Anal Fissure (cont.)

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What are the symptoms of anal fissures?

Patients with anal fissures almost always experience anal pain that worsens with bowel movements. The pain following a bowel movement may be brief or long lasting; however, the pain usually subsides between bowel movements. The pain can be so severe that patients are unwilling to have a bowel movement, resulting in constipation and even fecal impaction. Moreover, constipation can result in the passage of a larger, harder stool that causes further trauma and makes the fissure worse. The pain also can affect urination by causing discomfort when urinating (dysuria), frequent urination, or the inability to urinate. Bleeding in small amounts, itching (pruritus ani), and a malodorous discharge may occur due to the discharge of pus from the fissure. As previously mentioned, anal fissures commonly bleed in infants.

How are anal fissures diagnosed and evaluated?

A careful history usually suggests that an anal fissure is present, and gentle inspection of the anus can confirm the presence of a fissure. If gentle eversion (pulling apart) the edges of the anus by separating the buttocks does not reveal a fissure, a more vigorous examination following the application of a topical anesthetic to the anus and anal canal may be necessary. A cotton-tipped swab may be inserted into the anus to gently localize the source of the pain.

An acute anal fissure looks like a linear tear. A chronic anal fissure frequently is associated with a triad of findings that includes a tag of skin at the edge of the anus (sentinel pile), thickened edges of the fissure with muscle fibers of the internal sphincter visible at the base of the fissure, and an enlarged anal papilla at the upper end of the fissure in the anal canal.

If rectal bleeding is present, an endoscopic evaluation using a rigid or flexible viewing tube is necessary to exclude the possibility of a more serious disease of the anus and rectum. A sigmoidoscopy that examines only the distal part of the colon may be reasonable in patients younger than 50 years of age who have a typical anal fissure. In patients with a family history of colon cancer or age greater than 50 (and, therefore, at higher risk for colon cancer), a colonoscopy that examines the entire colon is recommended. Atypical fissures that suggest the presence of other diseases, as discussed previously, require other diagnostic studies including colonoscopy and upper gastrointestinal (UGI) and small intestinal X-rays.


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