#Anal Fissures (AF)
-An AF is a longitudinal tear or crack in the skin of the anal canal.
-Caused by trauma to the anoderm 2/2 to passing hard stools. May also be caused by Crohn’s. The goal of treatment is to break the vicious cycle of pain > spasm > ischemia that prevents healing of the fissure, prevent further tearing of the anal mucosa, and promotes healing of the fissure.
-Counseling & patient education: Dietary and behavioral counseling provided.
–High fiber diet: Increase dietary fiber and water intake to soften and bulk the stool. The recommended dietary fiber intake is between 20 and 35 grams per day.
–Drink lots of water: At least 2 Liters or 67 ounces per day. That is eight 8-oz glasses of water.
–Fiber supplements: If the patient is still constipated after dietary fiber, take either psyllium husk (Metamucil), or methylcellulose (Citrucel), or wheat dextran (Benefiber), or calcium polycarbophil (Fibercon). Take as directed.
-Stool softener or laxative: If a fiber supplement is not sufficient, take a stool softener or laxative.
–Sitz bath: Warm sitz baths about 10 to 15 minutes 2-3 times per day and after each BM will relax the anal sphincter and improve blood flow to the anal mucosa facilitating healing. Get Sitz bath kit or portable bowl from a drugstore. A bathtub may be used for a sitz bath by filling it with 2-3 inches of warm water. Don’t add soap and bubble bath. Wipe thoroughly with a towel or blow dry after each sitz bath.
–Balneol (Main ingredients: Water, mineral oil, propylene glycol, and lanolin oil.) – Use as needed for anal itching.
–Calmoseptine (Menthol and Zinc Oxide topical) cream BID for six weeks.
–Pharmacological sphincterotomy: Nifedipine 0.2% + Lidocaine 2.5% + Hydrocortisone 2.5% ointment. Apply BID to affected area. Dispense 50g.
-F/u every 4 weeks until resolution.
-Will refer for endoscopy if no resolution of symptoms after 8 weeks of treatment as above. Reason: To r/o Crohn’s.
-If Crohn’s is present will refer to GI; If not, refer to colorectal surgery if no resolution after endoscopy.
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***NTG 0.2% or 0.4% twice daily for eight weeks can also be used as a vasodilator. However, it has side effects of hypotension and headaches. Hypotension can cause dizziness. B/c of that, the patient should sit or lie down when applying the NTG ointment and should stand up slowly afterward. Headaches usually occur 10-15 minutes after putting the NTG and last around 30 minutes. Don’t use it in patients who use viagra or other ED medications or nitrates.
Topical nifedipine is usually used as 0.2 to 0.3 % ointment and can be applied 2-4 times per day.
Nifedipine works better and has less side-effects than NTG. However, it needs to be compounded.
If the patient has access to a compounding pharmacy, use nifedipine ointment rather than nitroglycerin ointment. If a patient doesn’t have access to a compounding pharmacy, use NTG.
Dr. Jenkins, a colorectal surgeon, uses the combination of nifedipine + hydrocortisone + lidocaine above. Uptodate.com supports that.
The following information came from a noon lecture
-NTG* 0.125% PR TID – QID x 3 months. Must be placed inside the anal verge. Apply to area of the fissure on the anoderm.
-If no improvement and no headaches, increase to NTG* 0.2% TID or QID
-If headaches or pt uses ED medications, Diltiazem 2%* or Nifedipine 0.5% QID
-If no better, Botox* (up to 40 units total), keep on NTG*
-If no better, surgery. Lateral Internal Sphincterotomy (LIS): 2-4% post-op incontinence.
-If symptoms are severe, do NOT start treating hemorrhoids concurrently. May also use a short course of steroid-containing suppository to aid placement of NTG.
**Use tuberculin syringe with a blunt tip to push the NTG in.
I have used this in the clinic
**Proctofoam HC = Hydrocortisone / Pramoxine topical, rectal: Apply to affected areas 3 to 4 times daily.
Diagram from: Madalinski, Mariusz H. “Identifying the Best Therapy for Chronic Anal Fissure.”
Resources
- Madalinski, Mariusz H. “Identifying the Best Therapy for Chronic Anal Fissure.” World Journal of Gastrointestinal Pharmacology and Therapeutics 2.2 (2011): 9–16.
- Zaghiyan, Karen N., and Phillip Fleshner. “Anal Fissure.” Clinics in Colon and Rectal Surgery 24.1 (2011): 22–30.
- Farkas, Nicholas et al. “Are We Following an Algorithm for Managing Chronic Anal Fissure? A Completed Audit Cycle.” Annals of Medicine and Surgery 5 (2016): 38–44.