If the patient is too apprehensive and in much discomfort, the examination should be aborted. A gentle spreading of the buttocks can reveal the fissure in some patients. The patient is usually examined in the prone position. Anal examination can confirm the diagnosis at the initial visit but is often limited by the patient's discomfort. Several anorectal disorders can present with severe anal pain anal fissure is the most common cause of pain with or after defecation ( Table 1). The diagnosis of anal fissure is often made on the basis of the patient's medical history. Once this cycle sets in, the likelihood of spontaneous healing decreases and the edges of the fissures become more fibrosed, leading to a chronic fissure. A vicious cycle ensues whereby the anal spasm exacerbates the ischemia and prevents the fissure from healing, which in turn sustains the anal spasm to prevent further tearing. 8, 10 The anal spasm is a defense mechanism to prevent further stretching of the anal canal and worsening of the tear. It is believed that the decreased blood flow to the midline portion of the anus contributes to a relatively ischemic milieu that becomes more profound secondary to the associated sphincter spasm noted in the majority of patients with anal fissure. Most fissures heal spontaneously, but some persist. Anterior fissures are seen more often in women. Most anal fissures are located in the midline and are posterior more frequently than anterior. Constipation and passage of hard stools is often the cause of an anal fissure, although diarrhea can also contribute to its development. An anal fissure is a tear or a cut in the anoderm ( Figure 1).

Sentinel pile in rectal exam