Examination may be facilitated by application of a topical anesthetic. Most fissures are visible externally when patient bears down as if having a bowel movement. Note depth of fissure and its orientation to the midline. Majority of tears are found in the posterior midline. Rectal examinations generally are not tolerated because of sphincter spasm and pain.
Acute fissures are erythematous and bleed easily.
With chronic fissures, classic fissure triad may be seen. Fistula can be identified by small circles of granulation tissue, which exude pus when compressed if tissue is patent. A fistulous tract that opens internally can be visualized with aid of an anoscope. Inguinal lymph nodes may be enlarged and painful. Causes of anal fistula include opened perianal or ischiorectal abscesses, which drain spontaneously through these fistulous tracts.