Anal fissure

Question 1

Define

Answer 1

Tears in skin around the anus, usually as a side effect of constipation → sphincter stretches to allow hard dry stool out

Question 2

Clinical presentation

Answer 2

Painful passing of stool

Bright red blood on tissue (can examine for fissures)

Anal itching (pruritis ani)

Tears in the squamous lining of the anus O/E

Investigations
* Examine the anus under senior input
* Basic observations

Question 3

Management

Answer 3

Lifestyle changes

1. High-fibre diet - whole grains, veg
2. Good hydration (increase fluid intake)
3. Good anal hygiene- kept dry and clean
4. Advise against ‘stool withholding’ and undue straining during bowel movements

Medical Management
1. Consider constipation treatment pathway
2. Simple analgesia (paracetamol or ibuprofen)
3. Sitting in a shallow, warm bath several times a day
4. Secondary care treatment: rectal glyceryl trinitrate (GTN) ointment, lidocaine, topical dilitiazem, botulinum toxin injection, surgery

Follow up
* Return if fissure is unhealed in 2 weeks or return earlier if the child is in a lot of pain
* Seek paediatrician or paediatric surgeon’s advice if recurrent or unhealed

Question 4

Complications/ Prognosis

Answer 4

• Complications
• Constipation
• Chronic anal fissure

Prognosis

• In most people, the fissure will heal within a week or so
• Treatment revolves around easing pain by keeping the stools soft and relaxing the anal sphincter to promote healing.