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Chronic anal fissure — ESEGH MCQ

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EasyLuminal GIChronic anal fissureESEGH

A 32-year-old woman has had severe anal pain during and after defaecation, with bright red blood on the toilet paper, for 8 weeks. Examination shows a posterior midline anal fissure with a sentinel tag and increased resting sphincter tone. Her symptoms persist despite adequate fibre, fluid intake and stool-softening treatment. She has no contraindication to nitrate therapy. What is the most appropriate next management?

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Correct answer: E — Topical glyceryl trinitrate 0.4% ointment

The correct answer is topical glyceryl trinitrate 0.4% ointment. The duration, sentinel tag and increased resting tone identify a chronic fissure associated with internal anal sphincter hypertonia. After stool optimisation has failed, topical GTN provides chemical sphincter relaxation, reduces resting pressure and improves anodermal perfusion; it is applied every 12 hours for up to 8 weeks. Headache is a common adverse effect. Topical diltiazem is an unlicensed alternative in UK practice when appropriate. Botulinum toxin injection and lateral internal sphincterotomy are escalation options for fissures persisting despite topical sphincter-relaxant treatment. Rubber-band ligation treats internal haemorrhoids, not fissures. Lidocaine may provide short-term analgesia but does not adequately address sphincter hypertonia when used alone.

Reference: Grünenthal Ltd. Rectogesic 4 mg/g Rectal Ointment: Summary of Product Characteristics, sections 4.1, 4.2 and 5.1. Revised February 2024. https://www.medicines.org.uk/emc/product/3933/smpc