1. Be aware of the presenting symptoms of a fissure
Anal fissure is a tear in the epithelium of the anal canal. It is one of the most common anorectal problems and may be caused by mechanical trauma, for example passing a large stool. The key feature is severe pain on defaecation, often described as a feeling of passing broken glass. The pain is typically shortlived – often lasting just a few minutes – compared with haemorrhoids, which can throb for hours. An anal fissure may also present with fresh bleeding and anal spasm following defaecation.
2. Have a low threshold for an anal or rectal examination
Always consider an anal or rectal examination in patients with anal symptoms because failure to examine the anus could miss a low rectal cancer.
Digital rectal examination in a patient with suspected fissure is often painful, but may reveal an elevated anal sphincter resting pressure. Examination may also show a visible split in the perianal skin on gentle retraction of the buttocks. Some 90% of fissures occur in the posterior midline. Chronic fissures are defined as those causing symptoms beyond six to eight weeks. They may exhibit a sentinel skin tag and exposed external sphincter muscle.
3. Beware concomitant diseases in atypical fissures
Atypical fissures can occur at any point on the circumference of the anal canal and tend to occur in association with other diseases such as Crohn’s disease, HIV, cancer, syphilis or tuberculosis.
4. Glyceryl trinitrate will heal more than 50% of fissures
Nitric oxide relaxes the internal anal sphincter, so topical application of 0.2% glyceryl trinitrate ointment is often used as the first management step for anal fissures. Healing rates are reported to be 48% to 68% of patients, but headache is a common side-effect, occurring in up to 50% of patients.
Topical diltiazem and nifedipine also cause relaxation of the internal anal sphincter but are unlicensed for this indication and are usually only prescribed in secondary care.
Botulinum toxin may be used to paralyse the anal sphincter muscle, allowing relaxation and subsequent healing of the fissure. The effect occurs within days and lasts for two to four months.
5. Reassure patients that most fissures resolve quickly
Most acute fissures resolve in a matter of days with simple perianal hygiene and a high-fibre diet. Advise the patient to avoid straining.
6. Internal and external haemorrhoids present with different symptoms
Haemorrhoids can be classified as internal or external depending on their relation to the dentate line.
External haemorrhoids are highly innervated, hence acutely painful when thrombosed. Patients with external haemorrhoids commonly present with pain, itching and fresh anal bleeding.
Internal haemorrhoids are covered by columnar epithelium and are not sensitive to pain, touch or temperature. Haemorrhoids can be graded from I to IV (see table below). Typical presentation includes painless bleeding, mucus discharge, incomplete evacuation and tissue protrusion.
| Grade | Symptoms | Treatment |
|---|---|---|
| I | Bleed but do not prolapse | Stool softeners, topical creams |
| II | Prolapse but spontaneously reduce | Rubber band ligation, sclerotherapy, electrocoagulation, (haemorrhoidectomy) |
| III | Prolapse requiring manual reduction | Rubber band ligation, sclerotherapy, electrocoagulation, (haemorrhoidectomy) |
| IV | Irreducible prolapse | Haemorrhoidectomy |
7. Increase fibre and fluid for patients with haemorrhoids
A high-fibre diet enables stools to be passed easily without straining. Increased fluid intake helps prevent constipation.
Alteration in bathroom habits, including spending less time on the toilet, may also reduce straining and minimise haemorrhoidal symptoms.
8. Identify red flag symptoms
In patients over 50 years old it is very risky to put anal symptoms down to haemorrhoids, as colorectal cancer can present in a similar manner in this age group.
Red flag symptoms for bowel cancer are:
- a change in bowel habit (particularly looser stools) which persists for more than six weeks
- unexplained anaemia
- a palpable abdominal or rectal mass
- rectal bleeding without anal symptoms.
9. Topical creams treat symptoms of haemorrhoids, not pathology
Many topical agents exist, mainly local anaesthetics, astringents and mild steroid creams, but there is limited evidence for efficacy. They tend to work by improving the symptoms rather than treating the underlying pathology. Newer agents on the horizon may be able to manipulate the local vascular supply and so treat one of the primary underlying aetiologies.
10. Warn patients what to expect before referring for haemorrhoid surgery
Only 5-10% of patients require surgical intervention involving formal excision of the haemorrhoid, ligation of the underlying vascular pedicle and closure of the overlying mucosa.
Haemorrhoid surgery is associated with significant discomfort postoperatively, often requiring a combination of local and systemic analgesics and two to four weeks off work. Patients should be warned that they will be sore and will have blood and purulent discharge for several weeks after surgery. Fortunately, serious complications such as bleeding, anal stenosis and incontinence are rare.
Professor John Scholefield is professor of surgery and consultant general and colorectal surgeon and Mr Alastair Simpson is a specialist registrar in surgery at Nottingham University Hospitals NHS Trust.
