**3. Clinical presentation and diagnosis**

Patients usually present with moderate to severe anal pain, described as "like passing broken glass," aggravated by defecation, and lasts several minutes to hours afterward [9]. Although bleeding occurs less commonly in anal fissures than hemorrhoidal diseases, patients may notice a small amount of bright-red blood on the toilet

paper resulting from chronic ulceration in the epithelium (**Figure 2**).

Based on these predominant symptoms, an acute or chronic anal fissure can be diagnosed during the first interrogation. Nevertheless, the clinician should always consider an underlying cause of chronic constipation related to the fissure, such as rectocele, diverticular disease, and colorectal cancer.

#### **Figure 1.**

*Operative image of a patient with chronic anal fissure shows the spasm in the sphincter complex even under sedation.*

*Sphincterotomy is the Gold-Standard Treatment of Chronic Anal Fissure: But How Should it be… DOI: http://dx.doi.org/10.5772/intechopen.104109*

**Figure 2.** *Chronic anal fissure presenting with bleeding.*

#### **Figure 3.**

*Physical examination involves the inspection of number of fissures and the presence of skin tags. a) Multiple skin tags b) multiple chronic fissures in the posterior, lateral, and anterior of the anal canal.*

On physical examination, the location, depth, and the number of fissures should be noted in addition to the presence of skin tags and chronic inflammation surrounding the lesion (**Figure 3**). Initially, a digital rectal examination may not be performed due to severe pain in an acute anal fissure; in that case, a detailed examination under anesthesia with anoscope and rectosigmoidoscopy may be required [10].
