Signs and Symptoms
- Bright red blood per rectum usually on toilet paper
- Sharp, cutting, throbbing, or burning pain with bowel movement:
- Constipation; unable to pass stool owing to pain:
- Hard, nondeformable stools
History
- Passage of hard stool or constipation
- Episode(s) of diarrhea
- Bright red blood on toilet paper
Physical Exam
Anal exam:
- Gently retract buttocks and have patient bear down to visualize the fissure
- Severe pain usually prevents a manual or digital exam:
- Use lidocaine jelly or ELA-Max5, a topical lidocaine ointment, before attempting digital rectal exam
- Need to exclude abscess or tumor
Pediatric Considerations |
| A clear test tube may be used as an anoscope to visualize the anal canal/fissure |
Essential Workup
Careful rectal exam
Diagnostic Tests & Interpretation
Lab
Hematocrit if severe bleeding by history
Imaging
CT pelvis:
- To exclude anal rectal abscess/tumor if palpable mass on rectal exam
Differential Diagnosis
- Crohn disease
- Chronic ulcerative colitis
- Anorectal carcinoma
- Perirectal abscess
- Thrombosed hemorrhoid
- Sexual abuse
- TB
- Syphilis
- Lymphoma
- Leukemia
- Previous anal surgery
Prehospital
Establish IV access for patients with significant rectal bleeding
Initial Stabilization/Therapy
Administer pain medications for patients with significant pain
ED Treatment/Procedures
- IV/IM/PO pain medications:
- Topical anesthetics:
- ELA-Max5
- Lidocaine jelly 2%
- Sitz baths (with warm water) to relieve sphincter spasm
Diet
- High-fiber diet instruction:
- Fiber/bran: 20 g/d
- Psyllium seeds (Metamucil or Konsyl): 1-2 tsp (peds: 0.25-1 tsp/d) PO q24h
- Encourage consumption of 10-12 oz glasses of water per day
Medication
- Cyclobenzaprine (Flexeril): 10 mg (peds: Not indicated) PO TID
- Diazepam (Valium): 5 mg (peds: 0.12-0.8 mg/kg/d) PO TID PRN for spasm
- Diltiazem 2% ointment: Apply to fissure BID
- Docusate sodium (Colace): 50-200 mg (peds: <3 yr, 10-40 mg/d; 3-6 yr, 20-60 mg/d; 6-12 yr, 40-150 mg/d) PO q12h
- ELA-Max5 (5% lidocaine anorectal cream): Apply to perianal area q4h PRN pain (pediatric dose: Not for those <12 yr)
- Ibuprofen: 400-600 mg (peds: 40 mg/kg/d) PO q6h
- Nifedipine ointment 0.3%: Apply to fissure TID with cotton swab (peds: Not indicated)
- Nitroglycerin ointment 0.2%: Apply a small pea-sized dot to fissure BID-TID with cotton swab. (peds: Not indicated)
Disposition
Discharge Criteria
- Initial treatment is conservative therapy for acute anal fissures as an outpatient
- Operative referral for chronic fissures
Follow-up Recommendations
Colorectal or GI follow-up for patients with symptomatic fissures
- HerzigDO, LuKC. Anal fissure . Surg Clinf North Am. 2010;90(1):22-44.
- NelsonRL, ThomasK, MorganJ, et al. Non-surgical therapy for anal fissure . Cochrane Database Syst Rev. 2012;2:CD003431.
- OrsayC, RakinicJ. Practice parameters for the management of anal fissures (revised) . Dis Colon Rectum. 2004;47:2003-2007.
- RakinicJ. Anal fissure . Clin Colon Rectal Surg. 2007;20(2):133-138.
See Also (Topic, Algorithm, Electronic Media Element)