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CLINICAL
Jenny StewartColorectal Nurse Practitioner,
Nottingham UniversityHospitals, Queens MedicalCentre Campus,
Department
of Colorectal SurgeryEmail: jenny.stewart@nuh.
nhs.uk
ABSTRACT
Role of the nurse prescriberin managing anal fissure
A nal f issure is a common, benign condit ionthat often affects
young, otherwise healthyadults (Jonas et al, 2002). They are
characterisedby pain on defecation and anal bleeding (Porrettet al,
2003; Lund et al, 2006). A fissure is a splitin the lower part of
the anal canal extending fromthe anal verge towards the dentate l
ine. Most fis-sures are posterior, but anterior fissures are
alsoseen in women.
The cause of a fissure is not always clear, but afissure often
starts following a bout of either con-stipation or diarrhoea
(Jones, 1999). Some healspontaneously but many become chronic,
causingmonths of misery for the patient. A fissure is
usuallyconsidered t o be acute if it has been present for lessthan
6 weeks , and chronic if present for more than 6weeks (Prodigy,
2006).
Approximately 87% of chronic sufferers arebetween 20 and 60
years old. In approximately10 % of cases the fissure occurs during
childbirth(Prodigy, 2006).SymptomsTypically patients present with
rectal bleeding, whichthey often believe to be caused by
haemorrhoids,or severe pain on defecation. It has regularly
beendescribed by patients as 'like passing glass'. Thereis also an
associated burning pain that may lingerfor several hours after
defecation in some patients(Lund et al, 2006). These symptoms
significantlyimpair quality of life. Successful treatment of
analfissure means improvement of quality of life (Griffinet al ,
2002; Hyman, 2004) Patients with fissures gen-erally have internal
anal sphincter tightness leading
In December 2005 a team of colorectal clinicians from across
Europe metwith the aim of developing an evidence-bas ed treatment
algorithm for analfissure, to be used in both primary and secondary
care. In this article, Je nnyStewart explores its implications for
the m anagem ent of a nal fissure by
to raised resting canal pressure and anal spa(Lund and
Scholefield, 1997; Jonas et al, 20and treatment shou d be directed
at reducing thefactors (Jonas et alactivity and restingwith either
surgicai
, 2002). Internal anal sphincanal pressure can be reducor
pharmacological treatme
(Bielecki and Kolodziejczack, 2002).Medical management of
analfissureBefore the algorithm, treatment for anal fissvaried from
clinician to clinician and many trement centres followed guidelines
based on loexperience (Lund et al, 2006) Treatment for anal sure
was dependent on which clinician trained colorectal nurse
practitioner. Without any clguidelines this could not improve.
Some doctors in primary care are highly comtent in fissure
diagriosis and management, wherothers are not so confident.
However, the publicatof this treatment algorithm now provides
evidenbased guidance to help health care professiondecide on the
most appropriate treatment.
the European algorithm for aAlgorithmThe development o'fissure
managemerit has benefits for all concernMost importantly the
patients can receive fast reof their symptoms^ as it allows them to
recefirst line treatment within primary care. It can adelay or stop
the rieed for a referral to secondcare. Often referrals into
secondary care can tmany weeks and during this time a patient canin
severe pain. Haying an algorithm gives primcare doctors and nurses
the knowledge to optimtreat anal fissures n the best way possible,
whin turn will reduce the pressure and waiting timessecondary
care.Treatment optionsOn presentation, the patient is assessed
andfull history is taker|. On diagnosis of anal fissur
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Table 1Causes and symptoms of an anal fissure (Porrett et
al,2003; Lund et ai, 2006)Causes Habitual use of laxatives
Constipation Diarrhoea Injury to anal canal during labour
Symptoms Sud den, severe pain in and around anus, ofen occu
rring during , or shortly after, bowel m ovement Streak of blood on
toilet paper 'Sentinel pi le ': a small tag of skin that develop s
on the edge of the anus where the fissure lies
Glyceryl trinitrate ointmen tGlyceryl trinitrate (GTN) ointment
has been used toproduce a chemical sphincterotomy with varied
heal-ing rates of up to 86% in some studies (DasGupta etal , 2002;
Lund et al, 2006). In the recent Cochranereview GTN was found to be
significantly better thanplacebo in healing fissures (Nelson,
2006). However,up to 80% of patients develop headaches
duringtreatment and this can lead to poor compliance(DasGupta et
al, 2002). Although the concentrationof GTN has not been found to
affect outcomes,education of how to use it does (Brown et al,
2001).It should be used 2-3 times daily for 6-8 weeks toimprove
outcomes. Nurses should inform patientsof the side-effects, and
that they do improve withtime to help promote compliance (Nelson,
2006).The headaches experienced are temporary and relieffrom these
headaches can be achieved with simpleoral analgesia (Lund et al,
2006).
Calcium channel blockersDiltiazem, a calcium channel blocker,
has beenevaluated as an alternative treatment to GTN withup to 75%
healing rates observed (Brown et al,2001). In the Cochrane review
there was insuf-ficient evidence to conclude the effectiveness
ofdiltiazem but several studies have found that it isequally
effective in healing anal fissure comparedwith GTN (Bielecki and
Kolodziejczak, 2002); this isthough to result from increased
compliance as fewerside-effects occur.
fissure were unlicensed for that use. Both diltiazamand GTN 0.2%
had to be prepared at the requestof doctors and could only be
prescribed withinsecondary care. Diltiazam is still unlicensed for
usebut Rectogesic (GTN 0.4%) was launched in June2005 in the UK and
was the first licensed topicaltreatment for the pain management of
chronic analfissure. Unlike GTN 0.2%, Rectogesic is a standardunit
dose and therefore provides consistent qual-ity, supply and dose.
The most common adverseevent was dose-related headache which
occurredwith an incidence of 50% (Rectogesic Summary ofProduct
Characteristics, 2005). It can be prescribedin both primary and
secondary care and can also beprescribed by nurse prescribers as
well as by ourmedical colleagues. This makes it easier and
quickerfor patients to obtain treatment and, therefore, reliefof
symptoms.
According to the treatment algorithm, if the fissureremains
unhealed after 6-8 weeks, patients shouldbe referred to secondary
care for consideration offurther pharmacological treatment or
surgery.SurgeryEvidence has suggested that surgical
sphincterotomyis an excellent treatment for chronic anal fissure
asit relieves the symptoms and has a low recurrencerate (Brown et
al, 2001; Richard et a l, 2002). Surgerycan lead to rapid healing
in 90-95% of patients(Lund et al, 2006). However, there is an
increasedrisk of anal incontinence from surgery, with the inci-
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CLINICAL
Primary care manage ment o f chronic anal fissureAdapted from
and approved by: Lund JN et al. An evidence-based treatment
algorithm tor anal10 : 176-179. Reproduced vwith permission from
Springer .
Patient history and external examination
Also recurrentuncomplicatedanal fissures
lion A
Idiopathic anal fissure(first presentation, no history ofCrohn's
disease, HIV infection, etc)
issune. Tech Coloproctol 2006;
First-line treatm ent*:Licensed: topical GTN 0.4%,Unlicensed:
GTN 0.2% , ISD N, calcium channel blockeragents and dietary
modifications bulkingnn -z 6-8 weeks Analgesics (local
>anaesthetic, NSAiDs)^ if pain extreme6-8 weeks
Healed: \ XV discharge I Unhealedand \\ I V symptomatic |
L Refer to \secondary care ]
Unhealed andasymptomatic orsome improvementird \;ic or \sment
I
Second 6-8 weekcourse of topicaltherapy
Unhealed: refer tosecondary care
"according to licensing availability, costs and
contraindicationsGTN - glyoeryl trinitrate; ISDN - isosorbide
dinitrate; NSAIDs - non-steroidal anti-inflamma toty drugs
Nelson, 2006). It is because of these risks thatalternatives to
surgery, such as topical GTN, weresought to reduce the anal canal
pressure andspasm.Nursing management of analfissureIt is now
accepted that many areas of treatmentfor common coloproctological
conditions can bemanaged by a suitably trained nurse
practitioner(Porrett, 1996; Porrett et al, 2003; Lewis et al,2004;
Fitzgerald-Smith et ai, 2005). In 2002 Porrettet al published a
study looking specifically at themanagement of anal fissure by
nurses. The authorsconcluded that patients respond more
positivelyto a nurse practitioner compared with a doctor, asnurses
were able to offer more time for discussion,information giving and
education.
In terms of management, treating the cause is agood piace to
start. This involves encouraging thepatient to increase fibre
intake often using a bulklaxative, and ensuring a high fiuid intake
to make a
These methods, along with a nurse-led educatican be effective in
relieving anal fissure and shoualways be considered along with
other treatmentsfissure (Porrett and Lum iss, 2001; Porrett et al,
200Lund et al, 2006).Nurse prescribing for anal fissureBefore May
2006, :he British National Formula(BNF) nurse prescriDers' extended
formulary wvery limited. Independent prescribers couid onprescribe
from a set list of conditions and fromiimited number of
medications. The only conditia nurse prescriber couid independently
prescrifor was constipatiori, from within the gastro-intetinal
conditions (BNF, 2006). Specifically, with tmanagement of anal
fissure in mind, this wouallow the prescription of a buik-forming
laxatibut neither of the topical treatments for anal fissu
I(GTN or diltiazem). Under supplementary prescring any drug
couldcolorectal clinic the be prescribed, but within tjse of
supplementary prescring has iimited effeci iveness as the doctor
agreei
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condition. Traditionally, the use of nurses withinthese clinics
came from the need for them to seenewly referred patients, thus
ruling out the useof supplementary prescribing (Lewis et al,
2003;Fitzgerald-Smith et al, 2005).
Although anal fissures can be chronic in nature,patients with
them are rarely seen in the outpatientclinic on more than three
occasions. This was alimiting factor on the usefulness of
supplementaryprescribing in this setting. It may be that there
arenot many nurse prescribers who specialise withinthe area of
colorectal. To obtain a prescription forGTN or dilt iazam in the
past required a good workingand trusting professional relationship
with a medicalcolleague who would prescribe treatment based onthe
nurse's diagnosis.
The opening of the BNF in May 2006 has enabledmore nurses from m
ore varied clinical background s,including colorectal, to become
independent nurseprescribers. We can now prescribe any
licensedmedicine within our clinical competence and mayeven
prescribe medicines outside of their licensedindication. However we
must accept profession-al, clinical and legal responsibility
(Department ofHealth, 2006). This allows full nursing managementof
anal fissure. The treatment algorithm recommendsthat first line
treatment should be based on licensing,availability, costs and
contraindications. Currently,Rectogesic is the only licensed
treatment for analfissure pain - diltiazem currently remains
unlicensedfor anal fissure pain based on the available
evidence(Brown et al, 2001; Bielecki and Kolodziejczak,
2002;DasGupta et al, 2002). Therefore, if we prescribe aproduct
which is not licensed for anal fissure pain,we must accept the
professional, cl inical and legalresponsibility, although we have
the algorithm onwhich to base our prescribing decision.
Nurses who work in primary care have the samerights to prescribe
as a colore ctal nurse in second arycare and therefore could use
the algorithm. However,there is currently no literature available
on nurse-led anal fissure management within primary care.One
published study looks at nurse-led colorectalintervention within
primary care. It concluded thatprimary care can provide a service
with extendednursing roles but that extensive training and
supportfrom secondary care is needed for this to be trulysuccessful
(Maruthachalam et al, 2006). This wouldseem to indicate that the
majority of colorectalnurses who manage, diagnose and prescribe are
insecondary care.Conclusion
Table 2Advice to help patients manage chronic anaifissure
(Prodigy, 2006)Lifestyle adviceConstipation can be helped by:
High-fibre diet with plenty of fluids Fibre supplem ents Bulk form
ing laxatives
Dealing with the discomfort Warm baths Anaesthetic creams or
ointments Hydrocortlsone Lubricants Goo d toilet hygiene
Analgesics, such as paracetamol
tially been changed by the publication of theseguidelines. It
has enabled primary care teams toinitiate first-line treatment by
providing them with anevidence-base to make their decisions. If
successfuland adopted by primary care the number of referralsto
secondary care wil l be reduced which can onlybe beneficial for all
involved, especially the patientwho will be able to receive
immediate treatment andhopefully relief of their symptoms.
Currently, it wouldseem that the nursing management and
prescribingfor colorectal condit ions is focused mainly in
sec-ondary care. In the future it may be that primary carenurses
receive training to manage simple colorectalcondit ions and this
algorithm will strengthen thepossibility of this happening.
Although this algorithmseems to transfer responsibility of anal
fissure tothe primary care team what it actually aims to do
isrationalise the treatment of anal fissure in primaryand secondary
care settings (Lund et al, 2006). Itmay even improve the
relationships and team work-ing between primary and secondary care
as a whole,which would only benefit the patient if successful.
a
Bieiecki K, Kolodziejczak M (2002) A prospective random
izedtrial of diltiazem and glyceryltrinitrate ointment in
thetreatment of chronic anal fissure. Colorectal Dis 5:256-257
British National Formulary (2006) BMJ Publishing, London
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CLINICAL
KEY POINTSAnal fissure Is a common, benign condition that
affects otherwise healthy adults. It is a split in thelower 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 thefissure 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.In
2005, a European team of colorectal clinicians met with the aim of
developing an evidence-basedtreatment 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 byproviding them with an evidence base on which to make
their decisions.
management of persistent and recurrent chronic analfissures.
Colorectal Dis 4: 226-232DasGupta R, Franklin I, Pitt J , Dawson PM
(2002) Successfultreatment of chronic anal fissure with diltiazem
gel.Colorectal Dis 4: 20-22Department of Health (2006) Improving
patients' access tomedicines; a guide to implementing nurse and
pharmacistindependent prescribing within theNHS. Department
ofHealth, LondonFitzgerald-Smith AM , Madigan P, Collins B,Kiff R.
(2005) Acomplete nurse-led service for patients with
suspectedcolorectal cancer - ca n it work? Coiorectai Dis 7
(suppl1)1-42Griffin N, Acheson AG, Sheard G (2002) Pain
copingstrategies and quality of life inpatients with chronic analf
issure. Gu(50 : 211Hyman N (2004) Incontinence after lateral
analsphincterotomy; a prospective study andquality of
lifeassessment. Dis Coion Rectum 47: 36-38Jonas M, Lund JN,
Scholefield JH (2002) Topical 0.2%glyceryl trinitrate ointment for
anal fissures; long termefficacy in routine clinical practice.
Colorectal Dis4:317-320Jones DJ (1999) AB C of Coiorectai Diseases.
2nd Edition.BMJ Publishing, LondonLewis M, Haray P, Harinath M
(2003) Nurse led colorectalclinics; is this the solution for fast
track colorectal c linics?Colorectal Dis 5 (suppl 2) 5-55Lewis
M,Shah PR, Joseph A, Haray PN(2004) CoiorectaiD/s 6 (suppl 2)
11-67Lund JN, Scholefield JH (1997) Internal sphincter spasm in
anal fissure. Br J Surg 84: 1723-1724Lund JN , Nystrom PO
Coremans G, Karaitianos I, SpyM, Schouten WR, Sebastion /W,
Pescatori M (2006)evidence-based treatment algorithm for anal
fissuTech Coloproctol io|: 176-179Maruthachalam K, Stoker E,
Nicholson G, Horgan AF (20Nurse-led flexible s gmo idosco py in
primary care - tfirst thousand patients. Colorectal Dis 8:
557-562Nelson R (2006) Non surgical therapy for anal fiss(Review)
The Coclirane Collaboration. The CochraLibrary. Issue 4 !
Porrett T (1996) Extending the role of the stoma care nurNurs
Stand 10: 33-35Porrett T, Lunniss PJ(2001) A prospective randomised
tof consultant-led injection sclerotherapy compared wnurse
practitioner-led non-invasive interventions in tmanagement of
patients with first and second deghaemorrhoids. Coloi^ectal Dis 3:
227-231Porrett T Knowles GH, Lunniss PL (2003) Creation otreatment
protocol |for nurse-led management of afissure. Colorectal Dm 5:
63-72Prodigy Guidance (2006) Anal fissure. Available at:
wprodigy.nhs.uk/analifissure/view_whole_guidance (daccessed
13Noveniber 2006).Rectogesic. Summary of Product Characteristics.
Febru2005. IRichard OS, Gregoire R, Piewes EA (2002)
Intersphincterotomy is superior to topical nitroglycerin in
treatment of chron ic anal fissure; results of a
randomizecontrolled trial by the Canadian Colorectal Su rgical
TrGroup. Dis Colon Rectum 4: 1048-1057
Is soya contraindicated in thosetaking thyroxine?See Questions
and AnswersI page 459
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