eMedicine Specialties > Emergency Medicine > Gastrointestinal
Anal Fistulas and Fissures: Treatment & Medication
Updated: Aug 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Emergency Department Care
- Use the WASH regimen in treatment of anal fissures.
- Warm water; shower or sitz bath after bowel movement
- Analgesics
- Stool softener
- High-fiber diet
- Most uncomplicated fissures resolve in 2-4 weeks with supportive care. Chronic anal fissures frequently require surgical treatment.5
- All surgical procedures involve stretching or cutting the internal sphincter. The most common surgical procedure is lateral internal sphincterotomy.5,6 Botulinum toxin has also been used with great success for treatment of anal fissures.7
- Treatment of anal fistulae depends on (1) presentation of the patient, (2) evidence of sepsis or a large abscess, or (3) no worrisome findings on physical examination.
- Administer intravenous antibiotics, antipyretic, and analgesic as needed.
- If the patient is septic with hypotension, intravenous fluids or a pressor may be necessary.
Consultations
- Consultation usually is not necessary for anal fissures.
- An emergent surgical consultation may be necessary for fistulous abscess.
- Consult a gastroenterologist if inflammatory bowel disease is suspected.
Medication
For treatment of anal fissures, no medication other than stool softeners is necessary to facilitate less painful passage of stool during acute disease. Anal fissures can cause a vicious cycle in which the patient, in anticipation of pain associated with bowel movement, resists the urge to defecate, causing stools to become larger and harder; more pain with defecation results.
Antibiotics may be necessary for treatment of anal fistulas, especially if the patient presents with systemic symptoms.
Laxative/bulking agent
This agent facilitates easier passage of stools.
Psyllium (Fiberall, Metamucil, Konsyl)
Promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.
Adult
1-2 wafers, 1-2 packets, or 1-2 rounded tsp dissolved in 240 mL of liquid tid
Pediatric
<6 years: Not recommended
6-12 years: 0.5-1 rounded tsp dissolved in 120 mL of liquid tid
>12 years: Administer as in adults
May decrease the absorption and effects of salicylates, nitrofurantoin, tetracyclines, and diuretics
Documented hypersensitivity; fecal impaction; intestinal obstruction; undiagnosed abdominal pain
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Intestinal adhesions, ulcers, stenosis
Muscle relaxant
This agent is used for relief of anal spasm.
Diazepam (Valium)
Indicated for the relief of severe anal sphincter spasms.
Adult
5 mg/kg/d PO tid prn spasm
5-10 mg slow IV/IM
Pediatric
0.12-0.8 mg/kg/d PO tid prn spasm
Potentiates CNS depression with alcohol or other CNS depressant; increased serum level with cimetidine; potentiated by sertraline
Documented hypersensitivity; acute narrow-angle glaucoma
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not for use in untreated open-angle glaucoma; may increase tonic-clonic seizures; do not use with small vein
Antibiotics
Therapy must cover both aerobic and anaerobic gram-negative organisms.
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who are unable to receive or who have not responded to penicillins and cephalosporins or for infections with resistant staphylococci. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.
Adult
0.5 g IV q6h or 1 g IV q24h
Pediatric
Neonates:
<7 days and >2000 grams: 30 mg/kg/d IV divided q12h
>7 days and >2000 grams: 45 mg/kg/d IV divided q8h
<1 month and <1200 grams: 15 mg/kg/d IV q24h
<1 month and 1200-2000 grams: 20-30 mg/kg/d IV divided q12-18h
Infants >1 month and children: 40 mg/kg/d IV divided q8h
Seriously ill cancer patients and patients with suspected infection of the CNS: 60 mg/kg/d IV divided q6h
The necessity of monitoring drug levels is debated; in order to achieve an adequate therapeutic level in severe infections, the upper range of the peak (40 mcg/mL) should be reached
Erythema, histamine-like flushing and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few minutes) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction
Metronidazole (Flagyl)
Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells. Intermediate metabolized compounds are formed and bind DNA and inhibit protein synthesis, causing cell death. Antimicrobial effect may be due to production of free radicals.
Adult
Load 1 g or 15 mg/kg IV, then 500 mg or 7.5 mg/kg IV/PO q6h
Pediatric
7.5 mg/kg IV/PO q6h
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Adult
1.5-3 g IV/IM q6-8h
Pediatric
<3 months: Not established
3 months to 12 years: 100-200 mg/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Ticarcillin and clavulanate potassium (Timentin)
Inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth; antipseudomonal penicillin plus a beta-lactamase inhibitor that provides coverage against most gram-positive, gram-negative, and anaerobic organisms.
Adult
3.1 g IV q6h
Pediatric
75 mg/kg IV q6h
Tetracyclines may decrease effects of ticarcillin; high concentrations of ticarcillin may physically inactivate aminoglycosides if administered in same IV line; probenecid may increase penicillin levels; effects of this drug when administered concurrently with aminoglycosides are synergistic
Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with oral penicillin during acute stage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Perform CBC prior to initiation of therapy; if renal impairment is known or suspected, adjust dose and monitor blood levels to avoid possible neurotoxic reactions
Clindamycin (Cleocin)
Clindamycin is effective in the treatment of anaerobic bacteria. It has been shown to have superior effectiveness against streptococci and staphylococci. It continues to be effective against methicillin-resistant Staphylococcus aureus (MRSA).
Adult
600-900 mg IV q6h
Pediatric
2-4 mg/kg IV q6h
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
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
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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].
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].
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].
Oh C, Divino CM, Steinhagen RM. Anal fissure. 20-year experience. Dis Colon Rectum. Apr 1995;38(4):378-82. [Medline].
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].
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].
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].
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].
Farquharson M. Haemorrhoids, fissures and anal fistulae. Trop Doct. Oct 2002;32(4):196-201. [Medline].
Isbister WH, Prasad J. Fissure in ano. Aust N Z J Surg. Feb 1995;65(2):107-8. [Medline].
Jonas and Scholefield. American Gastroenterology Association. 2004.
Further Reading
Keywords
fissure-in-ano, anal tear, anorectal disorder, intersphincteric fistula, transsphincteric fistula, suprasphincteric fistula, extrasphincteric fistula, anorectal abscess, rectal bleeding, rectal pain, bloody stools, pruritus, malodorous perianal drainage, perianal pain, sentinel pile, enlarged anal papillae, skin tag, acute fistulous abscess, chronic diarrhea, habitual use of cathartics, perianal abscesses, ischiorectal abscesses, syphilis, sexually transmitted diseases, tuberculosis, leukemia, inflammatory bowel disease, Crohn disease, diverticulitis, actinomycosis, chlamydia, lymphogranuloma venereum, LGV, radiation exposure, HIV, anorectal fistula
