What is the diagnosis and treatment for a 46-year-old male patient with a one-month history of anal pain and burning, previously treated with Lidex (fluocinonide) for a similar issue, with a past medical history (PMH) of hemorrhoids, presenting with two small external anal cuts, and currently experiencing daily bowel movements (BMs)?

From the Guidelines

I strongly recommend a comprehensive approach for this 46-year-old male with anal fissures, prioritizing conservative management to reduce morbidity, mortality, and improve quality of life. The treatment plan includes sitz baths 2-3 times daily for 10-15 minutes using warm water to soothe the area and promote healing, as suggested by the American Gastroenterological Association 1.

• Fiber-lax (psyllium) should be taken daily to soften stool and prevent constipation.
• Docusate sodium (Colace) 100mg twice daily will further soften stool to reduce pain during bowel movements.
• Anusol-HC cream should be applied to the affected area 2-3 times daily for up to two weeks to reduce inflammation and discomfort. The patient should increase water intake to at least 8 glasses daily and consider adding more dietary fiber through fruits, vegetables, and whole grains. This regimen addresses the anal fissures by reducing pain, promoting healing, and preventing recurrence through softer stools. The hydrocortisone in Anusol-HC reduces inflammation while the emollient base soothes the area. If symptoms don't improve within two weeks, the patient should return for reevaluation as persistent fissures may require additional treatment, such as topical therapy with calcium channel blockers or botulinum toxin, as recommended by recent guidelines 1. It is essential to note that the patient's past medical history of hemorrhoids is relevant, but the current symptoms and physical examination suggest anal fissures as the primary diagnosis, and the treatment plan should focus on managing this condition, as supported by the American Gastroenterological Association's medical position statement 1.

From the Research

Patient Presentation and Treatment

• The patient presents 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 reports daily bowel movements (BMs).
• Observation of the patient revealed two external small cuts on the anal area, with no hemorrhoids or bleeding noted.
• The treatment plan includes sitz baths, fiber-lax, Colace, and Anusol-HC Cream.

Anal Fissure Treatment Options

• According to 2, anal fissure is a common anorectal complaint, and its treatment options include conservative therapy, such as dietary fiber and sitz baths, as well as surgical interventions.
• The study 3 found that medical therapies, such as topical nitrates, calcium channel blockers, and botulinum toxin injection, can be effective in treating anal fissure, but may have varying degrees of efficacy and adverse events.
• The review 4 notes that half of all patients with anal fissures heal with nonoperative management, such as high fiber diet, sitz baths, and pharmacological agents.
• The systematic review and meta-analysis 5 compared various treatment options for anal fissure, including surgical and non-surgical procedures, and found that partial lateral internal sphincterotomy (LIS) was superior to non-surgical therapies in achieving sustained cure of fissure.

Treatment Rationale

• The treatment plan for the patient is consistent with the recommendations for anal fissure treatment, which include conservative measures such as sitz baths and fiber-lax to promote healing and prevent further irritation.
• The use of Anusol-HC Cream may help to reduce inflammation and promote healing of the anal fissure, as suggested by 6.
• The patient's history of hemorrhoids and daily BMs may be relevant to the development of anal fissure, and the treatment plan takes into account the need to manage these factors to promote healing and prevent recurrence.