Anal Fistulas and Fissures Follow-up
- Author: Ingrid Legall, MD; Chief Editor: Robert E O'Connor, MD, MPH more...
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.[11] 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
- Diet modification is indicated in the case of anal fissures.
- For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Anal Abscess, Rectal Pain, and Rectal Bleeding.
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