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_2Physical Examination
Most anal fissures are seen by separating the buttocks with opposing traction of the thumbs while the patient is in a prone jackknife position. If no fissure is visible, gentle pressure over the anterior or posterior anal sphincter may elicit the characteristic pain. A digital rectal examination causes severe pain and should be deferred in most cases. If a sentinel skin tag (sentinel pile) 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 primary anal fissures are located in the posterior midline of the anus and are often associated with sphincter hypertonicity. While 10% (8% in men and 13% in women) are anteriorly located, a small fraction of patients (2-3%) may have both anterior and posterior fissures. Secondary fissures, particularly those that are multiple, located in atypical non-midline positions, slow to heal or associated with a normal or reduced internal anal sphincter tone, should prompt further investigation for underlying conditions (eg Crohn’s disease, malignancy [hematologic cancer], human immunodeficiency virus [HIV]/acute immune deficiency syndrome, TB, syphilis). Coordination of care with appropriate specialists (eg gastroenterologists, rheumatologists, oncologists, infectious disease clinicians, surgeons, pain specialists, dietitians) may be necessary to ensure optimal outcomes. Lastly, anal fissures may often be misdiagnosed as hemorrhoids by primary care providers.