How is the physical exam for anal fistula or fissure performed?

Updated: Nov 09, 2018
  • Author: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
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The physical examination of patients with fistulas or fissures begins by optimizing patient placement; place the patient in the left lateral decubitus position with knees drawn up toward the chest. [14] Examine the patient carefully to help avoid inflicting further pain or sphincter spasm. Rectal examination is generally difficult to tolerate because of sphincter spasm and pain. Examination may be facilitated by application of a topical anesthetic, such as lidocaine jelly, before digital rectal examination (DRE); however, a DRE may not be tolerated by some patients.

Most fissures are visible externally when the buttocks are gently spread apart. Having the patient bear down as if having a bowel movement may also help visualize an anal fissure. Acute fissures appear similar to a laceration, while a chronic fissure may be accompanied by external skin tags distally and hypertrophied anal papillae proximally. Most tears are found in the posterior midline. Acute fissures are erythematous and bleed easily.

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