• Small tears or cracks in the anal canal lining.
• Typically located in the posterior midline.

• Pain during defecation.
• Bleeding (haematochezia) seen as blood on wiping.

• Increased anal sphincter tone.
• Trauma or underlying disease.

• Often idiopathic.
• Trauma from hard stools.
• Constipation.
• Chronic diarrhea.

• Acute: Less than 6 weeks.
• Chronic: 6 weeks or more.

• Primary: No apparent cause.
• Secondary: Due to conditions like constipation, IBD, STIs, or rectal malignancy.

• Associated with increased anal tone leading to reduced healing due to ischemia.

• Constipation.
• Straining during bowel movements.
• Diarrhoea.
• Inflammatory Bowel Disease.
• Childbirth.

• Trauma and injury to anal canal lining.

• Impaired blood flow.
• Hindered healing process.

• Haemorrhoids (especially if thrombosed).
• Perianal Abscess.
• Inflammatory Bowel Disease.
• Anal Cancer.
• Proctitis.
• Perianal Sepsis.
• Proctalgia Fugax.

• Lifetime incidence of approximately 11%.

• Most frequent in younger adults (second to fourth decades) and less common in the elderly.
• Equal prevalence in men and women.

• Pain during bowel movements
• Bright red blood on the stool or toilet paper
• Itching and discomfort in the anal region

• Experienced during defecation
• Described as feeling like passing shards of glass
• Pain may persist for several hours after passing stool

• Bowel habits: Constipation, diarrhea, recent changes
• Associated symptoms: Abdominal pain, weight loss, rectal discharge
• Family history: Inflammatory bowel disease, colorectal disease
• Consideration of sexual abuse in children

• Abdominal Examination: Palpate for masses, organomegaly, fecal loading
• Anal Examination: Linear split in the mucosa, usually posterior and in the midline
• Avoid Digital Rectal Examination (DRE) initially due to extreme pain

• Acute: Clear edges and linear
• Chronic: Deeper, may have an external skin tag

• Physical examination of the anal area
• Clinical evaluation based on patient history

• In chronic cases or when conservative measures fail
• Presence of risk factors such as STDs, Crohn’s disease, anal cancer
• Unclear history where further investigation is needed

• Anal manometry to assess anal sphincter pressures
• Anal ultrasound (Endoanal Ultrasound) to identify sphincter defects
• Digital Rectal Exam (DRE) to help identify the fissure

• Paracetamol and ibuprofen
• Topical anesthetics like lidocaine

• Increased dietary fiber intake
• Adequate fluid intake
• Warm sitz baths

• Glyceryl trinitrate (GTN) ointment
• Topical diltiazem 2%
• Nifedipine (oral and topical)

• Botulinum toxin injections
• Lifestyle modifications

• Lateral internal sphincterotomy
• Posterior internal sphincterotomy
• Anterior levatorplasty
• Fissurectomy

• Children with non-healing fissures within two weeks
• Adults with ongoing pain after 6-8 weeks
• Elderly patients with prolonged fissures or suspicious symptoms

• Topical treatments: diltiazem, nifedipine, botulinum toxin
• Surgical options: lateral internal sphincterotomy, posterior internal sphincterotomy, anterior levatorplasty, fissurectomy

• Rarely indicated as they often respond to conservative measures

• Acute anal fissures: Most heal within 2 weeks with conservative treatment
• Some may take 6-8 weeks
• Chronic anal fissures: Lateral internal sphincterotomy offers a high cure rate and low recurrence risk
• Significant risk of long-term continence issues

• Up to half of patients treated with topical GTN may experience recurrence
• About half of patients heal with non-operative methods

• Early referral recommended if no healing occurs after two weeks to prevent stool withholding and worsening constipation

• Infection.
• Abscess formation.
• Anal stenosis (narrowing of the anal canal).