(Conclusion)
Medically, treatment consists of increased water intake, incorporation of more fiber in the diet, undertaking warm baths a couple times a day, and application of a pea-sized amount of topical 2 percent diltiazem three times daily on the outside of the anus for 6-8 weeks.
Compliance is huge. This whole thing is about consistency. Oftentimes, the reason treatment fails is people can’t do this. They feel good after about a week, so they stop before the fissure is completely healed.
The topical diltiazem must be prepared at a compounding pharmacy. It’s usually covered by insurance. Even if it’s not, an 8-week prescription cost only about $25. The drug is effective in up to 95 percent of patients who follow the instructions.
Topical 0.2 percent nitroglycerin, an alternative treatment, is less attractive because 30 percent of patients experience often-disabling headaches as a side effect. Topical diltiazem has a much better side effect profile. If a patient shows a partial response to 6-8 weeks of topical diltiazem, it’s worth prescribing a second round. If the fissure still hasn’t healed after that, it’s time for referral to a surgeon. The options are onabotulinumtoxinA (Botox) and lateral internal sphincterotomy.
Botox is effective in 60-80 percent of patients, she explained, providing temporary benefit lasting up to 3 months with a much lower risk of incontinence than with lateral internal sphincterotomy. Open and closed sphincterotomy techniques yield a similar success rate, with healing in 93 percent of cases.
For internal hemorrhoids, stool softeners, 25-30 g of fiber supplements per day, warm sitz baths, avoiding straining during defecation, and not loitering on the toilet are key elements in achieving symptomatic control nonoperatively.
Patients who don’t have a bathtub in which to take sitz bath can accomplish the same thing using an easily removable, commercially available device that fits over a toilet bowl.
Disposable baby wipes for adults have become the No. 1 cause of anal itching and are to be shunned by patients with internal hemorrhoids or other anorectal disorders.
Patients often engage in excessive wiping because of the poor consistency of their bowel movements. If they’re pasty and not coming out in one fell swoop, it leads to residue that patients appropriately feel they need to dipe wipe multiple times to keep clean. The majority of these wipes for adults are alcohol based, and even though on your exam you may see nothing, the dipe wipes cause microexcoriations of the skin. The patient itches and doesn’t know why.
Primary care physicians can readily learn to do mucosal banding for grade II and III prolapsing hemorrhoids in the office, she noted. However, banding should never be attempted on external thrombosed hemorrhoids, though.
Surgical excisional hemorrhoidectomy is a lasting solution for such hemorrhoids, but patients need to understand that, even though it’s only 10- to 15-minute procedure performed in an outpatient setting, it’s excruciatingly painful for a week – and that’s not the end of the story.
I tell patients to take a week offwork. And don’t sit on a donut; it pulls on the suture line. Pillows are okay. But it takes 6-8 weeks to heal, so even though they’re only in excruciating pain for about a week, they have to poop past the suture line, so they’ve got to avoid rock-hard stools.”
With an anoperineal abscess, first-line treatment is incision of the abscess as close as possible to the anus, followed by placement of a drain to be left in place for 7-10 days. Prophylactic antibiotics are reserved for immunosuppressed patients.
Patients need to understand up front that, 30-50 percent of the time, a fistula can develop after drainage of an abscess. Indeed, abscessed anoperineal fistula is one of the most common conditions seen in the emergency department and clinic. The telltale symptoms are recurrent abscess and/or epersistent drainage. Those patients need referral to a colorectal surgeon.
Fistula-in-ano is a frustrating disease for the patient and the surgeon. As surgeons, we like to fix – and there’s really no good option.
Among the surgical treatment options are debridement followed by fibrin glue injection, an anal fistula plug, an endorectal flap closure, and ligation of the intersphinteric fistula tract, or LIFT, procedure.