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CLINICAL

Role of the nurse prescriber
in managing anal fissure

to raised resting canal pressure and anal spasm
Jenny Stewart
Colorectal Nurse Practitioner,
A nal fissure is a common, benign condition
that often affects young, otherwise healthy
adults (Jonas et al, 2002). They are characterised
(Lund and Scholefield, 1997; Jonas et al, 2002)
and treatment shou d be directed at reducing these
Nottingham University
Hospitals, Queens Medical by pain on defecation and anal bleeding (Porrett factors (Jonas et al , 2002). Internal anal sphincter
Centre Campus, Department et al, 2003; Lund et al, 2006). A fissure is a split activity and resting anal pressure can be reduced
of Colorectal Surgery in the lower part of the anal canal extending from with either surgicai or pharmacological treatments
the anal verge towards the dentate line. Most fis- (Bielecki and Kolodziejczack, 2002).
Email: jenny.stewart@nuh. sures are posterior, but anterior fissures are also
nhs.uk seen in women. Medical management of anal
The cause of a fissure is not always clear, but a fissure
fissure often starts following a bout of either con- Before the algorithm, treatment for anal fissure
stipation or diarrhoea (Jones, 1999). Some heal varied from clinician to clinician and many treat-
spontaneously but many become chronic, causing ment centres followed guidelines based on local
months of misery for the patient. A fissure is usually experience (Lund et al, 2006) Treatment for anal fis-
considered to be acute if it has been present for less sure was dependent on which clinician trained the
than 6 weeks, and chronic if present for more than 6 colorectal nurse practitioner. Without any clear
weeks (Prodigy, 2006). guidelines this could not improve.
Approximately 87% of chronic sufferers are Some doctors in primary care are highly compe-
between 20 and 60 years old. In approximately tent in fissure diagriosis and management, whereas
10% of cases the fissure occurs during childbirth others are not so confident. However, the publication
(Prodigy, 2006). of this treatment algorithm now provides evidence-
based guidance to help health care professionals
Symptoms decide on the most appropriate treatment.
Typically patients present with rectal bleeding, which
they often believe to be caused by haemorrhoids, Algorithm
or severe pain on defecation. It has regularly been The development o' the European algorithm for anal
described by patients as 'like passing glass'. There fissure managemerit has benefits for all concerned.
is also an associated burning pain that may linger Most importantly the patients can receive fast relief
for several hours after defecation in some patients of their symptoms^ as it allows them to receive
(Lund et al, 2006). These symptoms significantly first line treatment within primary care. It can also
impair quality of life. Successful treatment of anal delay or stop the rieed for a referral to secondary
fissure means improvement of quality of life (Griffin care. Often referrals into secondary care can take
et al, 2002; Hyman, 2004) Patients with fissures gen- many weeks and during this time a patient can be
erally have internal anal sphincter tightness leading in severe pain. Haying an algorithm gives primary
care doctors and nurses the knowledge to optimally
treat anal fissures n the best way possible, which
in turn will reduce the pressure and waiting times in
ABSTRACT secondary care.
In December 2005 a team of colorectal clinicians from across Europe met
with the aim of developing an evidence-based treatment algorithm for anal Treatment options
fissure, to be used in both primary and secondary care. In this article, Jenny On presentation, the patient is assessed and a
Stewart explores its implications for the management of anal fissure by full history is taker|. On diagnosis of anal fissure a
nurses in primary and secondary care. medication can be prescribed as first-line treatment
to heal the fissure.

454
Niiijrse Prescribing, 2006/2007 Vol 4 No 11

In the recent Cochrane but Rectogesic (GTN 0. Evidence has suggested that surgical sphincterotomy ficient evidence to conclude the effectiveness of is an excellent treatment for chronic anal fissure as diltiazem but several studies have found that it is it relieves the symptoms and has a low recurrence equally effective in healing anal fissure compared rate (Brown et al. Surgery with GTN (Bielecki and Kolodziejczak. Unlike GTN 0. 2005). Nurses should inform patients in both primary and secondary care and can also be of the side-effects. 2006) Causes • Habitual use of laxatives • Constipation • Diarrhoea • Injury to anal canal during labour Symptoms • Sudden. and that they do improve with prescribed by nurse prescribers as well as by our time to help promote compliance (Nelson. ofen occurring during. relief from these headaches can be achieved with simple of symptoms. 2006/2007 Vol 4 No 11 455 . with an incidence of 50% (Rectogesic Summary of It should be used 2-3 times daily for 6-8 weeks to Product Characteristics. or shortly after. 2006). Both diltiazam Glyceryl trinitrate (GTN) ointment has been used to and GTN 0. 2002). It can be prescribed improve outcomes. 2003.2%. Richard et al. 2001. 2006). 2002. Lund et ai. Rectogesic is a standard treatment and this can lead to poor compliance unit dose and therefore provides consistent qual- (DasGupta et al. Although the concentration ity. there is an increased side-effects occur. 2006). a calcium channel blocker. 2001). treatment for the pain management of chronic anal up to 80% of patients develop headaches during fissure. Lund et al. this is can lead to rapid healing in 90-95% of patients though to result from increased compliance as fewer (Lund et al. 2006). The most common adverse of GTN has not been found to affect outcomes. bowel movement • Streak of blood on toilet paper • 'Sentinel pile': a small tag of skin that develops on the edge of the anus where the fissure lies Glyceryl trinitrate ointment fissure were unlicensed for that use. Diltiazam is still unlicensed for use al. if the fissure remains unhealed after 6-8 weeks. Nurse Prescribing. supply and dose. However. According to the treatment algorithm.4%) was launched in June review GTN was found to be significantly better than 2005 in the UK and was the first licensed topical placebo in healing fissures (Nelson. In the Cochrane review there was insuf. risk of anal incontinence from surgery. evaluated as an alternative treatment to GTN with up to 75% healing rates observed (Brown et al.2% had to be prepared at the request produce a chemical sphincterotomy with varied heal. 2002). of doctors and could only be prescribed within ing rates of up to 86% in some studies (DasGupta et secondary care. medical colleagues. severe pain in and around anus. event was dose-related headache which occurred education of how to use it does (Brown et al. However. Table 1 Causes and symptoms of an anal fissure (Porrett et al. with the inci- Until recently the topical treatments for anal dence ranging from 8% to 39% (Brown et al. This makes it easier and quicker The headaches experienced are temporary and relief for patients to obtain treatment and. 2001. Surgery 2001). 2006). has been further pharmacological treatment or surgery. 2002). therefore. oral analgesia (Lund et al. patients should Calcium channel blockers be referred to secondary care for consideration of Diltiazem.

Porrett et al. ISDN. Nursing management of anal fissure Nurse prescribing for anal fissure It is now accepted that many areas of treatment Before May 2006. NSAiDs) agents and dietary modifications ^ if pain extreme Healed: z \ 6-8 weeks 6-8 weeks X Unhealed and irid . ISDN . 2006). but within the patient to increase fibre intake often using a bulk colorectal clinic the jse of supplementary prescrib- laxative. Fitzgerald-Smith et ai.glyoeryl trinitrate. 2001.isosorbide dinitrate. 2006/2007. this would nurses were able to offer more time for discussion. as management of anal fissure in mind. 1996. 10: 176-179. costs and contraindications GTN . An evidence-based treatment algorithm tor anal issune. from within the gastro-intes- concluded that patients respond more positively tinal conditions (BNF. 2006). 2001. 2005). The only condition et al published a study looking specifically at the a nurse prescriber couid independently prescribe management of anal fissure by nurses. Vol 4 No 11 . 2006). This involves encouraging the ing any drug could be prescribed. Analgesics (local > Unlicensed: GTN 0. Porrett et al. allow the prescription of a buik-forming laxative information giving and education.2%. prescribe from a set list of conditions and from a 2004. to the supplementary plan had to diagnose the 456 Nurse Prescribing. fissure (Porrett and Lumiss. Under supplementary prescrib- good piace to start. no history of anal fissures Crohn's disease. but neither of the topical treatments for anal fissure I In terms of management. Lund et al. CLINICAL Primary care management of chronic anal fissure Adapted from and approved by: Lund JN et al. etc) First-line treatment*: Licensed: topical GTN 0. In 2002 Porrett iimited number of medications. It is because of these risks that These methods. treating the cause is a (GTN or diltiazem). 2003. anaesthetic. Reproduced vwith permission from Springer ©. HIV infection. Lewis et al.non-steroidal anti-inflammatoty drugs Nelson. calcium channel blocker inn bulking »»»». Lund et al. and ensuring a high fiuid intake to make a ing has iimited effeci iveness as the doctor agreeing soft stool (Brown et al.4%. with the to a nurse practitioner compared with a doctor. :he British National Formulary for common coloproctological conditions can be (BNF) nurse prescriDers' extended formulary was managed by a suitably trained nurse practitioner very limited. Tech Coloproctol 2006. 2006). were can be effective in relieving anal fissure and should sought to reduce the anal canal pressure and always be considered along with other treatments of spasm. Specifically. along with a nurse-led education alternatives to surgery.ic or asymptomatic \ \ V discharge I Unhealedand \ sment I some improvement \ I V symptomatic | Second 6-8 week course of topical L Refer to secondary care \ ] therapy Unhealed: refer to secondary care "according to licensing availability. 2003. The authors for was constipatiori. Independent prescribers couid only (Porrett. lion A Patient history and external examination Also recurrent Idiopathic anal fissure uncomplicated (first presentation. NSAIDs . such as topical GTN.

Shorthouse AJ (2001) The Nurse Prescribing. It may be that there are • High-fibre diet with plenty of fluids not many nurse prescribers who specialise within • Fibre supplements the area of colorectal. the use of nurses within these clinics came from the need for them to see Table 2 newly referred patients. especially the patient product which is not licensed for anal fissure pain. it would responsibility. possibility of this happening. seems to transfer responsibility of anal fissure to One published study looks at nurse-led colorectal the primary care team what it actually aims to do is intervention within primary care. However. • Anaesthetic creams or ointments including colorectal. It nursing roles but that extensive training and support may even improve the relationships and team work- from secondary care is needed for this to be truly ing between primary and secondary care as a whole. To obtain a prescription for GTN or diltiazam in the past required a good working • Bulk forming laxatives and trusting professional relationship with a medical colleague who would prescribe treatment based on the nurse's diagnosis. This would which would only benefit the patient if successful. London The future of anal fissure management has poten. Kolodziejczak M (2002) A prospective randomized secondary care. 2001. 2006). «a seem to indicate that the majority of colorectal nurses who manage. to secondary care will be reduced which can only DasGupta et al. such as paracetamol Health. Currently. diagnose and prescribe are in Bieiecki K. Colorectal Dis 5: 256-257 Conclusion British National Formulary (2006) BMJ Publishing. 2006/2007. Brown SR. clinical and legal hopefully relief of their symptoms. Therefore. Advice to help patients manage chronic anai Fitzgerald-Smith et al. to become independent nurse • Hydrocortlsone prescribers. 2002). tially been changed by the publication of these availability. 2006). Taylor A. 2006). thus ruling out the use of supplementary prescribing (Lewis et al. who will be able to receive immediate treatment and we must accept the professional. for colorectal conditions is focused mainly in sec- Nurses who work in primary care have the same ondary care. 2003. patients with them are rarely seen in the outpatient clinic on more than three occasions. Dealing with the discomfort The opening of the BNF in May 2006 has enabled • Warm baths more nurses from more varied clinical backgrounds. guidelines. conditions and this algorithm will strengthen the there is currently no literature available on nurse. fissure (Prodigy. Traditionally. We can now prescribe any licensed medicine within our clinical competence and may • Lubricants even prescribe medicines outside of their licensed • Good toilet hygiene indication. It concluded that rationalise the treatment of anal fissure in primary primary care can provide a service with extended and secondary care settings (Lund et al. It has enabled primary care teams to Rectogesic is the only licensed treatment for anal initiate first-line treatment by providing them with an fissure pain . Although this algorithm led anal fissure management within primary care. Currently.condition. clinical and legal responsibility (Department of • Analgesics. If successful for anal fissure pain based on the available evidence and adopted by primary care the number of referrals (Brown et al. although we have the algorithm on seem that the nursing management and prescribing which to base our prescribing decision. costs and contraindications. if we prescribe a be beneficial for all involved. 2006) Although anal fissures can be chronic in nature.diltiazem currently remains unlicensed evidence-base to make their decisions. However we must accept profession- al. 2002. trial of diltiazem and glyceryltrinitrate ointment in the treatment of chronic anal fissure. 2005). Adam IJ. successful (Maruthachalam et al. In the future it may be that primary care rights to prescribe as a colorectal nurse in secondary nurses receive training to manage simple colorectal care and therefore could use the algorithm. Bielecki and Kolodziejczak. Vol 4 No 11 457 . This allows full nursing management of anal fissure. This was a Lifestyle advice limiting factor on the usefulness of supplementary Constipation can be helped by: prescribing in this setting. The treatment algorithm recommends that first line treatment should be based on licensing.

uk/analifissure/view_whole_guidance (date Jones DJ (1999) ABC of Coiorectai Diseases. Dawson PM (2002) Successful M. a European team of colorectal clinicians met with the aim of developing an evidence-based treatment algorithm for anal fissure to be used in both primary and secondary care. Gregoire R. • I n 2005. Lunniss PJ (2001) A prospective randomised trial strategies and quality of life in patients with chronic anal of consultant-led injection sclerotherapy compared with fissure. Karaitianos I. Colorectal Dis 4: Prodigy Guidance (2006) Anal fissure. Madigan P.nhs. • A fissure often starts following a bout of constipation or diarrhoea. Horgan AF (2006) medicines. Dis Colon Rectum 4: 1048-1057 Is soya contraindicated in those taking thyroxine? See Questions and Answers I page 459 458 Nurse Prescribing. results of a randomized. Scholefield JH (1997) Internal sphincter spasm in Group.can it work? Coiorectai Dis 7 (suppl Porrett T (1996) Extending the role of the stoma care nurse.the independent prescribing within the NHS. It is a split in the lower part of the anal canal extending from the anal verge towards the dentate line. Scholefield JH (2002) Topical 0. is this the solution for fast track colorectal clinics? Richard OS. Lunniss PL (2003) Creation of a Jonas M. February Lewis M. management of persistent and recurrent chronic anal anal fissure. Haray P. a guide to implementing nurse and pharmacist Nurse-led flexible s gmoidoscopy in primary care . Colorectal Dm 5: 63-72 efficacy in routine clinical practice. Lund JN. Kiff R. Harinath M (2003) Nurse led colorectal 2005. •The treatment algorithm recommends that first-line treatment shold be based on licensing availability. Department of first thousand patients. Stoker E. Collins B. Franklin I. Dis Coion Rectum 47: 36-38 Porrett T Knowles GH. In approximately 10% of cases the fissure occurs during childbirth. Br J Surg 84: 1723-1724 fissures. 2006/2007 Voi 4 No 11 . London Nelson R (2006) Non surgical therapy for anal fissure Fitzgerald-Smith AM. CLINICAL KEY POINTS •Anal fissure Is a common. •The publication of these guideiines has enabled primary care teams to initiate first-line treatment by providing them with an evidence base on which to make their decisions. Colorectal Dis 4: 226-232 Lund JN. Colorectal Dis 8: 557-562 Health. D/s 6 (suppl 2) 11-67 controlled trial by the Canadian Colorectal Surgical Trials Lund JN. Sebastion /W. 2nd Edition. Available at: www. Nicholson G. Shah PR. evidence-based treatment algorithm for anal fissure. Haray PN (2004) Coiorectai treatment of chronic anal fissure. Acheson AG.2% treatment protocol |for nurse-led management of anal glyceryl trinitrate ointment for anal fissures. Joseph A. such as diltiiazem and glyceryl trinitrate. I clinics. a prospective study and quality of life haemorrhoids. •Medical treatment options include calcium channel blockers. Gu(50: 211 nurse practitioner-led non-invasive interventions in the Hyman N (2004) Incontinence after lateral anal management of patients with first and second degree sphincterotomy. Colorectal Dis 4: 20-22 Tech Coloproctol io|: 176-179 Department of Health (2006) Improving patients' access to Maruthachalam K. Coloi^ectal Dis 3: 227-231 assessment. 1)1-42 Nurs Stand 10: 33-35 Griffin N. 317-320 prodigy. Summary of Product Characteristics. Piewes EA (2002) Internal Colorectal Dis 5 (suppl 2) 5-55 sphincterotomy is superior to topical nitroglycerin in the Lewis M. costs and contraindications. long term fissure. The Cochrane complete nurse-led service for patients with suspected Library. London Rectogesic. •Typically patients present with rectal bleeding or severe pain on defecation. BMJ Publishing. Sheard G (2002) Pain coping Porrett T. Nystrom PO Coremans G. (2005) A (Review) The Coclirane Collaboration. Pitt J. Schouten WR. Spyrou DasGupta R. Pescatori M (2006) An treatment of chronic anal fissure with diltiazem gel. Issue 4 ! colorectal cancer . benign condition that affects otherwise healthy adults. accessed 13 Noveniber 2006).