Introduction

Article Outline

• Copyright

Anal fissures are a very common, and surprisingly annoying, condition that has frustrated humans, and their physicians, for thousands of years. Fissures present with the symptoms of pain and minimal bleeding during bowel movements and are almost invariably attributed to “hemorrhoids” when the physician is consulted. The onset of fissures has been associated with constipation, diarrhea, and inflammatory bowel disease, but can sometimes occur spontaneously with no apparent inciting factor. It is suspected that most heal fairly rapidly, with or without the application of therapeutic substances, but those which do not resolve present to the physicians’ office for diagnosis and management.

Fissures can nearly always be seen simply by distracting the buttocks, a step in the diagnostic examination which is overlooked by many practitioners. While many physicians, having seen this from the external approach, are reluctant to examine the patient further for fear of causing undue pain, most patients can tolerate a gentle examination with the aid of topical local anesthesia creams, and most also benefit from examination with a pediatric sigmoidoscope, primarily to rule out more proximal conditions such as inflammatory bowel disease, hemorrhoids, or other rectal pathology.

Approximately half of those with acute and chronic fissures will find relief with medical therapy, but in those whose fissures and painful symptoms persist, surgical therapy is usually offered. The most common surgical therapy of this condition is the lateral internal sphincterotomy, which some consider the most effective procedure in all of surgery, as it allows healing in up to 98% of patients with very minimal perioperative discomfort. While many practitioners have never had one of their patients develop postoperative complications, others report the development of fecal incontinence of different degrees in up to 45% of patients. These outcome discrepancies are discussed in detail in the following monograph.

It is hoped that the reader will have the opportunity both to gain a detailed understanding of these issues as well as to have a simple algorithmic approach to management of a patient with anal fissure.