The correct answer is A. This patient has the classic symptoms of an acute anal fissure, which is a linear ulceration of the anoderm, often caused by hard stool, and is therefore initially treated with stool softeners and sitz baths. Increased dietary fiber is also recommended. It is often said that the pain of an anal fissure is disproportionate to the size of the lesion.
Acyclovir (choice B) is used to treat herpes infections, which are characterized by painful vesicles and pustules that ulcerate. A single linear ulcer is not the typical presentation.
Metronidazole (choice C) is often prescribed for anorectal abscesses associated with Crohn's disease, which may be larger, purulent, and less "benign" looking. The pain of an abscess may be constant and not necessarily triggered by defecation, as it is in this case. This patient does not have any of the symptoms associated with Crohn's disease.
Internal sphincterotomy (choice D) is often reserved for chronic anal fissures. It is not generally performed for an ulcer that has been present for 2 days. Conservative management is generally recommended.
A colonoscopy (choice E) is not indicated in this 24-year-old man with the classic presentation of an anal fissure. Even though he has a family history of colon cancer, it is extremely unlikely that this is fissure is associated with cancer. A colonoscopy may be indicated at an earlier age than usually recommended (50 years) because of his family history, but certainly not at age 24. This decision is often made based on many factors in each individual case.
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