During examination, it is essential that extreme gentleness is displayed since fi ssure in ano is an extremely painful condition and the patient suf­fering from it is usually very apprehensive of rec­tal examination. Examination of the perianal region on careful inspection typically shows a superfi cial mucosal split in acute fi ssure. This requires gentle parting of the buttocks suffi cient to open the anal orifi ce. A chronic fi ssure will have raised edges of the mucosal split with vary­ing depth mostly in the posterior midline, expos­ing the pale-colored internal sphincter at the fl oor. The induration at the edges gives an impression that of a button hole on palpation. There is often a skin tag at the distal end and a hypertrophied anal papilla at the proximal end (Gupta 2004 ). Proctoscopy may have to be deferred especially in an acute case in view of pain. The sphincter spasm and the fi brosis may be appreciated during palpa­tion. Occasionally, a fi stula may be demonstrated with an infected fi ssure in ano (Fig. locations and multiplicity should raise a suspi­cion, and attempts must be made to rule out spe­cifi c causes for the occurrence of fi ssure in ano as described above. Crohn’s fi ssures are multiple, asymptomatic, and eccentric in location. HIV­disease-related fi ssures are deep, broad based, or cavitating ulcers with poor sphincter function.