An elongated ulcer in the long axis of the lower half of the anal canal usually at midline posteriorly or anteriorly or both, and rarely laterally. It extends from the pectinate line (dentate line) to the margin of the anal verge where a sentinel pile is common in chronic cases. It is a painful condition, associated with extreme increase in anal tone, leading to distressful constipation. It may be acute, chronic or recurrent and usually occurs alone and sometimes with other anal diseases e.g. hemorrhoids. It is more common in young females, usually after child birth or lower abdominal operations eg, C section, TAH, etc.

1. ANAL FISSURE (FISSURE IN ANO)
A painful linear ulcer in the lower half of the anal canal
commonly in mid line posteriorly 90% or anteriorly 10% or both.

2. Anal Fissure
• An elongated ulcer in the long axis of the lower half of the
anal canal usually at midline posteriorly or anteriorly or
both, and rarely laterally.
• It extends from the pectinate line (dentate line) to the
margin of the anal verge where a sentinel pile is common in
chronic cases.
• It is a painful condition, associated with extreme increase in
anal tone, leading to distressful constipation.
• It may be acute, chronic or recurrent and usually occurs
alone and sometimes with other anal diseases e.g.
hemorrhoids.
• It is more common in young females, usually after child
birth or lower abdominal operations eg, C section, TAH, etc.

3. Acute anal fissure

4. Acute anal fissure

5. Etiology
slide a
• The primary anal fissure is due to trauma on defecation
and secondary anal fissure is due to diseases, (like
inflammatory bowel diseases, sexually transmitted
diseases, tuberculosis, malignancy and rarely the passage
of a sharp foreign body).
• Midline affection is due to comparative fixation of the anal
canal anteriorly by perineal body and posteriorly by coccyx
(which do not allow much dilatation on defecation), while
laterally ischiorectal fossas allow dilatation on defecation,
leads to stretching anteriorly and posteriorly, so fissures in
midline.
• More frequent posterior fissures are due to more rigidity of
coccyx posteriorly.

6. Etiology
Slide b
• Lower anal canal affection is due to unsupportive anal
verge and on sudden passage of hard stools after resistance
of coccyx and perineal body, to no resistance of anal verge
leading to trauma.
• The acute anal fissure on repeated trauma and infection
becomes chronic.
• Sentinel pile formation is due to over-healing and non
stretching of perineal skin as compared to the
anoderm where healing gives away on repeated trauma.
• This anal fissure leads to increased anal tone, so
constipation and vicious circle started; pain leads to
constipation which leads to exaggeration of ulcer.

7. Examination of anal fissure in a
child in out door.

8. Pathophysiology
Slide a
Acute anal fissure
• It is an acute ulcer of lower half of anal canal and its
base is formed by the anal sphincter muscles with
little inflammatory induration or oedema of its edges.
• Because the fissure occurs in the sensitive stratified
squamous epithelium of the anal canal, pain is the
most prominent symptom.
• The accompanying spasm of the anal sphincter is
marked.
• It is not palpable.
• Sentinel pile is not present.

9. Acute anterior and posterior
anal fissures

10. Acute anterior and posterior
anal fissure

11. Pathophysiology
Slide b
Chronic anal fissure
• It is characterized by inflamed indurated thick margins, a base
consisting of either scar tissue or the lower border of the anal
sphincter muscles and an oedematous tag of skin at its lower
end (sentinel pile).
• In chronic fissure, there may be spasm of musculature of the
anal sphincter and in long-standing cases, this muscle becomes
organically contracted by infiltration of fibrous tissue.
• Infection of the base may lead to an abscess, which may rupture
through the base of the fissure or through the skin, a short
distance away, leaving a short subcutaneous fistula.

12. Diagnosis
Slide a
• In acute fissure , tearing, cutting, burning , or agonizing pain starting during
defecation, lasting for a variable period afterwards is the main symptom.
• The typical history with tightly closed, puckered anus, is almost pathognomonic of
the condition.
• A simple longitudinal epithelial ulcer situated anteriorly or posteriorly or both,
visible at lower anal canal can be seen on slight traction at anal verge.
• An acute fissure being a shallow ulcer, is impalpable though the sphincter while
spasm is marked and proctoscopy is not tolerable. Examination under anesthesia
is recommended.
• The patient tends to become constipated, rather than go through the agony of
defecation, so a vicious cycle of pain, constipation, and pain is set up.
• Bleeding is usually slight and consists of bright streaks on one side of stool, rarely
profuse bleeding is presentation.
• No age group is exempted, common in women during the meridian of life
(pregnancy, delivery and operations of abdomen).

13. Inspection of anal verge

14. Diagnosis
Slide b
• In chronic fissure, irritation and discharge,
which soil the underclothing is present.
• A chronic fissure is felt as an indurated ulcer,
but the sphincter spasm is variable.
• In cases of chronicity a sentinel skin tag
(sentinel pile) is commonly seen and is of
varying sizes.
• Periods of remission may occur for days or
weeks.

15. Posterior anal fissure with sentinel pile

16. Posterior anal fissure with
sentinel pile

17. Anterior anal fissure with
sentinel pile

18. Anterior and posterior anal
fissure with sentinel piles

19. 25 years old long standing anal fissure
with large sentinel pile

20. 25 years old long standing anal fissure
with large sentinel pile and its
treatment.

21. Perianal soiling due to anal
fissure

22. Bleeding from anal fissure is
uncommon.

23. Bleeding from anal fissure is
uncommon.

24. A rare unusual small fistulae in
anal fissure

25. A fistula with anal fissure

26. Perianal abscess in anal fissure

27. Infection of base may lead to an abscess, which may
rupture through the base of the fissure or through the skin, a
short distance away, leaving a short subcutaneous fistula.

28. Differential Diagnosis
Slide a
• An acute fissure should be differentiated from an anal
abrasion. The latter is superficial with flat edges and is
transient. It is not associated with a sentinel pile and responds
to conservative treatment.
• If anal fissure is situated away from the midline, do suspect
pathology (e.g., tuberculosis, syphilis, leukemia, squamous
cell carcinoma, or inflammatory bowel disease, especially
Crohn's disease, sexually transmitted diseases, etc, and needs
biopsy confirmation.)

29. Lateral anal fissure
Rare one

30. Lateral anal fissure with
sentinel pile (Rare one)

31. Differential Diagnosis
Slide b
• Tuberculosis ulcer has an undermined edge, the discharge is thin
and watery while the presence of a lesion in the chest, a raised
erythrocyte sedimentation rate, sputum examination, biopsy may
be necessary to reach a diagnosis.
• Anal chancre may present as a painful rather than a painless ulcer,
has a good deal of induration along with inguinal
lymphadenopathy and the serous discharge contains spirochetes.
• Secondary syphilis presents as multiple fissures associated with
mucous patches in the perianal region and the Wasser mann
reaction is strongly positive.
• Carcinoma of the anus an epitheliomatous ulcer (malignant) is
indurated with raised edges, biopsy is needed for the diagnosis, as
in early stages to differentiate it from a fissure and is resistant to
the usual local treatment.

32. Differential Diagnosis
Slide C
• Fissures in inflammatory bowel disease tend to be
multiple, broad, and situated away from the midline.
• Multiple fissures in the perianal skin are commonly
seen as a complication of skin diseases, scratching,
homosexual practices (sodomy, fisting, use of anorectal
sex toys) and anorectal venereal disease.
• The possibility of AIDS virus (HIV) being transmitted
through this route should be kept in mind:
• Specific fissures of this type are often less painful than
the appearances of the lesion would suggest and
usually associated with delay in wound healing or an
early recurrence.

33. An example of histopathology of anal fissure

34. Anal abrasions- D/D anal fissure

35. Conservative treatments
Slide a
• It consist of application of local anesthetic
ointment (xylocaine 5 %) with anal dilators, oral
analgesics, metronidazole, suitable broad-
spectrum antibiotic, mild laxatives to soften stool,
and frequent sitz baths, but it takes prolong time
with frequent recurrence.
• Should these measures prove ineffective, or if the
fissure is chronic with fibrosis, a skin tag (sentinel
pile), a hypertrophied anal papilla, presence of
large haemorrhoids, or a subcutaneous fistula
are indications for operation.

36. Operative treatment
Slide b
• The simplest procedure is controlled dilatation of the
sphincter in young adults and children, while moderate
dilatation in old age and weak patients by experienced
surgeon.
• It can be done under caudal, saddle, spinal or SSS with
locoregional anaesthesia.
• The index and middle finger of each hand are inserted
simultaneously into the anus and pulled apart, up to point
when sphincter tone gives away.
• Apply injection SKL to every case it will almost completely
subside post maneuver pain, no infection,no abscess
formation and immediate recovery is only possible with this.
• No bed rest, no precautions, no incontinence, just normal
life.

37. Treatment of anal fissure

38. Excision of
sentinel
pile

39. Treating acute anal fissure

40. Operative treatment
Slide C
• Lateral internal sphincterotomy is not
recommended, it is full of complications,
incontinence is serious issue, recurrence is high,
and no two surgeons on same page.
• You can not differentiate between the internal
and external sphincter during operation, it is just
an anal sphincter complex, so no fun in cutting
the sphincter.
• It should be condemned.
• Many other procedures are also not required.

41. Treatment (Final verdict)
• Simplest, and definite treatment is to over come on increased anal
tone by controlled calculated anal dilation (up to the point where
sphincter tone definitely gives away).
• It can be done under saddle, spinal, or SSS with loco regional
anesthesia.
• Inject SKL in anal sphincter is a must and due to this is no infection,
no abscess formation, no post operative pain and early recovery
ensues.
• Do excise the sentinel pile.
• The fissure will heal itself after spasm has disappeared.
• No recurrence noted after this way of treatment.
• Incontinence is not an issue in routine. (Only old, weak, debilitated
patients needs gentle handing).
• Immediate back to normal life with no precautions or medications.

42. Treatment of anal fissure
(Final verdict)

43. Thanks