Pain of the sharp, cutting variety is the most common symptom. Typically, the pain is most severe during and immediately after a bowel movement. The pain may persist for a few hours after each bowel movement, but invariably it subsides between movements, which is a distinguishing feature of fissures from other forms of painful anorectal disease. The bleeding is bright and small in quantity, usually being noticed only on the toilet paper. In infants, the presence of small amounts of bright blood on the stool or toilet paper is usually the presenting complaint for an anal fissure. Sphincter spasm and pain may be severe enough to make the patient retain stool and avoid defecation.
Diagnosis of anal fissure is usually suggested by the history; however, the anal area must be examined in all cases. With proper exposure, the sentinel pile, if present, and frequently the distal end of the fissure itself, may be seen. The mere retraction of the buttocks and the anal skin may cause considerable discomfort; sphincter spasm may be so severe that the patient will not permit digital examination. Application of a topical anesthetic may provide some relief. If the fissure can be visualized and is present in the posterior midline, rectal examination can be deferred until the patient is having less spasm and pain.
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