Chapter 1 14 General introduction Chronic anal fissure (CAF) is a debilitating, painful anorectal condition associated with reduced quality of life.1,2 Searching for medical care is often deferred due to embarrassment.3 Prolonged persistence of symptoms and high recurrence rates indicate that present treatment modalities are not always sufficient. At present, there is a gap in treatment modalities between conservative management and surgery. This general introduction gains more knowledge on CAF, the relevant relationship between CAF and pelvic floor dysfunction, the current diagnostics and (conservative) management in patients with CAF. Definition, epidemiology, symptoms, anatomy, and pathophysiology Chronic anal fissure (CAF) is defined as a longitudinal tear in the anoderm with one or more signs of chronicity including hypertrophied anal papilla, sentinel pile and exposed internal sphincter muscle with symptoms present for longer than 4-6 weeks or recurrent fissures.4,5 The earliest known description dates from 1934 by Lockhart-Mummery.6 The classical symptom is pain during and immediately after defecation, caused by an injury of the multilayer squamous epithelium of the anoderm, which is richly innervated with pain fibers through the inferior rectal nerve. The pain can persist for hours and is often accompanied by bleeding.7,8 The majority of the fissures (80-90%) is located in the posterior midline. Approximately 10% of the fissures are affected in the anterior midline, mostly in female patients.9 It is theorized that the predisposition for the posterior midline has to do with the fact that specifically this area is poorly perfused.10 Fissures located off the midline position are considered atypical fissures and are more often associated with human immunodeficiency virus, syphilis, tuberculosis, herpes, leukaemia, Crohn’s disease, ulcerative colitis, and anal cancer.5
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