K60.2 Anal fissure, unspecified

ICD10CM code

#### Name of the Condition
- Anal fissure, unspecified

#### Summary
An anal fissure is a small tear in the lining of the anus, which can cause pain and bleeding during bowel movements. It is a common condition affecting individuals of all ages.

#### Causes
- Straining during bowel movements
- Constipation or diarrhea
- Tight anal sphincter muscles
- Childbirth trauma
- Less commonly, inflammatory bowel disease

#### Risk Factors
- Chronic constipation or diarrhea
- Anal intercourse
- Young age (common in infants and young children)
- Older age-related changes in anal blood flow

#### Symptoms
- Sharp pain during and after bowel movements
- Visible tear in the skin around the anus
- Bright red blood on the stool or toilet paper
- Itching or irritation around the anus

#### Diagnosis
- Physical examination by a healthcare provider
- Visual inspection of the anal region
- In some cases, anoscopy to examine the anal canal

#### Treatment Options
- Increasing fiber and fluid intake to soften stools
- Topical anesthetics or pain relievers
- Sitz baths to relax the anal muscles
- Prescription creams to relax the sphincter muscles
- In severe cases, surgical intervention (e.g., lateral internal sphincterotomy)

#### Prognosis and Follow-Up
- Most anal fissures heal within a few weeks with appropriate treatment.
- Chronic fissures may require further intervention.
- Regular follow-up can prevent recurrence and manage chronic symptoms.

#### Complications
- Chronic anal fissures
- Painful bowel movements and avoidance leading to constipation
- Secondary infection or abscess formation

#### Lifestyle & Prevention
- Maintain a diet high in fiber
- Stay hydrated to prevent constipation
- Regular exercise to promote bowel regularity
- Proper bathroom habits: avoid straining and limit time on the toilet

#### When to Seek Professional Help
- Severe pain during bowel movements
- Persistent bleeding
- Symptoms not improving with over-the-counter treatments
- Signs of infection (e.g., fever, excessive redness or swelling)

#### Additional Resources
- American Society of Colon and Rectal Surgeons: [fascrs.org](https://www.fascrs.org)
- National Institute of Diabetes and Digestive and Kidney Diseases: [niddk.nih.gov](https://www.niddk.nih.gov)

#### Tips for Medical Coders
- Ensure the specificity of fissure is noted as "unspecified" (K60.2).
- Do not confuse with hemorrhoids or perianal abscess codes.
- Verify documentation guidelines for accuracy and completeness.

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