First, nifedipine has been found to result in a higher healing rate compared to nitroglycerin. While both have been shown to be effective treatments, topical nifedipine is regarded to be superior to topical nitroglycerin in two ways. Topical nitroglycerin acts as a vasodilator to encourage increased blood flow to the area of the fissure, increasing the rate of healing. Topical nifedipine works by reducing anal sphincter tone, which promotes blood flow and faster healing. If conservative management with dietary changes and laxatives fail, other options can be used, including topical analgesics such as 2% lidocaine jelly, topical nifedipine, topical nitroglycerin, or a combination of topical nifedipine and lidocaine compounded by another medication. Adequate fluid intake is also helpful in preventing the recurrence of anal fissures and is strongly encouraged. Prevention of recurrence is the primary goal. Frequent sitz baths, analgesics, stool softeners, and a high-fiber diet are recommended. The initial treatment of anal fissures is with medical interventions. ![]() Granulation tissue may or may not be present, depending on the chronicity and the stage of healing. Also, due to the repeated injury and healing cycle, the edges sometimes appear raised, and thickening of tissue at the distal ends of the tears may be present, which is called a sentinel pile. ![]() In chronic anal fissure, there may be a tear large and deep enough to expose the muscular fibers of the anal sphincter. In an obese patient, gently pressing on the anterior or posterior anal sphincter may reproduce the pain, and a diagnosis can be made. In thin patients, this laceration is usually easily identified however, in obese patients, it may not be as identifiable. The fissure and sometimes the entire anal sphincter may be extremely tender to palpation. It is imperative that physical manipulation of the anus or rectum via digital exam should be kept to a minimum, and instrumentation such as anoscopy should never be used.Īn anal fissure will appear as a superficial laceration in the acute presentation, usually, longitudinal extending proximally. However, many times, an adequate physical exam can be achieved by having the patient in a lateral decubitus position. Therefore, the best way to achieve this position in the acute care or office setting would be to have the patient bend over the exam table. The bed typically used to achieve this position is usually in an operating room or procedure room. Literature suggests the best position is the prone jackknife position where the patient lies prone, and the bed is folded so that the patient is flexed at the hips. The physical exam of the patient with an anal fissure should involve the most comfortable position for the patient. Patients with underlying granulomatous diseases such as Crohn disease, among others, will sometimes provide a history of chronic anal pain during defecation that is intermittent rather than constant over an extended period. Associated constipation is the most common factor involving chronic anal fissures, and patients will provide a longstanding history of hard stools. Patients with chronic anal fissures will have a history of painful defecation with or without rectal bleeding that has been ongoing for several months to possibly years. Therefore, a thorough physical exam should be performed to delineate between the two. Often, acute anal fissures may be misdiagnosed as external or internal hemorrhoids. The pain usually persists for hours after defecation. Patients with acute anal fissures present with complaints of anal pain that is worse during defecation. At times, there is associated bleeding with bowel movements but usually not frank hemorrhage. Anterior fissures are rare and are associated with external sphincter injury and dysfunction. The cause of this other location is not well known. Other locations of anal fissures, such as lateral fissure, are indicative of an underlying etiology (HIV, tuberculosis, Crohn disease, ulcerative colitis, among others). The perfusion of the anal canal has an inverse relationship to sphincter pressure. It is well known that the most common location of an anal fissure is the posterior midline because this location receives less than half of perfusion compared to the rest of the anal canal. Together with spasms of the sphincter, this creates severe pain with bowel movements, as well as some rectal bleeding. The tear can sometimes be deep enough to expose the sphincter muscle. Due to the high pressures in this area, it can result in the delayed healing secondary to ischemia. It is a very sensitive area to microtrauma and can tear with repetitive trauma or increased pressure. ![]() The location is inferior to the dentate line. The anoderm refers to the epithelial component of the anal canal.
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