Anal fissure
Questionnaire/history:
Anal pain always occurs with defecation?
Pain severe and sharp on passing a stool, commonly followed by deep burning pain that persists for several hours afterwards?
Bleeding may occur with defecation (when present it is usually seen as a small quantity of bright red blood on the stool or toilet paper)?
Primary anal fissures are usually singular and occur in the posterior midline of the anus, although a few cases may be seen in the anterior midline (especially in women)?
Secondary anal fissures may have an irregular outline, be multiple, or occur laterally
Past medical history?
Current medication?
Known drug allergies?
Examination:
Digital rectal examination NOT recommended in primary care to diagnose an anal fissure
Management:
Advised:
Most primary anal fissures resolve with conservative measures in 6-8 weeks
Increase fluid, fibre and consider stool softeners
Paracetamol or ibuprofen (do not use opiates)
Sitting in a warm bath to ease pain
Topical lignocaine (debated - can cause a localised skin reaction)
Symptoms > 1 week and not improved with conservative treatment, consider:
Rectal glyceryl trinitrate (GTN) 0.4% ointment BD for 6-8 weeks (30% get a headache, tolerance can develop)
If the anal fissure is unhealed:
Child: after 2 weeks refer
Adult: after 6-8 weeks and asymptomatic or improved: second 6-8 week course of rectal glyceryl trinitrate (GTN) 0.4% ointment or refer
Adult after 6–8 weeks and still symptomatic check adherence:
– If uncompliant: repeat GTN
– If inadequate due to side effects: consider Diltiazem 2% (unlicensed and expensive but has similar rates of ulcer healing to GTN and with fewer side effects)
– If adequate: refer
Resource(s):