In addition to increasing dietary fiber, patients should begin fiber supplementation once a day (ie, 6 g psyllium), and if that is tolerated, their dosage should be increased to twice a day within a week. Ideally the adult diet should contain 25 to 35 g of fiber daily ( Table 4). For patients who cannot tolerate psyllium because of excess gas or bloating, other fiber products are available ( Table 3).
Psyllium-based products are our preferred fiber supplement. Increasing dietary fiber and water intake should be coupled with fiber supplementation. Conservative management is the first line of therapy. More than 90% of fissures heal spontaneously. If there are findings suspicious for other disorders, such as draining pus from anal opening, swelling and erythema of the perianal area, or a mass, then the patient should undergo an examination under anesthesia. Under such circumstance, carrying out the examination causes needless suffering and often cannot be completed despite the perseverance of the examiner. The clinician should be ready to abort the examination at any time if the patient has severe pain. The exposed white fibers of the internal sphincter muscle can be seen in the center of chronic fissures. In addition to direct visualization of the fissure, the clinician may note a sentinel pile or tag just distal to the fissure and a hypertrophied anal papilla just proximal to it ( Figure 1). If the patient tolerates the digital examination, then anoscopy can be performed. Posterior or anterior midline tenderness can be elicited with gentle palpation. If the fissure is not visualized, lidocaine 2% jelly is used to locally anesthetize the anal opening so that a gentle digital examination can be attempted. The patient is treated for the presumed diagnosis of anal fissure and a complete examination is deferred to the next visit, usually three or four weeks later. If the patient is too apprehensive and in much discomfort, the examination should be aborted. A gentle spreading of the buttocks can reveal the fissure in some patients. The patient is usually examined in the prone position. Anal examination can confirm the diagnosis at the initial visit but is often limited by the patient's discomfort. Several anorectal disorders can present with severe anal pain anal fissure is the most common cause of pain with or after defecation ( Table 1). The diagnosis of anal fissure is often made on the basis of the patient's medical history. Once this cycle sets in, the likelihood of spontaneous healing decreases and the edges of the fissures become more fibrosed, leading to a chronic fissure. A vicious cycle ensues whereby the anal spasm exacerbates the ischemia and prevents the fissure from healing, which in turn sustains the anal spasm to prevent further tearing. 8, 10 The anal spasm is a defense mechanism to prevent further stretching of the anal canal and worsening of the tear.
It is believed that the decreased blood flow to the midline portion of the anus contributes to a relatively ischemic milieu that becomes more profound secondary to the associated sphincter spasm noted in the majority of patients with anal fissure. Most fissures heal spontaneously, but some persist. Anterior fissures are seen more often in women. Most anal fissures are located in the midline and are posterior more frequently than anterior.
Constipation and passage of hard stools is often the cause of an anal fissure, although diarrhea can also contribute to its development. An anal fissure is a tear or a cut in the anoderm ( Figure 1).
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