What does a physical exam reveal about the etiology of anal fissures?

From the Guidelines

A physical exam can reveal important clues about the etiology of anal fissures, including the location, size, and associated findings, which can help differentiate between primary and secondary causes, as noted in the American Gastroenterological Association medical position statement 1. During examination, the presence of a visible tear in the anal canal, typically located in the posterior midline (6 o'clock position) for primary fissures, suggests a mechanical cause related to passage of hard stool. Some key points to consider during the physical exam include:

• The location of the fissure, with posterior midline fissures being more common and suggestive of primary fissures
• The presence of associated findings, such as sentinel tags or hypertrophied anal papillae, which can support the diagnosis of chronic fissures
• The absence of purulent discharge, which can help differentiate fissures from anorectal abscesses
• The absence of multiple ulcerations, which can help distinguish fissures from inflammatory bowel disease The physical exam may also reveal sphincter hypertonicity, which contributes to fissure development by reducing blood flow to the anal canal, as mentioned in the study 1. Pain during digital rectal examination is characteristic, and patients often exhibit guarding behavior. Understanding these physical exam findings is crucial for determining whether the fissure is primary (related to constipation and sphincter hypertonicity) or secondary to another underlying condition requiring specific treatment, as outlined in the American Gastroenterological Association medical position statement 1.

From the Research

Physical Exam Findings

A physical exam for anal fissures may reveal the following:

• Severe pain with defaecation that persists for one to two hours 2
• Hypertonic anal sphincter, although some cases may present as hypotonic or secondary 2
• Acute or chronic presentation of the fissure 2

Etiology of Anal Fissures

The etiology of anal fissures is unclear, but it is commonly associated with:

• Local trauma 2
• Chronic conditions 2
• The exact cause may not be determined through physical exam alone, as the condition is often characterized by its symptoms and presentation rather than a specific underlying cause 2

Diagnostic Considerations

A physical exam may not be sufficient to determine the etiology of anal fissures, and further evaluation may be necessary to:

• Rule out other conditions that may be causing symptoms 3, 4, 5, 6
• Determine the best course of treatment, which may include conservative therapy, topical treatments, or surgical options 2, 3, 4, 5, 6