Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with sharp, tearing anal pain during and after defecation, often described as "passing glass." Reports bright red blood on toilet paper or stool surface. Symptoms associated with constipation, hard stools, and occasional pruritus ani. Duration: [Insert duration]. No history of IBD or previous anorectal surgery.
Clinical Examination Findings
Anorectal examination reveals a linear mucosal tear, typically located at the posterior midline (6 o'clock position). Presence of sentinel skin tag or hypertrophied anal papilla noted. Digital rectal exam (DRE) is limited due to severe sphincter spasm. No evidence of perianal abscess, fistula, or malignancy.
Treatment Protocol
Conservative management initiated: High-fiber diet, increased fluid intake, and stool softeners (e.g., psyllium husk). Topical therapy: Diltiazem 2% or Nitroglycerin 0.4% ointment applied twice daily to the anal canal. Warm sitz baths 2-3 times daily for 15 minutes. Follow-up in 6 weeks to assess for healing or consideration of Botox injection/Lateral Internal Sphincterotomy (LIS).