Fissure in ano is a common and painful condition that usually occurs in young adults.
It is characterised by severe pain on defecation (which may last for hours) associated with bright red rectal bleeding. Note that haemorrhoids usually cause painless fresh rectal bleeding.
B.C & H.P – 13-8-26
Who to refer:
Patients who are resistant to the treatments outlined in the Primary Care Management Section.
Patients in whom there is doubt about diagnosis:
- no anal fissure seen on examination. However, if their symptoms are typical of an anal fissure then it is still worth treating them, as per Primary Care Management, as well as making a referral.
- atypical symptoms
- does not fit usual patient demographic for anal fissure e.g. it is very unusual in elderly patients.
- Inability to exclude other pathologies (e.g. too sore to permit DRE)
How to refer:
Via Sci Gateway to Colorectal Surgeons stating “Fissure in Ano” as the problem.
Assessment
- History consistent with anal pain on defecation with bright red rectal bleeding.
- Exclude other anorectal pathologies such as Crohns, perianal warts, anal or rectal malignancy, perianal sepsis etc.
- Because a fissure is within the anal canal there may be little to see on anodermal inspection- sometimes getting the patient to bear down allows the edge of the fissure to be seen
- Patients should have a digital rectal examination to exclude other cause of their symptoms. However, often they are too sore to tolerate DRE. This could be done after a trial of treatment.
Treatment
Rationale for treatment is to soften the stool and relax the sphincter muscle. Treatment may not be successful unless both are done in conjunction.
Increase daily intake of fibre. Avoid dehydration, aiming for 1.5-2 litres of oral fluids per day.
Don’t put off going to the toilet until later. Avoid straining to pass a stool.
Review of medications with GP or Pharmacist to check if any are causing constipation. Avoid opioid analgesics.
Keep the area clean but avoid wiping too hard. Moistened toilet tissue can be helpful but avoid wipes containing alcohol. Warm salt/sitz baths can be soothing.
Stool Softeners
Stool softeners can be helpful when lifestyle management methods with diet and fluids is insufficient. Avoid bulk-forming laxatives. Please see LJF for advice on prescribing laxatives.
Painkillers
Simple analgesics such as Paracetamol or Ibuprofen may help.
Topical anaesthetics (Lidocaine 5% gel) can be used before opening bowels if it is particularly painful and applied 20-30 minutes beforehand.
Relax the sphincter – Chemical Sphincterotomy
Diltiazem Hydrochloride 2% cream
If the anal fissure does not heal with the above measures then topical Diltiazem Hydrochloride can be used. It works by relaxing the anal sphincter and thereby increasing the blood supply to the fissure. This helps to aid healing of the fissure.
How it is used
A small (pea sized) amount should be applied to the anoderm. The cream should be used twice a day every day (morning and evening) for 2 months. It is important to complete the full course to offer the best chance of successful healing.
Prescribe 2 tubes of the cream (2 x 30gm) because this should last approximately 2 months. Review the patient after this. A second course of Diltiazem can be prescribed if the anal fissure has not completely healed after the first.
Diltiazem is usually well tolerated but potential side effects include headaches, dizziness and itchiness or burning at the site when you use the cream. Most side effects will pass within a few days.
The LJF Formulary Committee agreed in November 2020 that Diltiazem 2% cream can be “routinely available in line with local guidance”. It can be prescribed by GPs in Primary Care following the advice set out above.
The Scottish Medicines Consortium (SMC) does not recommend Glyceryl trinitrate rectal ointment (Rectogesic) for use within NHS Scotland for the relief of pain associated with chronic anal fissure.
