Anal Fissure Initial Assessment

History

The symptoms of anal fissure are usually elicited during history taking and are often specific. Symptoms include pain that is often present at rest but severe during bowel movement. Patients may describe defecation as feeling like passing razor blades. Additionally, pain or burning may continue for several hours after defecation. Lastly, bright red blood may be seen with the stool or on the toilet tissue, but profuse bleeding is rare.

Anal Fissure_Initial Assessment_2

Physical Examination

Confirmatory Physical Exam Findings

Most anal fissures are seen by separating the buttocks with opposing traction of the thumbs while the patient is in a prone jacknife position. A digital rectal examination causes severe pain and should be deferred in most cases. If a sentinel skin tag is seen, the physician should be alerted to the possible presence of a fissure, even if there is none readily apparent. Notably, the majority of anal fissures are located in the posterior midline of the anus. While 10% (8% in men & 13% in women) are anteriorly located, with a small fraction of patients (2-3%) may have both anterior and posterior fissures. Atypical, non-midline or multiple fissures should lead to a suspicion of underlying diseases (eg Crohn’s disease, malignancy [hematologic cancer], human immunodeficiency virus [HIV]/acute immune deficiency syndrome, tuberculosis, syphilis). Lastly, anal fissures may often be misdiagnosed as hemorrhoids by primary care providers.