[5] Anal Fissure Flashcards
What is an anal fissue?
A tear in the mucosal lining of the anal canal
What is an anal fissure most commonly due to?
Trauma from defecation of hard stool
What can anal fissures be classified as?
Acute or chronic
Primary or secondary
What is considered to be an acute anal fissure?
Present for <6 weeks
What is considered to be a chronic anal fissure?
Present for >6 weeks
What is a primary anal fissure?
One occurring with no underlying disease
What is a secondary anal fissure?
One occurring due to an underlying disease, e.g. Inflammatory bowel disease
What are anal fissures usually caused by?
Inflammation or trauma to the anal canal
What are the major risk factors for anal fissures?
Constipation
Dehydration
Inflammatory bowel disease
Chronic diarrhoea
What are the symptoms of anal fissures?
Post-defecation pain
Bleeding
Itching
Describe the pain in anal fissures?
Intense pain post-defecation, which can last several hours
Pain can be far out of proportion to the size of the fissure
Describe the blood in anal fissures
Commonly bright red blood on wiping
What may be found on examination with anal fissures?
Fissures can be visible and/or palpable on DRE
What may be required for diagnosis of anal fissures?
Examination under anaesthesia
Why may examination under anaesthesia be required for the diagnosis of anal fissures?
Because often patients will refuse a DRE due to the intense pain
Where might anal fissures present?
Posterior midline or anterior midline
What % of anal fissures present in the posterior midline?
90%
When are anterior anal fissures more likely?
In females, or if an underlying cause is present
How can fissures within the anal canal usually be identified?
With proctoscopy
What are multiple fissures and anteriorly located fissures more likely to be due to?
An underlying cause
What do multiple fissures and anteriorly located fissures require?
Further investigations (if no known cause is apparent)
What does the medical management of an anal fissure involve?
Reducing risk factors and providing adequate analgesia
Stool softening
Creams
How can stool softening be achieved in anal fissures?
Measures such as increasing fibre in the diet and fluid intake
What medication can be trialled if there is no change in stool following initial conservative management?
Stool softening laxatives
Give two examples of stool softening laxatives
Movicol
Lactulose
What creams can be used in anal fissures?
GTN cream or diltiazem cream
How do GTN or diltiazem creams work?
They increase the blood supply to the region and relax the internal anal sphincter, putting less pressure on the fissure, promoting healing and reducing pain
What is surgical treatment reserved for in anal fissure?
Chronic fissures, where medical management has failed to resolve the symptoms
What surgical technique is used to treat anal fissures?
A lateral sphincterotomy
What is the recurrence of anal fissures after surgery?
Between 1-5%
Where do the majority of cases of recurrence of anal fissures after surgery occur?
In those with an underlying predisposition to the condition
