ABSTRACT
CHALLENGING CASE A 35-year-old woman presents with a recurrent posterior anal fissure. She had a left lateral anal sphincterotomy 4 years ago for an unresponsive anal fissure. Her fissure healed until 6 months ago. She has had two previously vaginal deliveries. Exam reveals a posterior anal fissure with exposed sphincter muscle and a sentinel skin tag. Anal manometry revealed mildly decreased resting pressure and a hypertonic squeeze pressure. The patient’s symptoms have not responded to stool softners and topical medication.
