[5] Anal Fissure

Question 1

What is an anal fissue?

Answer 1

A tear in the mucosal lining of the anal canal

Question 2

What is an anal fissure most commonly due to?

Answer 2

Trauma from defecation of hard stool

Question 3

What can anal fissures be classified as?

Answer 3

Acute or chronic

Primary or secondary

Question 4

What is considered to be an acute anal fissure?

Answer 4

Present for <6 weeks

Question 5

What is considered to be a chronic anal fissure?

Answer 5

Present for >6 weeks

Question 6

What is a primary anal fissure?

Answer 6

One occurring with no underlying disease

Question 7

What is a secondary anal fissure?

Answer 7

One occurring due to an underlying disease, e.g. Inflammatory bowel disease

Question 8

What are anal fissures usually caused by?

Answer 8

Inflammation or trauma to the anal canal

Question 9

What are the major risk factors for anal fissures?

Answer 9

Constipation
Dehydration
Inflammatory bowel disease
Chronic diarrhoea

Question 10

What are the symptoms of anal fissures?

Answer 10

Post-defecation pain
Bleeding
Itching

Question 11

Describe the pain in anal fissures?

Answer 11

Intense pain post-defecation, which can last several hours

Pain can be far out of proportion to the size of the fissure

Question 12

Describe the blood in anal fissures

Answer 12

Commonly bright red blood on wiping

Question 13

What may be found on examination with anal fissures?

Answer 13

Fissures can be visible and/or palpable on DRE

Question 14

What may be required for diagnosis of anal fissures?

Answer 14

Examination under anaesthesia

Question 15

Why may examination under anaesthesia be required for the diagnosis of anal fissures?

Answer 15

Because often patients will refuse a DRE due to the intense pain

Question 16

Where might anal fissures present?

Answer 16

Posterior midline or anterior midline

Question 17

What % of anal fissures present in the posterior midline?

Answer 17

90%

Question 18

When are anterior anal fissures more likely?

Answer 18

In females, or if an underlying cause is present

Question 19

How can fissures within the anal canal usually be identified?

Answer 19

With proctoscopy

Question 20

What are multiple fissures and anteriorly located fissures more likely to be due to?

Answer 20

An underlying cause

Question 21

What do multiple fissures and anteriorly located fissures require?

Answer 21

Further investigations (if no known cause is apparent)

Question 22

What does the medical management of an anal fissure involve?

Answer 22

Reducing risk factors and providing adequate analgesia
Stool softening
Creams

Question 23

How can stool softening be achieved in anal fissures?

Answer 23

Measures such as increasing fibre in the diet and fluid intake

Question 24

What medication can be trialled if there is no change in stool following initial conservative management?

Answer 24

Stool softening laxatives

Question 25

Give two examples of stool softening laxatives

Answer 25

Movicol

Lactulose

Question 26

What creams can be used in anal fissures?

Answer 26

GTN cream or diltiazem cream

Question 27

How do GTN or diltiazem creams work?

Answer 27

They increase the blood supply to the region and relax the internal anal sphincter, putting less pressure on the fissure, promoting healing and reducing pain

Question 28

What is surgical treatment reserved for in anal fissure?

Answer 28

Chronic fissures, where medical management has failed to resolve the symptoms

Question 29

What surgical technique is used to treat anal fissures?

Answer 29

A lateral sphincterotomy

Question 30

What is the recurrence of anal fissures after surgery?

Answer 30

Between 1-5%

Question 31

Where do the majority of cases of recurrence of anal fissures after surgery occur?

Answer 31

In those with an underlying predisposition to the condition