Cardinal Signs and Symptoms

Sharp pain associated with scant, bright red rectal bleeding is the hallmark of anal fissure disease. The pain occurs during and after passage of stool "like passing a piece of glass." Pain may radiate into the rectum or buttocks and sometimes seems out of proportion to what would be expected given the small size of the lesion. If pain is severe enough, patients may have difficulty with urinary hesitancy, retention, or frequency. Anticipation of pain with bowel movements may discour-

Fig. 2. The classic triad of chronic anal fissure: hypertrophic papilla, anal fissure, and sentinel pile. (Adapted with permission from ref. 2.)

age subsequent stools. This sets up a vicious cycle of constipation, which only exacerbates the condition. Bleeding is generally self-limited and of low volume, spotting the toilet tissue or coating the stool surface. Repeated trauma at the site may cause intermittent bleeding. Patients may also develop discharge and pruritis.

Anal fissures are best identified by careful inspection. The buttocks should be aggressively spread with special attention to the posterior midline. Marked tenderness and sphincter spasm may limit the ability to perform a digital exam or anoscopy even with topical anesthesia, but such tenderness itself suggests a fissure, particularly in the absence of an acutely thrombosed hemorrhoid or other lesion. A fissure can be identified as a small, linear tear oriented perpendicular to the dentate line. Fissures are so commonly located in the posterior midline that, if found laterally, a predisposing disease process (such as inflammatory bowel disease, syphilis, tuberculosis, and others) should be considered. The classic triad of a chronic anal fissure includes (a) a sentinel pile or skin tag, the result of lymphatic edema and low-grade infection at the distal skin margin; (b) the fissure itself; and (c) a hypertrophied anal papilla proximally caused by edema and fibrosis (Fig. 2). An anal fissure must be differentiated from other perianal conditions that may have a similar presentation and appearance such as perirectal abscess, fistula-in-ano, perianal inflammatory bowel disease, thrombosed hemorrhoid, and squamous cell cancer of the anal skin.

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