The patient complains of painful rectal bleeding and perhaps constipation. The pain occurs with and immediately after defecation, and the patient is relatively comfortable between bowel movements. Bleeding with defecation is usually slight, only staining the toilet tissue. Mucus discharge may increase perineal moisture and cause itching. Examination of anus reveals a radial tear or ulceration of the posterior midline 95% of the time (the fissure is anterior in 10% of women but only 1% of men). If the condition becomes chronic, distal edema may produce a "sentinel pile."
What to do:
Provide topical anesthesia with lidocaine jelly or viscous lidocaine in order to perform a reasonably comfortable rectal examination.
Advise the patient to use psyllium seed supplements (e.g. Metamucil) to soften stools and to use a glycerin suppository twice daily to maintain lubrication of the anal canal.
Instruct the patient to use warm, soothing sitz baths after each painful bowel movement.
Prescribe analgesics if needed.
Inform the patient that an acute superficial fissure will take about one month to heal. He should follow up if symptoms continue.
What not to do:
Do not assume that a lesion located outside the anterioposterior midline saggital plane of the anus is an anal fissure. Other possibilities include ulcerative colitis, squamous cell carcinoma, leukemia, tuberculosis, syphilis, herpes and trauma from instrumentation and anal intercourse.
Do not confuse a "sentinel pile" with a hemorrhoidal vein.
Pruritis ani has multiple etiologies. Infections such as pinworms, Candida albicans, Tinea cruris and erythrasma can cause anal itching. Mechanical trauma from overly vigorous cleansing of the perianal area may also cause pruritis and may be aggrivated by diarrhea and by the presence of external or prolapsed hemorrhoids or multiple skin tags which make cleansing more difficult. Another cause of pruritis ani is allergic or contact dermatitis from agents such as soaps, perfumes in toilet tissue and frminine hygene sprays as well as spicy foods, tomatoes, citrus fruits and colas, coffee and chocolate. Other causes of pruritis ani include chronic anorectal disease and cancer. If a specific cause of anal pruritis can be determined, then treat it accordingly. If the etiology is obscure, the patient can be treated with hydrocortisone cream to reduce itching and imflammation, followed by zinc oxide as a barrier cream. The patient should be instructed to gently cleanse the anal area with a cotton ball and a perineal cleansing lotion after each bowel movement, and should be directed to obtain follow up care. A systemic anti-pruritic agent such as hydroxyzine (Vistaril) 50mg qid may be prescribed.
Lieberman DA: Common anorectal disorders. Ann Intern Med 1984;101:837-846.
Brenner BE, Simon RR: Anorectal emergencies. Ann Emerg Med 1983;12:367-376.