eMedicine Specialties > Emergency Medicine > Gastrointestinal

Anal Fistulas and Fissures: Follow-up

Author: Ingrid Legall, MD, Assistant Professor, Department of Emergency Medicine, Florida Hospital-Flagler
Contributor Information and Disclosures

Updated: Jan 6, 2010

Follow-up

Further Inpatient Care

  • In the case of anal fissures, if the patient is having a great deal of pain, a topical anesthetic may be applied.
  • Depending on the presence of systemic symptoms and the condition of the patient, the patient with an anal fistula may require continued intravenous antibiotics, fluids, pressors, and, possibly, surgery.
  • Open lateral internal sphincterotomy is considered the treatment of choice for chronic anal fissure.10 It reduces the hypertonia of the internal anal sphincter, decreases pain, and allows the fissure to heal.

Further Outpatient Care

  • For anal fissures, the WASH regimen is indicated.
  • For anal fistulas, outpatient follow-up with a surgeon is indicated if consultation did not take place at the time of presentation.
  • Botulinum toxin injection has been shown to be an effective alternative to surgery for the treatment of uncomplicated idiopathic anal fissure.7
  • Topical application of clove oil cream has demonstrated significant benefit in patients with chronic anal fissure.
  • The application of topical 0.5% nifedipine ointment has been used as a chemical sphincterotomy agent. It has been shown to offer a significant healing rate for acute anal fissure and may prevent it from becoming a chronic fissure.

Inpatient & Outpatient Medications

  • Psyllium may be prescribed for patients with anal fissures.
  • For patients with anal fistulas, the following medications may be useful (if the patient is stable enough for discharge with outpatient follow-up):
    • Analgesics
    • Antipyretics
    • Antibiotics

Deterrence/Prevention

  • Stress the importance of diet modification to soften stools.
  • Patients should increase fruits, vegetables, and soluble and insoluble fibers in their diets and increase fluid intake.

Complications

  • Constipation or fecal impaction may occur.
  • The pain from an anal fissure can be so overwhelming that it discourages people from defecating.
  • Acute fissures can become chronic.
  • Sentinel pile can result.
  • Permanent skin tag can result.
  • Fistulas may form.
  • The following surgical complications may occur:5,1
    • Urinary retention
    • Bleeding
    • Abscess formation
    • Flatus and liquid incontinence
    • Recurrence of fissures
  • Without treatment, chronically infected fistulas may cause systemic illness.
  • Carcinoma has been reported in chronic untreated anorectal fistulas.

Prognosis

  • Most uncomplicated fissures resolve in 2-4 weeks with supportive care.
  • Fissures that heal with conservative treatment have a reoccurrence rate of up to 27%.
  • Chronic anal fissures frequently require surgical treatment.
  • Surgical treatment of anal fissures is associated with some degree of incontinence in 30% of patients.
  • Prognosis for fistulas is excellent after surgery.

Patient Education

Miscellaneous

Related guidelines
Practice parameters for the management of anal fissures (revised)

Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised)

Practice parameters for the evaluation and management of constipation

ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease

Medicolegal Pitfalls

  • Failing to consider sexual abuse as a possible cause for anal fissure in a child
  • Failing to refer the patient for further medical or surgical evaluation in the case of chronic anal fissure
 


More on Anal Fistulas and Fissures

Overview: Anal Fistulas and Fissures
Differential Diagnoses & Workup: Anal Fistulas and Fissures
Treatment & Medication: Anal Fistulas and Fissures
Follow-up: Anal Fistulas and Fissures
Multimedia: Anal Fistulas and Fissures
References
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References

  1. Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum. Jul 1996;39(7):723-9. [Medline].

  2. Kuehn HG, Gebbensleben O, Hilger Y, Rohde H. Relationship between anal symptoms and anal findings. Int J Med Sci. 2009;6(2):77-84. [Medline].

  3. North JH Jr, Weber TK, Rodriguez-Bigas MA, Meropol NJ, Petrelli NJ. The management of infectious and noninfectious anorectal complications in patients with leukemia. J Am Coll Surg. Oct 1996;183(4):322-8. [Medline].

  4. Nordgren S, Fasth S, Hulten L. Anal fistulas in Crohn's disease: incidence and outcome of surgical treatment. Int J Colorectal Dis. Dec 1992;7(4):214-8. [Medline].

  5. Oh C, Divino CM, Steinhagen RM. Anal fissure. 20-year experience. Dis Colon Rectum. Apr 1995;38(4):378-82. [Medline].

  6. Khan JS, Tan N, Nikkhah D, Miles AJ. Subcutaneous lateral internal sphincterotomy (SLIS)-a safe technique for treatment of chronic anal fissure. Int J Colorectal Dis. Jul 21 2009;[Medline].

  7. Brisinda G, Cadeddu F, Mazzeo P, Maria G. Botulinum toxin A for the treatment of chronic anal fissure. Expert Rev Gastroenterol Hepatol. Dec 2007;1(2):219-28. [Medline].

  8. Corno F, Marano A, Volpatto S, Mistrangelo P. [Topical use of glyceryl-trinitrate in the treatment of anal fissure]. Minerva Chir. Jun 2009;64(3):307-11. [Medline].

  9. Vila S, Garcia C, Piscoya A, De Los Rios R, L Pinto J, Huerta Mercado J, et al. [Use of glycerol trinitrate in an ointment for the management of chronic anal fissure at the National Hospital "Cayetano Heredia"]. Rev Gastroenterol Peru. Jan-Mar 2009;29(1):33-9. [Medline].

  10. Mousavi SR, Sharifi M, Mehdikhah Z. A comparison between the results of fissurectomy and lateral internal sphincterotomy in the surgical management of chronic anal fissure. J Gastrointest Surg. Jul 2009;13(7):1279-82. [Medline].

  11. Chung CC, Choi CL, Kwok SP, Leung KL, Lau WY, Li AK. Anal and perianal tuberculosis: a report of three cases in 10 years. J R Coll Surg Edinb. Jun 1997;42(3):189-90. [Medline].

  12. Farquharson M. Haemorrhoids, fissures and anal fistulae. Trop Doct. Oct 2002;32(4):196-201. [Medline].

  13. Isbister WH, Prasad J. Fissure in ano. Aust N Z J Surg. Feb 1995;65(2):107-8. [Medline].

  14. Jonas and Scholefield. American Gastroenterology Association. 2004.

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Further Reading

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Contributor Information and Disclosures

Author

Ingrid Legall, MD, Assistant Professor, Department of Emergency Medicine, Florida Hospital-Flagler
Ingrid Legall, MD is a member of the following medical societies: American Academy of Emergency Medicine and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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