Diagnostics

A digital rectal exam, which may be painful, may be needed if a definitive diagnosis of anal fissures cannot be made based on a patient’s history.1 Anoscopy, which also may be painful, can be used to better visualize an anal fissure that is not evident on exam. No laboratory tests are indicated at this time.

Medical treatment

A majority of anal fissures heal on their own, and no treatment is needed. If treatment is necessary, the goal is to relieve pain and constipation. Maintaining bulky, formed stools is the first-line treatment in medical management of anal fissures and in preventing their reoccurrence. First-line therapies include a diet high in fiber, approximately 25 to 35 g per day. If the patient cannot consume this amount of fiber from dietary sources, over-the-counter fiber supplements may be needed. A diet rich in fruits, vegetables (roughage), and grains, along with increased fluid intake, can prevent hard stools and constipation. Stool softeners can be used in conjunction with fiber supplementation; softer stools are easier to pass and cause less pain. If necessary, laxatives may be used in the beginning of management to establish a bowel regimen. Sitz baths for 10 to 20 minutes after each bowel movement can assist in the healing process by cleaning the fissure and relaxing the internal sphincter muscles.


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If stool-bulking agents and dietary interventions do not work, pharmacologic interventions can be used. Nifedipine—a medication approved as an oral treatment for blood pressure—can reduce internal anal pressure when used in topical gel form. A small amount of the ointment can be applied by the patient directly onto the affected area, 0.2% four times per day.5 Topical nitroglycerin also can be used to treat anal fissures. In oral form, the drug dilates blood vessels to increase blood flow to the heart; the topical ointment can decrease inter-anal pressure, relieve pain, and promote blood flow to tissues for healing. Patient-applied treatment is with a small amount of 0.2% nitroglycerin ointment around the anal opening two to three times per day and, if needed, before and after bowel movements.5 Nitroglycerin ointment is FDA-approved for the treatment of pain associated with chronic anal fissures.6 Understanding the side effects of these topical ointments is important because some patients may not be able to tolerate the associated headaches and dizziness. It is imperative that the right amount of medication be compounded to make the topical ointment and that the patient wash his or her hands before and after application.

Narcotics are not recommended in the treatment of anal fissures because they can cause constipation. OnabotulinumtoxinA injection into the interior anal sphincter can be considered as another nonsurgical option. The injection can last up to three months and provide time for an acute or chronic anal fissure.6 OnabotulinumtoxinA injections do not have the side effect of severe headaches that can be associated with nitroglycerin ointment. In a study by Brisinda and colleagues that compared onabotulinumtoxinA injection with nitroglycerin ointment (twice-daily application) for anal fissures, neither side effects nor fecal incontinence was seen in patients who received the injection.2 Several participants in the nitroglycerin arm, however, had severe headaches. For patients whose anal fissure fails to respond to a minimum of one to three months of medical therapy, surgical intervention will most likely be required.5 Nonsurgical treatments for chronic anal fissures are noninvasive, but they do have a higher recurrence rate than surgery.

Surgical treatment

Surgical treatment of anal fissures is not usually needed, but if it is, a lateral internal sphincterotomy (LIS) is considered to be the gold standard, with a cure rate greater than 90%.4,7 The goal of LIS is to decrease pressure on the internal anal sphincter. This is done by cutting and separating a portion of the anal muscle.8 During the procedure, the surgeon may divide up to 30% of the internal sphincter fibers with either an open or closed technique.8 LIS is an option for chronic anal fissures that do not heal after four to six weeks.4 The complications associated with LIS are infection, fistula, and incontinence. Postoperative care includes stool softeners, fiber supplementation, and a postoperative visit to the surgeon to ensure healing and resolution of the fissure. Because the incidence of postoperative fecal incontinence is 10%, it is important for a patient to understand the possible side effects of LIS.7 Fecal incontinence is a contraindication for surgery because the incontinence could be worsened and delay healing in the postoperative period.

Prognosis/reoccurrence

Anal trauma or a hard bowel movement can cause recurrence of anal fissures. Lifestyle changes, including a diet high in fiber, fruits, vegetables, and grains for bulk, as well as good bowel habits, can prevent a recurrence. If an anal fissure continues to recur without an obvious reason or if it fails to heal with medical management, further investigation is needed. Crohn’s disease, excessive scar tissue, sexually transmitted infections, or an anal tumor can be causes of recurring fissures. An anal exam under anesthesia or a colonoscopy may be necessary to find the underlying etiology for recurring fissures. Patients should be informed that anal fissures do not cause anal cancer.

Margaret C. Teu, DNP, RN, MS, WHNP-BC, is an assistant professor and program director of graduate nursing at South University in Richmond, Va.

References

  1. Poritz LS. Anal fissure. October 31, 2014. Available at emedicine.medscape.com/article/196297-overview
  2. Brisinda G, Maria G, Bentivoglio, et al. A comparison of injections of botulinum toxin and topical nitroglycerin ointment for the treatment of chronic anal fissure. N Engl J Med. 1999;341(2):65-69. Available at www.nejm.org/doi/full/10.1056/NEJM199907083410201
  3. Altomare DF, Binda GA, Landolfi V, et al. The management of patients with primary chronic anal fissure: a position paper. Tech Coloproctol. 2011;15(2):135-141. Available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3099002/
  4. Madalinski MH. Identifying the best therapy for chronic anal fissure. World J Gastrointest Pharmacol Ther. 2011;2(2):9-16. Available at www.wjgnet.com/2150-5349/full/v2/i2/9.htm
  5. Breen E, Bleday R. Patient information: anal fissure (beyond the basics). Available at www.uptodate.com/contents/anal-fissure-beyond-the-basics
  6. Poritz LS. Anal fissure treatment and management. October 31, 2014. Available at emedicine.medscape.com/article/196297-treatment
  7. Gupta PJ. A review of ano-rectal disorders and their treatment. Bratisl Lek Listy. 2006;107(8):323-331. Available at www.bmj.sk/2006/10708-12.pdf
  8. Schubert MC, Sridhar S, Schade RR, Wexner S. What every gastroenterologist needs to know about common anorectal disorders. World J Gastroenterol. 2009;15(26):3201-3209. Available at www.wjgnet.com/1007-9327/15/3201.asp

All electronic documents accessed March 10, 2015.