Atypical Anal Fissures and Underlying Pathology

Introduction to Atypical Anal Fissures

The World Journal of Emergency Surgery suggests that atypical anal fissures indicate serious underlying pathology such as inflammatory bowel disease, sexually transmitted infections, anorectal cancer, or tuberculosis that must be ruled out 1, 2
Approximately 90% of typical anal fissures are located posteriorly in the midline, while anterior fissures occur in 10% of women versus 1% of men, according to the World Journal of Emergency Surgery 1, 2
Atypical fissures are lateral in location or multiple in number, which should immediately raise suspicion for associated diseases, as stated in the World Journal of Emergency Surgery 1, 2

The WSES-AAST guidelines recommend collecting a focused medical history and performing a complete physical examination for patients with atypical anal fissures 1, 2
The WSES-AAST guidelines also recommend performing laboratory tests based on suspected associated illness for patients with atypical anal fissures 1, 2
Investigations such as endoscopy, CT scan, MRI, or endoanal ultrasound should be conducted only when there is suspected concomitant inflammatory bowel disease, anal or colorectal cancer, or occult perianal sepsis, as suggested by the World Journal of Emergency Surgery 1, 2

The American College of Surgeons and other medical societies imply that when atypical fissures are present, one must investigate for inflammatory bowel disease (IBD), sexually transmitted diseases (HIV, syphilis, herpes), anorectal cancer, or tuberculosis 1, 2
The critical error is attributing atypical fissures to pelvic floor dysfunction and missing serious underlying pathology, such as malignancy, IBD, or infection, as warned by the World Journal of Emergency Surgery 1, 2