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6.11 Anal fissure


Presentation

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:

What not to do:

Discussion

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.

References:


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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD