or if the fissure doesn’t heal with treatment.
Management
  • Conservative:
    • Bulk-forming laxatives to soften stools (e.g., ispaghula husk).
    • Sitz baths: Warm water baths for symptomatic relief.
    • Topical anaesthetics (e.g., lidocaine) for pain relief.
  • Medical:
    • Topical glyceryl trinitrate (GTN): Reduces anal sphincter spasm.
    • Topical calcium channel blockers (e.g., diltiazem).
    • Botulinum toxin injections: Temporary paralysis of the anal sphincter.
  • Surgical: Reserved for chronic fissures not responding to treatment.
    • Lateral internal sphincterotomy: Most common surgical treatment.
    • Fissurectomy: Removal of the fissure and any underlying scar tissue.
Complications
  • Chronic pain.
  • Abscess or fistula formation.
  • Incontinence (rare and usually temporary, especially after surgery).
Prevention
  • High-fibre diet to prevent constipation.
  • Regular fluid intake.
  • Avoiding straining during bowel movements.

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