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Niiijrse Prescribing, 2006/2007 Vol 4 No 11
Table 1
Causes and symptoms of an anal fissure (Porrett et al,
2003; Lund et ai, 2006)
Causes
• Habitual use of laxatives
• Constipation
• Diarrhoea
Symptoms
• Sudden, severe pain in and around anus, ofen occurring during, or shortly after, bowel movement
• 'Sentinel pile': a small tag of skin that develops on the edge of the anus where the fissure lies
Glyceryl trinitrate ointment fissure were unlicensed for that use. Both diltiazam
Glyceryl trinitrate (GTN) ointment has been used to and GTN 0.2% had to be prepared at the request
produce a chemical sphincterotomy with varied heal- of doctors and could only be prescribed within
ing rates of up to 86% in some studies (DasGupta et secondary care. Diltiazam is still unlicensed for use
al, 2002; Lund et al, 2006). In the recent Cochrane but Rectogesic (GTN 0.4%) was launched in June
review GTN was found to be significantly better than 2005 in the UK and was the first licensed topical
placebo in healing fissures (Nelson, 2006). However, treatment for the pain management of chronic anal
up to 80% of patients develop headaches during fissure. Unlike GTN 0.2%, Rectogesic is a standard
treatment and this can lead to poor compliance unit dose and therefore provides consistent qual-
(DasGupta et al, 2002). Although the concentration ity, supply and dose. The most common adverse
of GTN has not been found to affect outcomes, event was dose-related headache which occurred
education of how to use it does (Brown et al, 2001). with an incidence of 50% (Rectogesic Summary of
It should be used 2-3 times daily for 6-8 weeks to Product Characteristics, 2005). It can be prescribed
improve outcomes. Nurses should inform patients in both primary and secondary care and can also be
of the side-effects, and that they do improve with prescribed by nurse prescribers as well as by our
time to help promote compliance (Nelson, 2006). medical colleagues. This makes it easier and quicker
The headaches experienced are temporary and relief for patients to obtain treatment and, therefore, relief
from these headaches can be achieved with simple of symptoms.
oral analgesia (Lund et al, 2006). According to the treatment algorithm, if the fissure
remains unhealed after 6-8 weeks, patients should
Calcium channel blockers be referred to secondary care for consideration of
Diltiazem, a calcium channel blocker, has been further pharmacological treatment or surgery.
evaluated as an alternative treatment to GTN with
up to 75% healing rates observed (Brown et al, Surgery
2001). In the Cochrane review there was insuf- Evidence has suggested that surgical sphincterotomy
ficient evidence to conclude the effectiveness of is an excellent treatment for chronic anal fissure as
diltiazem but several studies have found that it is it relieves the symptoms and has a low recurrence
equally effective in healing anal fissure compared rate (Brown et al, 2001; Richard et al, 2002). Surgery
with GTN (Bielecki and Kolodziejczak, 2002); this is can lead to rapid healing in 90-95% of patients
though to result from increased compliance as fewer (Lund et al, 2006). However, there is an increased
side-effects occur. risk of anal incontinence from surgery, with the inci-
Until recently the topical treatments for anal dence ranging from 8% to 39% (Brown et al, 2001;
lion A
Patient history and external examination
First-line treatment*:
Licensed: topical GTN 0.4%, Analgesics (local >
Unlicensed: GTN 0.2%, ISDN, calcium channel blocker inn
bulking »»»»- anaesthetic, NSAiDs)
agents and dietary modifications ^ if pain extreme
Healed:
z \
6-8 weeks 6-8 weeks
X
Unhealed and
irid
;ic or
asymptomatic
\
\
V discharge I Unhealedand \ sment I
some improvement
\ I V symptomatic |
L Refer to
secondary care
\
]
therapy
Unhealed: refer to
secondary care
Nelson, 2006). It is because of these risks that These methods, along with a nurse-led education
alternatives to surgery, such as topical GTN, were can be effective in relieving anal fissure and should
sought to reduce the anal canal pressure and always be considered along with other treatments of
spasm. fissure (Porrett and Lumiss, 2001; Porrett et al, 2003;
Lund et al, 2006).
Nursing management of anal
fissure Nurse prescribing for anal fissure
It is now accepted that many areas of treatment Before May 2006, :he British National Formulary
for common coloproctological conditions can be (BNF) nurse prescriDers' extended formulary was
managed by a suitably trained nurse practitioner very limited. Independent prescribers couid only
(Porrett, 1996; Porrett et al, 2003; Lewis et al, prescribe from a set list of conditions and from a
2004; Fitzgerald-Smith et ai, 2005). In 2002 Porrett iimited number of medications. The only condition
et al published a study looking specifically at the a nurse prescriber couid independently prescribe
management of anal fissure by nurses. The authors for was constipatiori, from within the gastro-intes-
concluded that patients respond more positively tinal conditions (BNF, 2006). Specifically, with the
to a nurse practitioner compared with a doctor, as management of anal fissure in mind, this would
nurses were able to offer more time for discussion, allow the prescription of a buik-forming laxative
information giving and education. but neither of the topical treatments for anal fissure
I
In terms of management, treating the cause is a (GTN or diltiazem). Under supplementary prescrib-
good piace to start. This involves encouraging the ing any drug could be prescribed, but within the
patient to increase fibre intake often using a bulk colorectal clinic the jse of supplementary prescrib-
laxative, and ensuring a high fiuid intake to make a ing has iimited effeci iveness as the doctor agreeing
soft stool (Brown et al, 2001; Lund et al, 2006). to the supplementary plan had to diagnose the
KEY POINTS
•Anal fissure Is a common, benign condition that affects otherwise healthy adults. It is a split in the
lower part of the anal canal extending from the anal verge towards the dentate line.
• A fissure often starts following a bout of constipation or diarrhoea. In approximately 10% of cases the
fissure occurs during childbirth.
•Typically patients present with rectal bleeding or severe pain on defecation.
•Medical treatment options include calcium channel blockers, such as diltiiazem and glyceryl trinitrate.
• I n 2005, a European team of colorectal clinicians met with the aim of developing an evidence-based
treatment algorithm for anal fissure to be used in both primary and secondary care.
•The treatment algorithm recommends that first-line treatment shold be based on licensing availability,
costs and contraindications.
•The publication of these guideiines has enabled primary care teams to initiate first-line treatment by
providing them with an evidence base on which to make their decisions.
management of persistent and recurrent chronic anal anal fissure. Br J Surg 84: 1723-1724
fissures. Colorectal Dis 4: 226-232 Lund JN, Nystrom PO Coremans G, Karaitianos I, Spyrou
DasGupta R, Franklin I, Pitt J, Dawson PM (2002) Successful M, Schouten WR, Sebastion /W, Pescatori M (2006) An
treatment of chronic anal fissure with diltiazem gel. evidence-based treatment algorithm for anal fissure.
Colorectal Dis 4: 20-22 Tech Coloproctol io|: 176-179
Department of Health (2006) Improving patients' access to Maruthachalam K, Stoker E, Nicholson G, Horgan AF (2006)
medicines; a guide to implementing nurse and pharmacist Nurse-led flexible s gmoidoscopy in primary care - the
independent prescribing within the NHS. Department of first thousand patients. Colorectal Dis 8: 557-562
Health, London Nelson R (2006) Non surgical therapy for anal fissure
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Hyman N (2004) Incontinence after lateral anal management of patients with first and second degree
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