This page is dedicated to organizing various examples of standardized exam questions whose answer is anal fissure. While this may seem a odd practice, it is useful to see multiple examples of how anal fissure will be characterized on standardized exams (namely the boards and the shelf exams). This page is not meant to be used as a traditional question bank (as all of the answers will be the same), however seeing the classic “test” characterization for a disease is quite valuable.
KEY CHARACTERISTICS OF THIS CONDITION (ON EXAMS)
When it comes to standardized exams, each topic has its own “code” marked by key buzzwords, lab findings, clues, etc. If you are well versed in this code you will be able to more quickly identify the condition that is being discussed, and get the right answer on the exam you are taking. Below is the “code” for anal fissure.
- Severe rectal pain with defecation is the classic chief complaint
- Blood in stool may accompany the pain (usually small volume of bright blood on stool/toilet paper).
- Constipation/infrequent bathroom usage is very common in these patients (which results in passing of hard stools).
- Inability to perform/severe pain during rectal exam: patients may defer the exam or experience severe pain.
- Increased resting sphincter tone may also be noted on the rectal exam.
- Skin tags can be present near the anus
- Visualization of anal mucous tears are diagnostic of this condition.
Question # 1
A 25 year old lady describes exquisite pain with defecation and blood streaks on the outside of her stools. Because of the pain she avoids having using the restroom, and when she finally does, the stools are hard and even more painful. A rectal examination can not be done, as she refuses to allow anyone to even spread her cheek to look at the anus for fear of causing her pain.
Explanation # 1
Explanation: severe rectal pain during defecation + inability to perform rectal due to the pain = anal fissure
Question # 2
A 34 year old male come to the clinic with a 1 week history of very severe pain during defecation. He explains that he is in so much pain that he tries to avoid using the restroom. The patient explains that the caliber of his stool has not changed, however there is visible bright red blood on the surface of the stool. His past medical history is notable for constipation. He does not take any medications. A physical exam reveals an unremarkable abdominal exam. A rectal exam is difficult to conduct due to the patient’s pain, however a skin tag is appreciated at the anus. What is the diagnosis?
Severe rectal pain during defecation + inability to perform rectal due to the pain + skin tag = anal fissure
Question # 3
A 65 yea told male is living in a nursing home. He has difficulty eating and drinking on his own, and has limited mobility ever since suffering a stroke. He is seen by the on-site physician because he has been constipated and has been experiencing rectal pain. His pain is worse with bowel movements, and he has to strain to have bowel movements. He denies any bleeding on the toilet paper after wiping. A physical exam shows that there are no external hemorrhoids. A digital rectal exam is very painful, however there is no fluctuance or masses felt. A small laceration is seen in the anal mucousa. What is the likely diagnosis?
Explanation # 3
severe rectal pain during defecation + pain during digital exam + tear in rectal mucosa = anal fissure
Question # 4
A 42 year old male comes to the clinic because he has been experiencing pain during bowel movements. He explains that he feels a sharp pain that is very severe during his bowel movements. He often notices spots of bright red blood on his toilet paper after wiping post defecation. The patient’s past medical history is notable for chronic constipation, and he has not tried laxatives. The patient also suffers from a lower back injury that occurred when he was lifting boxes at work, and he currently takes pain relievers regularly to manage his symptoms. He does not wish to perform a rectal exam because he fears it will be painful. What is the likely diagnosis in this patient?
Explanation # 4
Severe rectal pain during defecation + chronic constipation + deferred rectal exam due to pain = anal fissure
Question # 5
A 35 year old female coms to the clinic because she has been noticing bright red bleeding from her rectum, and severe pain during bowel movements that is sharp. She notices spots of blood on the toilet paper when she wipes after a bowel movement. For the past 3 months she admits to feeling constipated, and explains that she began a new job where it is hard for her to take regular water breaks. A rectal exam reveals a small tear in the posterior mucosa of the rectum, and a rectal exam is very painful. What is the diagnosis in this patient?
Explanation # 5
severe rectal pain during defecation + pain during digital exam + tear in rectal mucosa= anal fissure
TESTABLE FACTS ABOUT THIS TOPIC (BEYOND ITS IDENTIFICATION)
Many questions on standardized exams go beyond simply recognizing the underlying topic. Often there are specific testable facts regarding some aspect of the topic’s pathophysiology/management/clinical implications that are commonly asked. Some of these are listed below:
Most common location:
- Posteror midline tears of rectal mucosa (distal to the dentate line) are the most common location of these anal fissures
- Anesthetic ointments can be first line methods of receiving pain.
- Stool softeners are another first line treatment method to try and make stools easier to pass/less likely to further agitate rectal tear.
- Topical nitrates can be used for cases refractory to first line treatment methods.
Page Updated: 03.07.2017