Anal Fistulas and Fissures 

  • Author: Ingrid Legall, MD; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Jul 11, 2011
 

Background

An anal fissure is a superficial linear tear in the anoderm most commonly caused by passage of a large, hard stool. This tear is distal to the dentate line. Anal fissures are among the most common anorectal disorders in the pediatric population; however, adults also are affected.

An anal fistula is an inflammatory tract between the anal canal and skin, shown in the image below. The 4 categories of fistulas, based on the relationship of fistula to sphincter muscles, are intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric.[1]

Anal fistulas and fissures. This patient reported Anal fistulas and fissures. This patient reported constipation.

Fissures are defined as acute if present for less than 6 weeks, and they are defined as chronic if present for more than 6 weeks.

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Pathophysiology

In anal fissures, anus distal to dentate line is involved. About 90% of anal fissures occur in the posterior midline where skeletal muscle fibers that circle the anus are weakest. The remaining 10% are found in the anterior midline.

Most anal fistulas originate in anal crypts, which become infected with abscess formation. When the abscess is opened or ruptures, a fistula is formed.

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Epidemiology

Sex

Anal fissures affect both sexes equally; however, an anterior fissure is more likely to develop in women (25%) than in men (8%).

  • Anal fistulas are a complication of anorectal abscesses, which are more common in men than in women (male-to-female ratio of 2:1 to 3:1).
  • Only 8% of anal fissures are anterior in men; 75-90% of fissures in women are posteriorly located.
  • For reasons of intrinsic anatomy, rectovaginal fistulas are found only in women.

Age

Although anal fissures are the most common cause of rectal bleeding in infants, they are primarily seen in young adults.

  • Eighty-seven percent of people with a chronic anal fissure are between the ages of 20 and 60 years old.
  • Anal fissures in children may indicate sexual abuse.
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Contributor Information and Disclosures
Author

Ingrid Legall, MD  Assistant Professor, Department of Emergency Medicine, Florida Hospital-Flagler

Ingrid Legall, MD is a member of the following medical societies: American Academy of Emergency Medicine and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael S Beeson, MD, MBA, FACEP  Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eugene Hardin, FAAEM, FACEP  Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

References

  1. Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum. Jul 1996;39(7):723-9. [Medline].

  2. Kuehn HG, Gebbensleben O, Hilger Y, Rohde H. Relationship between anal symptoms and anal findings. Int J Med Sci. 2009;6(2):77-84. [Medline].

  3. North JH Jr, Weber TK, Rodriguez-Bigas MA, Meropol NJ, Petrelli NJ. The management of infectious and noninfectious anorectal complications in patients with leukemia. J Am Coll Surg. Oct 1996;183(4):322-8. [Medline].

  4. Nordgren S, Fasth S, Hulten L. Anal fistulas in Crohn's disease: incidence and outcome of surgical treatment. Int J Colorectal Dis. Dec 1992;7(4):214-8. [Medline].

  5. Oh C, Divino CM, Steinhagen RM. Anal fissure. 20-year experience. Dis Colon Rectum. Apr 1995;38(4):378-82. [Medline].

  6. Khan JS, Tan N, Nikkhah D, Miles AJ. Subcutaneous lateral internal sphincterotomy (SLIS)-a safe technique for treatment of chronic anal fissure. Int J Colorectal Dis. Jul 21 2009;[Medline].

  7. Brisinda G, Cadeddu F, Mazzeo P, Maria G. Botulinum toxin A for the treatment of chronic anal fissure. Expert Rev Gastroenterol Hepatol. Dec 2007;1(2):219-28. [Medline].

  8. Corno F, Marano A, Volpatto S, Mistrangelo P. [Topical use of glyceryl-trinitrate in the treatment of anal fissure]. Minerva Chir. Jun 2009;64(3):307-11. [Medline].

  9. Vila S, Garcia C, Piscoya A, De Los Rios R, L Pinto J, Huerta Mercado J, et al. [Use of glycerol trinitrate in an ointment for the management of chronic anal fissure at the National Hospital "Cayetano Heredia"]. Rev Gastroenterol Peru. Jan-Mar 2009;29(1):33-9. [Medline].

  10. Nitroglycerin rectal ointment (Rectiv) [package insert]. ProStrakan, Inc; 2011. [Full Text].

  11. Mousavi SR, Sharifi M, Mehdikhah Z. A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg. Jul 2009;13(7):1279-82. [Medline].

  12. Chung CC, Choi CL, Kwok SP, Leung KL, Lau WY, Li AK. Anal and perianal tuberculosis: a report of three cases in 10 years. J R Coll Surg Edinb. Jun 1997;42(3):189-90. [Medline].

  13. Farquharson M. Haemorrhoids, fissures and anal fistulae. Trop Doct. Oct 2002;32(4):196-201. [Medline].

  14. Isbister WH, Prasad J. Fissure in ano. Aust N Z J Surg. Feb 1995;65(2):107-8. [Medline].

  15. Jonas and Scholefield. American Gastroenterology Association. 2004.

 
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Anal fistulas and fissures. This patient reported constipation.
Anal fistulas and fissures. This patient has a history of Crohn disease.
 
 
 
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