Anal Fissure (cont.)
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 an anesthetic to the anus
and anal canal
may be necessary. An 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 bowel x-rays.
Next: How are anal fissures treated? »
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