Fig. 4.
Suggested algorithm for the evaluation and management of chronic anal fissure. 1 Sigmoidoscopy to rule out other sources of bleeding. In patients over the age of 50 years or with a suggestive family history of colon cancer, a colonoscopy is recommended for the evaluation of the entire colon. 2 The risk factors for the development of SCCA include anal HPV infection, high-risk sexual behavior, HIV infection, history of genital warts, current cigarette smoking, high-grade cervical/vulvar intraepithelial neoplasia, cervical/vulvar neoplasia and iatrogenic immunosuppression. 3 Atypical fissure includes fissures in lateral positions, nonlinear/excavated/indurated ulcer in the anal canal, associated with discharges of pus or bloody fluid, or fissures associated with ulcerated and indurated skin tag.