From the Guidelines
Anal fissures, tenesmus, and abdominal distension require a comprehensive approach to management, focusing on conservative measures as the initial step, with a strong emphasis on fiber supplementation, adequate hydration, and topical treatments, as evidenced by the American Gastroenterological Association's medical position statement 1.
Initial Management
For anal fissures, the initial management should include:
- Sitz baths 2-3 times daily to help relax the anal sphincter and increase blood flow to the area
- Increased fiber intake (25-30g daily) to soften stool and reduce straining during bowel movements
- Adequate hydration to prevent constipation
- Topical treatments such as nitroglycerin 0.2% ointment applied to the anal area twice daily or diltiazem 2% cream to help relax the anal sphincter and promote healing
Additional Measures
Over-the-counter stool softeners like docusate sodium (100mg twice daily) can prevent further trauma during bowel movements. For persistent tenesmus, antispasmodics such as hyoscyamine (0.125mg every 4 hours as needed) may provide relief. Abdominal distension often responds to simethicone (80-125mg after meals and at bedtime) and avoiding gas-producing foods.
Monitoring and Further Evaluation
If symptoms persist beyond 2 weeks despite these measures, or if you experience severe pain, bleeding, fever, or weight loss, seek immediate medical evaluation as these could indicate inflammatory bowel disease, infection, or other serious conditions, as highlighted in the WSES consensus guidelines on sigmoid volvulus management 1.
Considerations
It's essential to consider the potential for underlying conditions such as sigmoid volvulus, which can present with similar symptoms, and the importance of diagnostic imaging, including plain abdominal radiographs and CT scans, in cases where the diagnosis is in doubt or complications are suspected 1.
Prioritization
The priority in managing these symptoms is to alleviate discomfort, prevent further complications, and address any underlying conditions that may be contributing to the symptoms, with a focus on conservative management as the initial approach, as supported by the most recent and highest quality evidence 1.
From the Research
Symptoms of Anal Fissures
- Anal fissures can cause painful defecation and bleeding per anum 2
- Patients with anal fissures may present to general and colorectal clinics with symptoms, and can even present acutely to hospital 3
Treatment of Anal Fissures
- Conservative remedies have healing rates of up to 85% and have largely replaced surgery as first-line management 3
- Treatment options for chronic fissures are generally based on reducing the anal pressures and include non-surgical and surgical modalities 2
- Lateral internal sphincterotomy remains the gold standard for definitive management of anal fissure, though anal incontinence is a serious complication of the procedure 2