This was a cross-sectional observational study conducted from January 2014 to December 2015 at a tertiary care centre (People’s College of Medical Science and Research Centre, Bhopal, India). Study participants were of either sex and aged more than 18 years. All the patients visiting the Department of Surgery with anorectal complaints were screened and enrolled if eligible. The eligibility criteria included patients complaining of anorectal pain, bleeding, discharge or prolapse of rectum. The exclusion criteria were patients who underwent major anorectal surgery, patients diagnosed with rectal cancer and pregnant women.

All the patients provided written informed consent to participate in the study. Enrolled patients were examined and the diagnosis was based on clinical findings of anorectal evaluation by digital examination and proctoscopy. Data was collected in the approved case record form which included demographic details, medical history, signs/symptoms and final diagnosis.

Statistical analysis was performed using SPSS software (version 17.0). The data obtained was tabulated, analysed and presented using descriptive statistics-mean (standard deviations) or as number (percentages).

Overall 629 patients were enrolled in the study. The mean (SD) age of enrolled patients was 38.27 (9.25) years. A total of 438 (69.63%) of patients were males and 191 (30.37%) patients were females [Table/Fig-1]. The majority (n=413; 65.66%) of patients were aged between 18 to 40 years and 33.70% of patients were between 41 to 60 years. In about half of the patients (48.97%) BMI was normal and around 45% of patients were over weight or obese. The dietary habits of majority (78.06%) of the patients were mixed and around 75% of patients had no history of exercise or any physical activity (excluding day-to-day activities). Of the total 629 patients, 12.24% patients were hypertensive and 10.33% patients had diabetes mellitus medical records [Table/Fig-1].

The clinical examination revealed that a total of 112 (17.81%) of patients had a fissure; however, 517 (82.19%) of patients had no evidence of fissure. The prevalence of fissure was slightly higher in males than females (19.41% versus 14.14%; p<0.05) and was higher in patients aged between 18 to 40 years than 41 to 60 years group (18.64% versus 16.51%; p=0.0914) [Table/Fig-1]. When the prevalence of fissure was compared based on BMI; patients with normal BMI had a higher prevalence than underweight and overweight patients. Mixed dietary habits and history of constipation were found to be associated with the prevalence of fissure. Similarly, patients with no exercise or physical activity had more prevalence of fissure than patients who exercised on a regular basis (19.87% versus 11.54%; p<0.05) [Table/Fig-1].

[Table/Fig-2] summarises the signs and symptoms of patients who sought consultation for anorectal complaints and prevalence of fissure. The majority of patients had bleeding and pain (n=326), of which 89 (27.30%) had anal fissure. A total of 28 patients had only pain, of which 14 (50%) patients had anal fissure, and 156 patients had bleeding, pain, and prolapse, of which only 4 (2.26%) patients had anal fissure. In total, 32 patients had only bleeding and 26 had bleeding and were anaemic.

This cross-sectional observational study was conducted to evaluate the prevalence of anal fissure in patients who consulted for anorectal symptoms. Overall, the results showed that the prevalence of anal fissure in our study population was 17.81%. These results add data to the literature and contribute to study the trend of prevalence and disease symptoms in Indian patients with anorectal disorders. Our observations were consistent with previous reports [6-9].

In the present study, overall there was a predominance of male patients (69.63% versus 30.37%) and almost half of the patients were aged between 18 to 40 years. The difference could be possibly due to hesitance of female patients in seeking treatment. A total of 112 (17.81%) of patients were diagnosed to have anal fissure. Mixed dietary habits and history of constipation were found to be associated with the prevalence of fissure. Similarly, patients with no exercise or physical activity had more prevalence of fissure than patients who exercise on a regular basis (19.87% versus 11.54%). This observation corroborates the fact that diet and exercise or physical activity has significant impact on the occurrence of anal disorders. The majority of patients had bleeding and pain (n=326), out of these patients 89 (27.30%) had an anal fissure. This could be possibly due to the fact that, patients tend to seek medical advice only if the symptoms are unbearable or have symptoms like bleeding etc., [Table/Fig-3] summarises previous reports from India where anal fissure was studied [6-11].

In a previous study by Varadarajan MS et al., among 325 patients from Tamil Nadu (India) with anorectal ailments, 100 patients (30.7%) had anal fissures [6]. Of these 100 patients, 54 patients were males and 46 were females, and the majority was under 40 years of age. The majority of patients presented with pain during defecation (86%) followed by bleeding (62%), constipation, pruritus, and discharge [6].

Another study by Khan RM et al., which included 416 patients with anorectal ailments, showed that 65 (15.62%) patients were found to be suffering from anal fissure, out of these 48 were males and 17 were females [7]. Khan RM et al., also reported that constipation, low-fibre diet, and less physical activities were significantly associated with anal fissures. Overall, these observations were consistent with our results, except for slight variation in the prevalence of anal fissure.

The author also acknowledges following limitations of the study. This study was conducted at a single site and the findings may not be generalised. This study aimed to study the prevalence of anal fissure and did not collect information on other anorectal disorders.

The prevalence of anal fissure among patients with anorectal complaints is around 18%. Mixed dietary habits and constipation could be considered as risk factors for the anal fissure. These results add data to the literature and contribute to study the trend of prevalence and disease symptoms in Indian patients with anorectal disorders.