How you can best ass-ist your patients with anal fissures

What causes anal fissures?

Primary anal fissures are typically benign and are most likely related to local trauma such as hard stools, prolonged diarrhoea, pregnancy and childbirth, injury or penetration. ²

Secondary fissures usually indicate a more serious underlying pathology such as inflammatory bowel disease, sexually transmitted disease, tuberculosis, anal cancer or HIV. ² They may also be due to previous anal surgical procedures. ²

Once a fissure develops, pain and impaired healing (compromised by bowel movements) leads to persistent spasm of the internal anal sphincter (IAS). ³ The increased IAS pressure causes the tear to worsen and constricts blood flow, further delaying wound healing. ³

Adapted from Schlichtemeier S and Engel A, 2016. ²

In adults, acute anal fissures (those lasting less than 6 weeks) are thought to precede chronic anal fissures. ⁴ Evidence suggests that aggressive medical treatment in combination with ongoing conservative care can prevent the fissure from becoming chronic. ⁴

First-line treatment of anal fissures

When treating anal fissures, the goal is to break the cycle of anal sphincter spasm using a step-wise approach. ²

Initial medical treatment may include frequent sitz baths, stool softeners, a high fibre diet and adequate fluid intake. ⁵ If these conservative methods fail, other options such as topical glyceryl trinitrate – the active ingredient in Rectogesic® Ointment – can be very effective.

Glyceryl trinitrate reduces IAS spasm via the production of nitric oxide, which relaxes anal smooth muscle. ⁶ It also increases blood flow, relieves pain, and promotes wound healing. ^7,8

How to apply Rectogesic®

Patients should not apply more than the recommended dose of 1.5 cm of Rectogesic® Ointment. Headaches may occur but are usually mild and typically happen only after the first few applications. The use of a disposable glove or wrapping the finger in Gladwrap may help reduce absorption. If headaches occur with the recommended dose, then begin with a lower dose as outlined below: