Anal fissure

Question 1

Anal fissures, features

Answer 1

causes pain on defecation

usually develop after a period of constipation (may be brief period) and tenesmus.

Question 2

Treatment

Answer 2

Milder cases;

• the discomfort is slight
• anal spasm is a minor feature
• the onset is acute.

Usually heal spontaneously or within a few weeks of;

• a high-fibre diet
• warm sitz baths after bowel movements
• laxatives.

Question 3

Conservative management (if persistent)

Answer 3

• Xyloproct
• Proctosedyl or
• Scheriproct suppositories or ointment

or

GTN ointment (Nitro-bid 2%) diluted 1 part with 9 parts white soft paraffin applied to the lower anal canal e.g.

• Rectogesic 2% ointment gently inserted with a gloved finger tds for 4 wks)
• 2% diltiazem cream twice daily for 6–8 weeks.

Question 4

Prevention

Answer 4

High-residue diet (consider the addition of bran or wheat preparations) to give soft faeces

Avoidance of constipation with hard stools (aim for soft bulky stools)

Question 5

More severe chronic fissures

Answer 5

The feature here is a hyperactive anal sphincter

A practical procedure such as injection of botulinum toxin into the sphincter is necessary.

Otherwise —lateral internal sphinecterotomy is the gold standard.