Sections

Medication

Medication Summary

Medications may also be prescribed for anal fissures, such as topical nitrates, calcium channel blockers, and onabotulinumtoxinA injections, and are considered first-line therapy.^[18]These medications reduce anal sphincter tone, which, in turn, increases anodermal blood flow.

Antibiotics may be necessary for the treatment of anal fistulas, especially if the patient presents with systemic symptoms. Postoperative prophylactic antibiotic therapy for 7-10 days (eg, ciprofloxacin, metronidazole) appears to be a key part of preventing anal fistulas after incision and drainage of perianal abscess.^[56]

Class Summary

Psyllium facilitates easier passage of stools.

Psyllium (Fiberall, Metamucil, Konsyl, Reguloid, Natural Fiber Therapy)

View full drug information

Psyllium promotes bowel evacuation by forming a viscous liquid and promoting peristalsis.

Class Summary

Vasodilators that cause smooth muscle relaxation are used for relief of anal spasm.

Nitroglycerin rectal (Rectiv)

View full drug information

Organic nitrate is indicated for moderate to severe pain associated with chronic anal fissures. It elicits internal anal sphincter relaxation and reduces sphincter tone and resting intra-anal pressure.

Class Summary

These agents may potentiate the effects of gamma-aminobutyric acid (GABA) and facilitate inhibitory GABA neurotransmission.

Diazepam (Valium, Diastat)

View full drug information

Diazepam is indicated for the relief of severe anal sphincter spasms.

Class Summary

Antibiotic therapy must cover both aerobic and anaerobic gram-negative organisms.

Vancomycin

View full drug information

Vancomycin is a potent antibiotic that is directed against gram-positive organisms and is active against Enterococcus species. It is useful in the treatment of septicemia, enterocolitis, and skin-structure infections. Vancomycin is indicated for patients who are unable to receive or have not responded to penicillins and cephalosporins or for patients with resistant staphylococcus infections. Creatinine clearance measurements are used to adjust the dose in patients with renal impairment.

Metronidazole (Flagyl)

View full drug information

Metronidazole is active against various anaerobic bacteria and protozoa. It appears to be absorbed into cells. Intermediate metabolized compounds are formed and bind DNA and inhibit protein synthesis, causing cell death. The antimicrobial effect may be due to production of free radicals.

Ampicillin and sulbactam (Unasyn)

View full drug information

This drug combination of a beta-lactamase inhibitor with ampicillin interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Ticarcillin and clavulanate potassium (Timentin)

View full drug information

This drug combination of antipseudomonal penicillin plus a beta-lactamase inhibitor inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth. It provides coverage against most gram-positive, gram-negative, and anaerobic organisms.

Clindamycin (Cleocin)

View full drug information

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).

Class Summary

Calcium channel blockers work by decreasing resting anal pressures. In a recent review, calcium channel blockers were shown to be as effective as topical nitrates. Oral and topical calcium channel blockers (diltiazem and nifedipine) have been shown to be effective treatment options for anal fissures.

Nifedipine (Nifediac CC, Adalat CC, Procardia, Procardia XL)

View full drug information

Nifedipine is the prototypical dihydropyridine. The topical form is preferred but must be compounded in the pharmacy.

Diltiazem (Cardizem, Cardizem CD, Cartia XT, Dilacor XR, Tiazac)

View full drug information

Diltiazem is a nondihydropyridine that has been reported to be effective. The topical form is preferred but must be compounded in the pharmacy.

Class Summary

OnabotulinumtoxinA is used typically to treat muscle hypertonia and cosmetic disorders. Typically, onabotulinumtoxinA is injected into the internal sphincter, reducing hypertonia. Various dosing schemes have been used, and it is typically injected on both sides of the anal fissure. OnabotulinumtoxinA has been shown to be as effective as topical nitrates, but with fewer adverse effects, including headache, and can be an alternative to surgery.

OnabotulinumtoxinA (BOTOX)

View full drug information

OnabotulinumtoxinA is used typically to treat muscle hypertonia and cosmetic disorders. Typically, onabotulinumtoxinA is injected into the internal sphincter, reducing hypertonia.

Questions

Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014 Aug. 109(8):1141-57; (Quiz) 1058. [QxMD MEDLINE Link].
[Guideline] Wald A, Bharucha AE, Limketkai B, et al. ACG Clinical guidelines: management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1. 116(10):1987-2008. [QxMD MEDLINE Link]. [Full Text].
Garcia-Aguilar J, Belmonte C, Wong WD, Goldberg SM, Madoff RD. Anal fistula surgery. Factors associated with recurrence and incontinence. Dis Colon Rectum. 1996 Jul. 39(7):723-9. [QxMD MEDLINE Link].
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. 1997 Jun. 42(3):189-90. [QxMD MEDLINE Link].
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. 1996 Oct. 183(4):322-8. [QxMD MEDLINE Link].
Zaghiyan KN, Fleshner P. Anal fissure. Clin Colon Rectal Surg. 2011 Mar. 24(1):22-30. [QxMD MEDLINE Link].
Schouten WR, Briel JW, Auwerda JJ. Relationship between anal pressure and anodermal blood flow. The vascular pathogenesis of anal fissures. Dis Colon Rectum. 1994 Jul. 37(7):664-9. [QxMD MEDLINE Link].
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the inferior rectal artery: a possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989 Jan. 32(1):43-52. [QxMD MEDLINE Link].
Schouten WR, Briel JW, Auwerda JJ, De Graaf EJ. Ischaemic nature of anal fissure. Br J Surg. 1996 Jan. 83(1):63-5. [QxMD MEDLINE Link].
Nordgren S, Fasth S, Hulten L. Anal fistulas in Crohn's disease: incidence and outcome of surgical treatment. Int J Colorectal Dis. 1992 Dec. 7(4):214-8. [QxMD MEDLINE Link].
Hamalainen KP, Sainio AP. Incidence of fistulas after drainage of acute anorectal abscesses. Dis Colon Rectum. 1998 Nov. 41(11):1357-61; discussion 1361-2. [QxMD MEDLINE Link].
Abbas MA, Jackson CH, Haigh PI. Predictors of outcome for anal fistula surgery. Arch Surg. 2011 Sep. 146(9):1011-6. [QxMD MEDLINE Link].
Garg P, Garg M, Menon GR. Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis. Colorectal Dis. 2013 Mar. 15(3):e104-17. [QxMD MEDLINE Link].
van Koperen PJ, Wind J, Bemelman WA, Bakx R, Reitsma JB, Slors JF. Long-term functional outcome and risk factors for recurrence after surgical treatment for low and high perianal fistulas of cryptoglandular origin. Dis Colon Rectum. 2008 Oct. 51(10):1475-81. [QxMD MEDLINE Link].
Oh C, Divino CM, Steinhagen RM. Anal fissure. 20-year experience. Dis Colon Rectum. 1995 Apr. 38(4):378-82. [QxMD MEDLINE Link].
Kuehn HG, Gebbensleben O, Hilger Y, Rohde H. Relationship between anal symptoms and anal findings. Int J Med Sci. 2009. 6(2):77-84. [QxMD MEDLINE Link]. [Full Text].
Chang J, Mclemore E, Tejirian T. Anal health care basics. Perm J. 2016 Fall. 20(4):74-80. [QxMD MEDLINE Link]. [Full Text].
Perry WB, Dykes SL, Buie WD, Rafferty JF. Practice parameters for the management of anal fissures (3rd revision). Dis Colon Rectum. 2010 Aug. 53(8):1110-5. [QxMD MEDLINE Link].
Sahebally SM, Meshkat B, Walsh SR, Beddy D. Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta-analysis of randomized controlled trials. Colorectal Dis. 2018 Jan. 20(1):6-15. [QxMD MEDLINE Link].
Sarıısık AM, Karavana SY, Turkoglu GC, Rencber S, Onder T. Preparation and characterization of textile-based carrier systems for anal fissure treatment. J Microencapsul. 2017 Dec. 34(8):722-31. [QxMD MEDLINE Link].
Martellucci J, Rossi G, Corsale I, Carrieri P, D'Elia M, Giani I. Myoxinol ointment for the treatment of acute fissure. Updates Surg. 2017 Dec. 69(4):499-503. [QxMD MEDLINE Link].
Steele SR, Kumar R, Feingold DL, Rafferty JL, Buie WD. Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum. 2011 Dec. 54(12):1465-74. [QxMD MEDLINE Link].
de la Portilla F, Alba F, Garcia-Olmo D, et al. Expanded allogeneic adipose-derived stem cells (eASCs) for the treatment of complex perianal fistula in Crohn's disease: results from a multicenter phase I/IIa clinical trial. Int J Colorectal Dis. 2013 Mar. 28(3):313-23. [QxMD MEDLINE Link].
Rozalen V, Pares D, Sanchez E, et al. Advancement flap technique for anal fistula in patients with Crohn's disease: a systematic review of the literature [English, Spanish]. Cir Esp. 2017 Dec. 95(10):558-65. [QxMD MEDLINE Link].
[Guideline] Gecse KB, Bemelman W, Kamm MA, et al. A global consensus on the classification, diagnosis and multidisciplinary treatment of perianal fistulising Crohn's disease. Gut. 2014 Sep. 63(9):1381-92. [QxMD MEDLINE Link]. [Full Text].
Nelson RL, Thomas K, Morgan J, Jones A. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012 Feb 15. 2:CD003431. [QxMD MEDLINE Link].
Jonas M, Neal KR, Abercrombie JF, Scholefield JH. A randomized trial of oral vs. topical diltiazem for chronic anal fissures. Dis Colon Rectum. 2001 Aug. 44(8):1074-8. [QxMD MEDLINE Link].
Vaithianathan R, Panneerselvam S. Randomised prospective controlled trial of topical 2% diltiazem versus lateral internal sphincterotomy for the treatment of chronic fissure in ano. Indian J Surg. 2015 Dec. 77 (suppl 3):1484-7. [QxMD MEDLINE Link]. [Full Text].
Joshi MR, Bohara TP, Rupakheti S. Comparison of fissure healing and the incidence of headache among the patients treated with endo- and perianal application of 0.2% glyceryl trinitrate for chronic anal fissure. JNMA J Nepal Med Assoc. 2016 Oct-Dec. 55(204):45-50. [QxMD MEDLINE Link].
Carapeti EA, Kamm MA, McDonald PJ, Chadwick SJ, Melville D, Phillips RK. Randomised controlled trial shows that glyceryl trinitrate heals anal fissures, higher doses are not more effective, and there is a high recurrence rate. Gut. 1999 May. 44(5):727-30. [QxMD MEDLINE Link]. [Full Text].
Bailey HR, Beck DE, Billingham RP, et al. A study to determine the nitroglycerin ointment dose and dosing interval that best promote the healing of chronic anal fissures. Dis Colon Rectum. 2002 Sep. 45(9):1192-9. [QxMD MEDLINE Link].
Scholefield JH, Bock JU, Marla B, et al. A dose finding study with 0.1%, 0.2%, and 0.4% glyceryl trinitrate ointment in patients with chronic anal fissures. Gut. 2003 Feb. 52(2):264-9. [QxMD MEDLINE Link]. [Full Text].
Colak T, Ipek T, Urkaya N, Kanik A, Dirlik M. A randomised study comparing systemic transdermal treatment and local application of glyceryl trinitrate ointment in the management of chronic anal fissure. Eur J Surg Suppl. 2003 Jul. 18-22. [QxMD MEDLINE Link].
Ala S, Saeedi M, Hadianamrei R, Ghorbanian A. Topical diltiazem vs. topical glyceril trinitrate in the treatment of chronic anal fissure: a prospective, randomized, double-blind trial. Acta Gastroenterol Belg. 2012 Dec. 75(4):438-42. [QxMD MEDLINE Link].
Berkel AE, Rosman C, Koop R, van Duijvendijk P, van der Palen J, Klaase JM. Isosorbide dinitrate ointment vs botulinum toxin A (Dysport) as the primary treatment for chronic anal fissure: a randomized multicentre study. Colorectal Dis. 2014 Oct. 16(10):O360-6. [QxMD MEDLINE Link].
Lin JX, Krishna S, Su'a B, Hill AG. Optimal dosing of botulinum toxin for treatment of chronic anal fissure: a systematic review and meta-analysis. Dis Colon Rectum. 2016 Sep. 59(9):886-94. [QxMD MEDLINE Link].
Brisinda G, Cadeddu F, Mazzeo P, Maria G. Botulinum toxin A for the treatment of chronic anal fissure. Expert Rev Gastroenterol Hepatol. 2007 Dec. 1(2):219-28. [QxMD MEDLINE Link].
Jones OM, Ramalingam T, Merrie A, et al. Randomized clinical trial of botulinum toxin plus glyceryl trinitrate vs. botulinum toxin alone for medically resistant chronic anal fissure: overall poor healing rates. Dis Colon Rectum. 2006 Oct. 49(10):1574-80. [QxMD MEDLINE Link].
Elwakeel HA, Moneim HA, Farid M, Gohar AA. Clove oil cream: a new effective treatment for chronic anal fissure. Colorectal Dis. 2007 Jul. 9(6):549-52. [QxMD MEDLINE Link].
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. 2009 Oct. 24(10):1207-11. [QxMD MEDLINE Link].
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. 2009 Jul. 13(7):1279-82. [QxMD MEDLINE Link].
Sahebally SM, Walsh SR, Mahmood W, Aherne TM, Joyce MR. Anal advancement flap versus lateral internal sphincterotomy for chronic anal fissure- a systematic review and meta-analysis. Int J Surg. 2017 Dec 9. 49:16-21. [QxMD MEDLINE Link].
Cho DY. Controlled lateral sphincterotomy for chronic anal fissure. Dis Colon Rectum. 2005 May. 48(5):1037-41. [QxMD MEDLINE Link].
Rosa G, Lolli P, Piccinelli D, et al. Calibrated lateral internal sphincterotomy for chronic anal fissure. Tech Coloproctol. 2005 Jul. 9(2):127-31; discussion 131-2. [QxMD MEDLINE Link].
Mentes BB, Guner MK, Leventoglu S, Akyurek N. Fine-tuning of the extent of lateral internal sphincterotomy: spasm-controlled vs. up to the fissure apex. Dis Colon Rectum. 2008 Jan. 51(1):128-33. [QxMD MEDLINE Link].
Pelta AE, Davis KG, Armstrong DN. Subcutaneous fissurotomy: a novel procedure for chronic fissure-in-ano. a review of 109 cases. Dis Colon Rectum. 2007 Oct. 50(10):1662-7. [QxMD MEDLINE Link].
FitzDowse AJ, Behrenbruch CC, Hayes IP. Combined treatment approach to chronic anal fissure with associated anal fistula. ANZ J Surg. 2018 Jul-Aug. 88(7-8):775-8. [QxMD MEDLINE Link].
Quah HM, Tang CL, Eu KW, Chan SY, Samuel M. Meta-analysis of randomized clinical trials comparing drainage alone vs primary sphincter-cutting procedures for anorectal abscess-fistula. Int J Colorectal Dis. 2006 Sep. 21(6):602-9. [QxMD MEDLINE Link].
Ratto C, Litta F, Parello A, Donisi L, Zaccone G, De Simone V. Gore Bio-A® Fistula Plug: a new sphincter-sparing procedure for complex anal fistula. Colorectal Dis. 2012 May. 14(5):e264-9. [QxMD MEDLINE Link].
Liu WY, Aboulian A, Kaji AH, Kumar RR. Long-term results of ligation of intersphincteric fistula tract (LIFT) for fistula-in-ano. Dis Colon Rectum. 2013 Mar. 56(3):343-7. [QxMD MEDLINE Link].
Hall JF, Bordeianou L, Hyman N, et al. Outcomes after operations for anal fistula: results of a prospective, multicenter, regional study. Dis Colon Rectum. 2014 Nov. 57(11):1304-8. [QxMD MEDLINE Link].
Wright M, Thorson A, Blatchford G, et al. What happens after a failed LIFT for anal fistula?. Am J Surg. 2017 Dec. 214(6):1210-3. [QxMD MEDLINE Link].
Cheung FY, Appleton ND, Rout S, et al. Video-assisted anal fistula treatment: a high volume unit initial experience. Ann R Coll Surg Engl. 2018 Jan. 100(1):37-41. [QxMD MEDLINE Link].
Emile SH, Elfeki H, Shalaby M, Sakr A. A systematic review and meta-analysis of the efficacy and safety of video-assisted anal fistula treatment (VAAFT). Surg Endosc. 2018 Apr. 32(4):2084-93. [QxMD MEDLINE Link].
Hong Y, Xu Z, Gao Y, et al. Sphincter-preserving fistulectomy is an effective minimally invasive technique for complex anal fistulas. Front Surg. 2022. 9:832397. [QxMD MEDLINE Link]. [Full Text].
Ghahramani L, Minaie MR, Arasteh P, et al. Antibiotic therapy for prevention of fistula in-ano after incision and drainage of simple perianal abscess: A randomized single blind clinical trial. Surgery. 2017 Nov. 162(5):1017-25. [QxMD MEDLINE Link].
Wright M, Thorson A, Blatchford G, et al. Discussion of: "What happens after a failed LIFT for anal fistula?" [letter]. Am J Surg. 2017 Dec. 214(6):1214. [QxMD MEDLINE Link]. [Full Text].
Kang WH, Yang HK, Chang HJ, et al. High ligation of the anal fistula tract by lateral approach: A prospective cohort study on a modification of the ligation of the intersphincteric fistula tract (LIFT) technique. Int J Surg. 2018 Oct 19. 60:9-14. [QxMD MEDLINE Link].
Gold SL, Cohen-Mekelburg S, Schneider Y, Steinlauf A. Perianal fistulas in patients with Crohn's disease, Part 1: Current medical management. Gastroenterol Hepatol (N Y). 2018 Aug. 14(8):470-81. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Anal Fistulas and Fissures. This patient reported constipation.
Anal Fistulas and Fissures. Anal fissure present in a patient with Crohn disease.

of 2

Author

Bruce M Lo, MD, MBA, RDMS, FACEP, FAAEM, FACHE, FAAPL, CPE Chief, Department of Emergency Medicine, Sentara Norfolk General Hospital; Medical Director, Sentara Transfer Center; Professor and Assistant Program Director, Core Academic Faculty, Department of Emergency Medicine, Eastern Virginia Medical School; Board Member, American Academy of Emergency Medicine

Bruce M Lo, MD, MBA, RDMS, FACEP, FAAEM, FACHE, FAAPL, CPE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine, Emergency Nurses Association, Medical Society of Virginia

Disclosure: Nothing to disclose.

Coauthor(s)

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, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

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.

Eugene Hardin, 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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Anal Fistulas and Fissures Medication

Medication Summary

Laxatives, Bulk-Producing

Class Summary

Psyllium (Fiberall, Metamucil, Konsyl, Reguloid, Natural Fiber Therapy)

Psyllium (Fiberall, Metamucil, Konsyl, Reguloid, Natural Fiber Therapy)

Vasodilators

Class Summary

Nitroglycerin rectal (Rectiv)

Nitroglycerin rectal (Rectiv)

Anxiolytics, Benzodiazepines

Class Summary

Diazepam (Valium, Diastat)

Diazepam (Valium, Diastat)

Antibiotics

Class Summary

Vancomycin

Vancomycin

Metronidazole (Flagyl)

Metronidazole (Flagyl)

Ampicillin and sulbactam (Unasyn)

Ampicillin and sulbactam (Unasyn)

Ticarcillin and clavulanate potassium (Timentin)

Ticarcillin and clavulanate potassium (Timentin)

Clindamycin (Cleocin)

Clindamycin (Cleocin)

Calcium Channel Blockers

Class Summary

Nifedipine (Nifediac CC, Adalat CC, Procardia, Procardia XL)

Nifedipine (Nifediac CC, Adalat CC, Procardia, Procardia XL)

Diltiazem (Cardizem, Cardizem CD, Cartia XT, Dilacor XR, Tiazac)

Diltiazem (Cardizem, Cardizem CD, Cartia XT, Dilacor XR, Tiazac)

Neuromuscular Blockers, Botulinum Toxins

Class Summary

OnabotulinumtoxinA (BOTOX)

OnabotulinumtoxinA (BOTOX)

Anal Fistulas and Fissures Medication

Medication Summary

Laxatives, Bulk-Producing

Class Summary

Psyllium (Fiberall, Metamucil, Konsyl, Reguloid, Natural Fiber Therapy)

Vasodilators

Class Summary

Nitroglycerin rectal (Rectiv)

Anxiolytics, Benzodiazepines

Class Summary

Diazepam (Valium, Diastat)

Antibiotics

Class Summary

Vancomycin

Metronidazole (Flagyl)

Ampicillin and sulbactam (Unasyn)

Ticarcillin and clavulanate potassium (Timentin)

Clindamycin (Cleocin)

Calcium Channel Blockers

Class Summary

Nifedipine (Nifediac CC, Adalat CC, Procardia, Procardia XL)

Diltiazem (Cardizem, Cardizem CD, Cartia XT, Dilacor XR, Tiazac)

Neuromuscular Blockers, Botulinum Toxins

Class Summary

OnabotulinumtoxinA (BOTOX)

References

Tables

Contributor Information and Disclosures

What would you like to print?