Management of anal fissures in adults Patients under 18 years of age must be referred to secondary care and are not covered by this pathway Preliminary symptom assessment An anal fissure is a split in the skin at the opening of the anus, which leaves exposed some of the muscle fibres of the . Pain results from the recurrent opening of the wound when the bowels are opened, and it is often accompanied by bleeding. In addition, the inner internal sphincter goes into : this makes the pain worse and can prevent healing. Pain may be present in the absence of bowel opening. Anal fissures are different from haemorrhoids, may be difficult to see and have no relationship with cancer.

A typical patient presents with new onset fresh, bright-red rectal bleeding with pain. The anal fissure usually has a posterior or anterior location. The patient has no history or evidence of Crohn’s disease.

First line treatment – trial for at least 6-8 weeks; however this period may be shortened where patient is in severe pain. Bulk fibre supplements (advise to drink plenty of water) + / - stool softeners

Consider adding a local anaesthetic treatment

Second Line Treatment 1GP to prescribe one course of Diltiazem 2% ointment (unlicensed) applied TWICE daily EVERY DAY for 2 months (One course is two 30g tubes which should last 2 months) GP to supply MECCG patient information leaflet with the prescription. It is crucial that the ointment is applied twice daily everyday to offer the best chance of successful healing. N.B. Do not prescribe Diltiazem 2% cream as it is more expensive than ointment. GP to review patient in 2 months.  If healed no further treatment  If no improvement after the first course of Diltiazem 2% ointment refer to colorectal team.  If improving but not fully healed repeat the course of Diltiazem 2% ointment once only (2 x 30g), and if still not healed refer to colorectal team. Maximum of 4 x 30g Diltiazem 2% ointment to be prescribed in total. If second line treatment unsuccessful refer to secondary care-colorectal team  Consider endoscopy to rule out Crohn’s disease  Male patients-treat with lateral sphincterotomy (consider endoanal ultrasound prior to surgery  Female patients- o injection (50 units) into (IAS) o If unsuccessful after 90 days consider 2nd administration o If unsuccessful after further 90 days or not suitable for second injection consider lateral sphincterotomy 1Alternative treatment would be Glyceryl Trinitrate 0.4% rectal ointment. However a very high % of patients cannot tolerate side-effects and move onto Diltiazem anyway. Diltiazem has therefore been placed as second line therapy to improve patient compliance and outcome. Ref: ESUOM3 Chronic anal fissure: 2% topical diltiazem hydrochloride http://www.nice.org.uk/mpc/evidencesummariesunlicensedofflabelmedicines/ESUOM3.jsp

Title Management of anal fissures in adults Author Original copy was written by Helen Ellis Consulted with Mr Nigel Richardson, Consultant Colorectal Surgeon, Mid Essex Hospitals NHS Trust. Approved by Mid-Essex Area Prescribing Committee January 2014 Minor amendment June 2018: cream changed to ointment as cost effective choice Review due September 2020