Q&A: Management of Chronic Anal Fissure

Anal fissure is one of the most common benign anorectal diseases and one of the most common causes of anal pain and anal bleeding. Anal fissures typically start with a tear to the anoderm within the distal half of the anal canal. The tear then triggers cycles of recurring anal pain and bleeding, which lead to the development of a chronic anal fissure in as many as 40 percent of patients. The exposed internal sphincter muscle within the bed of the fissure frequently spasms, which not only contributes to severe pain but also can restrict blood flow to the fissure, preventing its healing.

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This is a Question & Answer revision article designed for medical students and professionals preparing for the PLAB, MRCP or USMLE examinations. They are based on actual questions from these examinations. You may find the Digestive Health articles more useful, or one of our many articles on Diseases & Conditions, Medical Syndromes, Health & Wellness or Home Remedies.

In this article:
Treatment of anal fissure
MCQ exam: clinical scenario
MCQ exam: answer
MCQ exam: explanation

Treatment of anal fissure

An anal fissure is a tear in the lining of the anal canal distal to the dentate line. A fissure may be primary, resulting from local trauma, or secondary from an underlying medical condition (eg, Crohn disease, malignancy, infection). Most primary acute anal fissures, as well as some primary chronic fissures, respond to medical management, while chronic fissures more often require surgical intervention.

MCQ exam: clinical scenario

A 35 year old male has a chronic anal fissure.

This is typically managed by:

a) Resection of the sigmoid colon
b) Left hemicolectomy
c) Abdominal perineal resection
d) Internal sphincterotomy
e) CT guided drainage

MCQ exam: answer

The correct answer is E.

MCQ exam: explanation

Chronic fissures are managed by subcutaneous or open lateral internal sphincterotomy, posterior internal sphincterotomy with advancement flap, or manual dilatation.

Reference(s)
1). UpToDate: Anal fissure: Clinical manifestations, diagnosis, prevention. Available online: https://www.uptodate.com/contents/anal-fissure-clinical-manifestations-diagnosis-prevention