Most common cause of painful defecation is associated with

ANAL FISSURE Definition An anal fissure (synonym: fissure-in-ano) is a longitudinal split in the anoderm of the distal anal canal, which extends from the anal verge proximally towards, but not beyond, the dentate line. Clinical features Although simple epithelial splits, acute anal fissures are, because of their location involving the exquisitely sensitive anoderm, characterised by severe anal pain associated with defaecation, which usually resolves spontaneously after a variable time only to recur at the next evacuation, as well as the passage of fresh blood, normally noticed on the tissue after wiping. Chronic fissures are characterised by a hyperophied anal papilla internally and a sentinel tag externally (both consequent upon attempts at healing and breakdown), between which lies the slightly indurated anal ulcer overlying the fibres of the internal sphincter. When chronic, patients may also complain of itching secondary to irritation from the sentinel tag, discharge from the ulcer or discharge from an associated intersphincteric fistula, which has arisen through infection penetrating the fissure base. Although most sufferers are young adults, the condition can affect any age, from infants to the elderly. Men and women are affected equally. Anterior fissures account for about 10% of those encountered in women (and many of these may occur postpaum) but only 1% in men. A fissure sited elsewhere around the anal circumference or with atypical features should raise the suspicion of a specific aetiology, and the inability to be able to conduct an adequate examination in the clinic should prompt early examination under anaesthesia, with biopsy and culture to exclude Crohn's disease, tuberculosis, sexually transmitted or human immunodeficiency virus (HIV)-related ulcers (syphilis, Chlamydia, chancroid, lymphogranuloma venereum, HSV, cytomegalovirus, Kaposi's sarcoma, B-cell lymphoma) and squamous cell carcinoma. Ref: Bailey and love 27th edition Pgno : 1352