Snapshot A 45-year-old man has severe rectal pain when he defecates. He reports the stool is covered with bright red blood. A sentinel pile is noted on physical exam. Introduction Tear or fissure in anal epithelium Can occur at any age Caused by irritating diarrhea hard stool disease process (Crohn's, STDs, ulcerative colitis, and AIDS) Leads to tightening of anal canal related to nervous tension Presentation Symptoms severe rectal pain on defecation bleeding anal tenderness Evaluation Anoscopy anal tag indicates location hypertrophied papilla is noted above the fistula. Treatment Medical nitroglycerine ointment botox Surgical in refractory cases