ANAL FISSURES AND HAEMMORHOIDS Flashcards
Anal fissures
Tear or ulcer in anal canal
causing bleeding and pain on defecation
Symptoms - anal fissure
Bleeding (bright red blood)
Sharp, persistent pain on defecation.
Linear spilt in anal mucosa
Anal fissures - acute management
Ensure stools are soft/easy to pass
- Bulk forming laxative OR osmotic
Pain relief
- Simple analgesia
- Warm bath
Prolonged burning pain following defecation
- Topical anaesthetic e.g. lidocaine 5% (1-2 mL PRN)
Chronic anal fissure treatment
(> 6 weeks)
- GTN 0.4% ointment to aid healing (high incidence of headache)
BD for 6-8 weeks
- topical/oral diltiazem or nifedipine (lower adverse effects, esp in topical)
- specialist: botulinum toxin
- surgery when no drug response
Common side effect of GTN rectal ointment use
headaches
true or false - recurrence of fissure after GTN rectal ointment treatment is common
true
Haemorrhoids
Swellings of the vascular mucosal anal cushions around the anus (high risk during pregnancy)
Haemorrhoids - symptoms
Pain after defecation
Bleeding after defecation
Swelling/lumps
Itchy, sore skin around anus
Haemorrhoids - risk factors
Pregnancy
Constipation
Types of haemorrhoids
Internal → painless
External → itchy or painful
Haemorrhoids - lifestyle advice
Increase fibre + fluid intake
Perianal hygiene
Haemorrhoids - treatment
Maintain easy stools to minimise straining: 1 dietary fibre + fluid or bulk-forming laxative
Haemorrhoids - treatment (pain)
Pain: Paracetamol (Opioids → constipation NSAIDs exacerbate rectal bleeding)
Haemorrhoids - treatment (pain/ itching)
Pain / itching: Topical preparations (anaesthetics, corticosteroid, lubricant, antiseptics)
Topical anaesthetics (lidocaine, benzocaine, cincochaine, pramocaine) → used for a few days
Topical corticosteroids → use no more than 7 days due to side-effect
Why are Topical anaesthetics (lidocaine, benzocaine, cincochaine, pramocaine) only used for a few days?
sensitisation of anal skin
can be absorbed through the rectal mucosa
rare: can cause increased irritatoin
excessive application avoided
Haemorrhoids - pregnancy
Bulk forming laxatives - No topical hemorrhoidal preparations (only a simple soothing prep if needed)
max duration of use for any topical preparations that contain LA (e.g. lidocaine, benzocaine, cinchocaine, pramocaine)
only for a few days
may cause sensitisation of anal skin
LA can be absorbed through rectal mucosa (thus theoretical risk of systemic SE) and also rarely causes increased irritation - avoid excessive application
why is use of CS containing preparations restricted to 7 days only
continuous or excessive use = risk of adrenal suppression and systemic effects
also long term use can cause ulceration or permanent damage due to thinning of perianal skin
Are there any topical haemorrhoidal prerarations licensed for use in pregnancy
No
If treatment is required, consider a soothing prep containing simple, soothing products - not LA or CC
