What is the best course of treatment for a 46-year-old male patient with a history of hemorrhoids, presenting with anal pain and burning sensation, despite using hydrocortisone cream, suppositories, and Preparation H (phenylephrine) cream, and found to have two small external anal fissures?

From the Guidelines

I strongly recommend against prescribing topical nitroglycerin as the first line of treatment for this 46-year-old male patient with anal fissures, and instead suggest a combination of dietary and lifestyle modification and medical therapy for 6-8 weeks before considering surgical treatment. The patient's presentation with small anal cuts and burning pain is consistent with anal fissures, and his previous treatments with hydrocortisone, suppositories, and Preparation H have been ineffective because they target hemorrhoids rather than fissures. According to the most recent guidelines 1, surgical treatment is not recommended for acute anal fissure, and instead, a combination of dietary and lifestyle modification and medical therapy should be tried for 6-8 weeks before considering surgical treatment.

Treatment Approach

• The patient should be advised to increase fiber intake, adequate hydration, and stool softeners to prevent constipation and further trauma to the area.
• Medical therapy, such as topical calcium channel blockers, can be considered as an alternative to topical nitroglycerin, as they have been shown to be as effective with fewer side effects 1.
• If no improvement occurs within 6-8 weeks, the patient should return for reevaluation, and surgical options, such as lateral internal sphincterotomy, can be considered 1.

Rationale

• The patient's symptoms are consistent with anal fissures, and the diagnosis can be made based on the presence of small anal cuts and burning pain.
• The patient's previous treatments have been ineffective, and a new treatment approach is needed.
• The most recent guidelines recommend a combination of dietary and lifestyle modification and medical therapy for 6-8 weeks before considering surgical treatment 1.
• Surgical treatment, such as lateral internal sphincterotomy, has been shown to be effective in treating chronic anal fissures, with a healing rate of over 90% 1.

From the Research

Patient Presentation

• The patient is a 46-year-old male presenting with pain and burning in the anal area, which started a month ago and feels like little burning cuts.
• The patient has a past medical history (PMH) of hemorrhoids and has experienced this issue before, for which he was prescribed Lidex.
• The patient reports daily bowel movements (BMs) and has been using various treatments such as hydrocortisone cream, suppositories, and Preparation H cream without improvement.

Observed Symptoms

• Two external small cuts were observed on the patient's anal area.
• The patient's symptoms are consistent with anal fissure, which is a common anorectal condition characterized by a longitudinal tear in the anoderm under the dentate line 2.

Treatment Options

• Topical nitroglycerin has been prescribed for the patient, which is a common medical therapy for anal fissure 3, 4.
• Other treatment options for anal fissure include topical calcium channel blockers, botulinum toxin injection, and surgical sphincterotomy 3, 5, 6.
• The choice of treatment depends on the severity and persistence of the fissure, as well as the patient's individual needs and medical history.

Efficacy of Treatment Options

• Topical nitroglycerin has been shown to be marginally but significantly better than placebo in healing anal fissure, with a healing rate of 48.9% vs. 35.5% 3.
• Botulinum toxin injection and topical calcium channel blockers have also been shown to be effective in treating anal fissure, with fewer adverse events than topical nitroglycerin 3, 6.
• Surgical sphincterotomy is a highly effective treatment option for chronic anal fissure, but it carries a risk of incontinence 3, 6.