Describe the aetiology, clinical features and management of anal fissure.
Anal Fissure – Aetiology, Features, and Management
An anal fissure is a linear tear in the anoderm, usually posterior midline. The primary cause is trauma from hard stools (constipation) or prolonged diarrhoea. Trauma triggers internal anal sphincter (IAS) spasm, reducing blood flow, impairing healing, and creating a pain-spasm-ischemia cycle. Less common causes include inflammatory bowel disease, infections, or foreign body trauma.
Clinical Features: Severe pain during and after defecation, bright red bleeding, constipation, anal spasm, pruritus ani, and sentinel piles in chronic cases.
Management:
Conservative: High-fiber diet, adequate fluids, stool softeners, sitz baths, and topical agents (nitroglycerin, calcium channel blockers, lidocaine).
Pharmacological: Botulinum toxin injection for persistent fissures.
Surgical: Lateral internal sphincterotomy (gold standard) reduces IAS spasm. Fissurectomy with advancement flap is reserved for complex or refractory fissures. The aim is pain relief, sphincter relaxation, healing, and recurrence prevention.
Most acute fissures heal with conservative management. Chronic fissures or those unresponsive to medical therapy usually require more aggressive intervention.
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