Anal Fissures

Question 1

define an anal fissure?

Answer 1

painful tear in the squamous lining of the lower anal canal (chronic is more than 6 weeks) characterised by pain on defecation and rectal bleeding, with a sentinel pile or mucosal tag at the external aspect

90% of anal fissures are posterior ( Anterior anal fissures tend to occur after childbirth)

Question 2

summarise the epidemiology of anal fissure?

Answer 2

affects 1/10 people during their life time both sexes are affected equally can occur at any age most cases occur in children and young adults 10-30 years

Question 3

explain the causes of anal fissure?

Answer 3

most caused by hard faeces

anal spincter spasm can constrict the inferior rectal artery-> causing ischaemia and impairing the healing process

rare causes-: syphilis, herpes, trauma, crohn’s, anal cancer, psoriasis

Question 4

what are the risk factors for an anal fissure?

Answer 4

○ Hard stools

○ Pregs (usually during 3rd trimester)

Opiate analgesia – associated with constipation and therefore increased incidence of anal fissures

Question 5

what are presenting symptoms of anal fissure?

Answer 5

Symptoms are intermittent

Tearing pain when passing stools shitting glass

There may be a little bit of blood in the faeces or on the paper (blood on top – NOT mixed in with the faeces)

Anal itching (pruritus ani)

Anal spasm

Question 6

what are the signs of anal fissure on physical examination?

Answer 6

tears in the squamous lining of the anus on examination

Question 7

what are the compliations?

Answer 7

Chronic anal fissure – if left untreated

Incontinence AFTER SURGERY

Question 8

summarise the prognosis for patients with anal fissure?

Answer 8

in most people-> 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

Question 9

what are the complications of anal fissures?

Answer 9

Chronic anal fissure – if left untreated

Incontinence AFTER SURGERY

Question 10

describe the diagnosis for anal fissure?

Answer 10

CLINICAL EXAM

If anal sphincter deficits suspected then may want to do an anal US to examine the internal and external sphincter

DRE is not conducted in suspected anal fissures due to immense pain

Question 11

what are the 3 types of management for anal fissure?

Answer 11

conservative

medical

surgical

Question 12

outline the conservative treatment for anal fissure?

Answer 12

High-fibre diet

Softening the stools (laxatives)

Good hydration

Question 13

outline the medical management for anal fissure?

Answer 13

Topical analgesic

Lidocaine ointment (local anaesthetic)

GTN ointment (relaxes the anal sphincter and promoted healing)

Diltiazem (relaxes the anal sphincter and promotes healing) - if the patient gets headaches from the GTN ointment

Question 14

outline the surgical management for

Answer 14

IF RESISTANT FISSURES

1st line surg: Botulinum toxin is used after failure of topical treatment – especially in females where there is concern over the integrity of sphincters after childbirth

1st line surg: Lateral partial internal sphincterotomy

This relaxes the anal sphincter and promotes healing but it has complications (e.g. anal incontinence) especially in women who have shorter and weaker sphincters e.g. childbirth injuries so it is reserved for patients who are intolerant or not responsive to non-surgical treatments

2nd Line surgical treatment: anal advancement flaps – higher failure rate but lower risk of incontinence