A 45-year-old patient complains of frequent anal itching, and post defecation pain.

الشرح

Core Concept: An anal fissure is a linear tear in the anoderm distal to the dentate line, usually caused by the passage of hard stool or local trauma. The tear exposes the underlying internal anal sphincter, leading to severe spasm and ischemia, which prevents healing and causes intense pain.

Clinical Presentation:

• Severe, tearing, 'glass-like' pain during and after defecation lasting for hours
• Bright red blood on the toilet paper
• Pruritus ani (anal itching) and a palpable 'sentinel pile' (skin tag)

Diagnosis:

• First-line: Gentle visual inspection of the perianal area (parting the buttocks reveals the posterior or anterior tear).
• Gold standard: Clinical examination. Digital rectal examination and anoscopy are typically deferred in the acute setting due to severe patient discomfort and pain.

Management:

• Acute: Warm sitz baths, topical anesthetics, stool softeners, high-fiber diet, and increased water intake to prevent constipation.
• Long-term/Definitive: Topical vasodilators (e.g., nitroglycerin, diltiazem, nifedipine) or botulinum toxin injections to relieve sphincter spasm and promote healing. For chronic or refractory fissures, the gold standard surgical treatment is a lateral internal sphincterotomy (LIS).