A WEEK AFTER UNDERGOING hemorrhoidectomy, Kelly Carlito, 40, comes to the clinic complaining of intense anal pain and bright red, scanty rectal bleeding during bowel movements. She says she contacted her health care provider, who recommended stool softeners and more liquids in her diet, but she's still having pain.
Mrs. Carlito may be suffering from an anal fissure. Causes of anal fissure include severe, chronic constipation or diarrhea; Crohn's disease or ulcerative colitis; anal intercourse; and rectal tearing during childbirth. Most anal tears resolve spontaneously without complications, but some don't heal and require treatment. A tear lasting more than 6 weeks becomes a chronic fissure that's slow to heal because bowel movements and sphincter spasms impede healing.
Even if the tear is small, the patient is likely to report severe and at times spasmodic pain during and after defecation, along with small amounts of bright red blood in stools or on toilet tissue, and anal burning and itching. She may be embarrassed to report these symptoms and delay seeking treatment.
Surgery to manage refractory anal fissures can permanently injure the anal sphincter, leading to fecal incontinence in as many as 30% of patients.1 To help your patient avoid this invasive option, make sure you know how to assess an anal fissure and what to teach her to encourage spontaneous healing.
Conservative treatment first
Initial treatment includes increased fiber and fluid intake, sitz baths, stool softeners, and topical analgesics.2 The health care provider may order a topical nitrate such as glyceryl trinitrate; causing local vasodilation, this drug improves blood flow to the area.3 He also may order topical calcium channel blockers to help relax vascular smooth muscle. About two-thirds of anal fissures respond to these agents.
According to anecdotal reports, zinc preparations also may successfully treat anal fissures, but more research is needed. Some topical medications are ready-made and suitable for application, but if more than one drug is used, consult a pharmacist about the best mix for application.
If the fissure doesn't respond to conservative treatment, the health care provider may inject botulinum toxin into the anal sphincter. One study reported that a single botulinum toxin injection healed as many as 82% of fissures with only a 6% recurrence rate. However, drawing conclusions about the efficacy of botulinum toxin is difficult, because few randomized controlled studies have examined it.2
Fissures refractory to treatment may require surgery. Options include lateral internal sphincterotomy and anal advancement flap.
Assessing your patient
Because anal fissures make bowel movements painful, some patients may take stool softeners and laxatives in an attempt to solve the problem. However, diarrhea associated with overuse of laxatives may further complicate healing. This is the case with Mrs. Carlito, who says she so dreads the pain associated with solid bowel movements that she's been taking laxatives twice a day, resulting in diarrhea 5 to 6 times a day. She describes the pain from solid bowel movements as “worse than childbirth,” and says she spends most of her time sitting in a warm bathtub, which relieves the pain.
When you assess her, you note a small anal fissure that's bleeding slightly. You reassure Mrs. Carlito that treatment is available and encourage her to report her symptoms so she can get proper care. Using warm water or 0.9% sodium chloride solution, you clean the area well, gently pat it dry, and apply the ordered topical agents prepared by the pharmacy (the combination may include glyceryl trinitrate, topical calcium channel blockers, a topical anesthetic, or zinc).
Teach Mrs. Carlito to clean the area well after bowel movements, using perfume-free toilet paper or moist wipes, and to take warm baths to keep the area clean, relax the rectal area (decreasing spasms), and improve circulation. Keeping the area moist rather than completely dry will enhance wound healing.
Tell Mrs. Carlito to use the topical analgesics prescribed by her health care provider and to use stool-bulking agents as prescribed. Because of her diarrhea, she also should use a protective ointment or skin barrier to protect her skin from breakdown.
Obtain blood specimens for lab work to determine if she needs fluid or electrolyte replacement. Once her stools are again formed, she should use stool softeners as prescribed until the fissure heals.
Over time, Mrs. Carlito's fissure heals without surgery. Moist healing, rather than keeping the area completely dry, healed the fissure in less than 5 weeks, preventing development of a chronic fissure. You advise her to continue good dietary habits, including fiber and fruit in her diet, and to promptly report any changes in bowel habits to her health care provider.
By knowing how to intervene, you helped your patient avoid a chronic fissure and subsequent complications.
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Sajid MS, et al. The efficacy of diltiazem and glyceryltrinitrate for the medical management of chronic anal fissure: A meta-analysis. International Journal of Colorectal Disease
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