ANAL FISSURES AND HAEMMORHOIDS

Question 1

Anal fissures

Answer 1

Tear or ulcer in anal canal
causing bleeding and pain on defecation

Question 2

Symptoms - anal fissure

Answer 2

Bleeding (bright red blood)
Sharp, persistent pain on defecation.
Linear spilt in anal mucosa

Question 3

Anal fissures - acute management

Answer 3

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)

Question 4

Chronic anal fissure treatment

Answer 4

(> 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

Question 5

Common side effect of GTN rectal ointment use

Answer 5

headaches

Question 6

true or false - recurrence of fissure after GTN rectal ointment treatment is common

Answer 6

true

Question 7

Haemorrhoids

Answer 7

Swellings of the vascular mucosal anal cushions around the anus (high risk during pregnancy)

Question 8

Haemorrhoids - symptoms

Answer 8

Pain after defecation
Bleeding after defecation
Swelling/lumps
Itchy, sore skin around anus

Question 9

Haemorrhoids - risk factors

Answer 9

Pregnancy
Constipation

Question 10

Types of haemorrhoids

Answer 10

Internal → painless
External → itchy or painful

Question 11

Haemorrhoids - lifestyle advice

Answer 11

Increase fibre + fluid intake
Perianal hygiene

Question 12

Haemorrhoids - treatment

Answer 12

Maintain easy stools to minimise straining: 1 dietary fibre + fluid or bulk-forming laxative

Question 13

Haemorrhoids - treatment (pain)

Answer 13

Pain: Paracetamol (Opioids → constipation NSAIDs exacerbate rectal bleeding)

Question 14

Haemorrhoids - treatment (pain/ itching)

Answer 14

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

Question 15

Why are Topical anaesthetics (lidocaine, benzocaine, cincochaine, pramocaine) only used for a few days?

Answer 15

sensitisation of anal skin
can be absorbed through the rectal mucosa
rare: can cause increased irritatoin
excessive application avoided

Question 16

Haemorrhoids - pregnancy

Answer 16

Bulk forming laxatives - No topical hemorrhoidal preparations (only a simple soothing prep if needed)

Question 17

max duration of use for any topical preparations that contain LA (e.g. lidocaine, benzocaine, cinchocaine, pramocaine)

Answer 17

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

Question 18

why is use of CS containing preparations restricted to 7 days only

Answer 18

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

Question 19

Are there any topical haemorrhoidal prerarations licensed for use in pregnancy

Answer 19

No
If treatment is required, consider a soothing prep containing simple, soothing products - not LA or CC